How to treat scalp psoriasis?

In a Nutshell

• Scalp psoriasis is a chronic inflammatory condition of scalp that is marked by itchiness, flakiness, and redness of scalp skin
• Mild cases can be managed with lifestyle modification and self-care
• Moderate to severe cases are managed with topical medications (Steroids, Calcipotriene, Tazarotene), medicated shampoos containing clobetasol propionate, scale softeners, oral medications (Methotrexate, Steroids etc.) and light therapy.

Brief Context:

Scalp psoriasis is a chronic inflammatory skin condition that is non-contagious and occurs on scalp. It is characterized by redness, flakiness, and itchiness of skin. In some cases, it extends beyond scalp to cause lesions on scalp. In advanced cases, scalp psoriasis may present with:

- Hair loss from scalp

- Soreness or burning sensation

- Intense itching

- Bleeding and cracking of scalp

- Dandruff like white, silvery rash that is embarrassing as well as discomforting for individuals

Fortunately, simple lifestyle modification and over-the-counter remedies can alleviate symptoms in mild cases.

Simple Treatment Regimen

Mild cases of scalp psoriasis can be managed with topical treatment options and lifestyle modifications such as:

Lifestyle Modifications

1. Avoid scratching your scalp (although it may be hard to resist). This is because scratching not only causes more flakiness, itching or even bleeding, but can also lead to hair loss.
2. Do not rub shampoo or other hair care products on your scalp as it may aggravate the scalp dryness.
3. Replace your existing shampoo with medicated shampoo that can alleviate the dryness of scalp and reduce itchiness and flakiness of skin.
4. Do not pick on your scales. Always use a scale softener (that usually contains salicylic acid and related compounds to soften the scales). Be extremely gentle as aggressive removal of scales can cause bleeding and hair loss. It is important to soften scales to allow optimal penetration of psoriasis treatment into the scalp.
5. Use a conditioner after every hair wash to prevent dryness.
6. Air dry your hair and refrain from using hair dryer.

For moderate to severe cases of scalp psoriasis, your dermatologist may suggest topical, oral, or injectable treatments that can reduce the intensity of symptoms. These include:

- Steroids: Steroids or corticosteroids are considered as number 1 treatment for the management of moderate to severe scalp psoriasis that is refractory to lifestyle modification. Topical steroids can be applied 1-2 times per day or as advised by your healthcare provider. Steroids exert their action by alleviating inflammation and soothing disturbing symptoms such as redness, pain, inflammation, and flakiness.

- Medicated shampoo: Daily hair wash for at least 4 weeks with medicated shampoos that contain ingredients like clobetasol propionate is also a part of scalp psoriasis management.

- Scale softeners: Scale softeners are highly recommended with other topical prescription medications to loosen the scaly skin on the scalp without causing any bleeding or discomfort.

- Prescription drugs: Other prescription drugs include topical formulations of Tazarotene and Calcipotriene that are often advised in combination with steroids. These drugs penetrate the scalp and help ease the scalp irritation and inflammation.

- Biologics: These drugs that have a localized/ targeted action along the area of administration only.

Very stubborn cases of scalp psoriasis can be managed in the dermatologist’s office with specialized treatment protocols such as injectable steroids and light therapy. Your doctor may also prescribe oral drugs like oral Retinoid, Cyclosporine, Methotrexate, and Apremilast.

Nuances/ Safety

Hair loss is fairly common in scalp psoriasis, but it is noteworthy that:

- Hair loss is not a direct result of psoriasis, but is caused by damage to the scalp skin, hair follicles

- Hair loss is temporary and once the symptoms are controlled, hair growth returns to normal

- Avoid scratching and aggressive combing to slow down the hair loss.

Strength of Evidence: B
Treatment modalities listed in this article are tested and proven by various clinical trials and research studies published in the peer reviewed journals.

Our Ruling

Scalp psoriasis is a chronic skin condition that is non-contagious but can cause significant discomfort and cosmetic issues due to hair loss, dandruff like scaly plaques and itching. Speak to a dermatologist to see if simple lifestyle modification can help ease your symptoms. Follow treatment plan advised by your dermatologist to alleviate symptoms.

Our Sources:

1. https://www.psoriasis.org/about-psoriasis/specific-locations/scalp
2. https://www.aad.org/public/diseases/psoriasis/treatment/genitals/scalp-treatment
3. https://www.uclahealth.org/dermatology/scalp-psoriasis