From creakyjoints.org
No two cases of scalp psoriasis are alike. Learn how the symptoms differ and what steps you or a loved one can take to manage the physical and mental effects of this chronic skin condition
For Beth M., the first signs of scalp psoriasis weren’t on her scalp at all: “I first noticed it on my face in a few spots about five or six years ago,” says the 44-year-old Vermonter of the flaky, itchy patches of rough skin. “Then it started appearing on my scalp.”
For Diane T., 65, the onset was more dramatic: “I got it in 1963, when I was 5 years old,” says the Washington DC-based patient advocate. “And while I don’t remember having it at 5, I do remember having it at age 6. This memory sticks with me so vividly because it was my first day of school. I wasn’t allowed to attend because they thought I was contagious, and I was taken to a hospital. The psoriasis was so thick on my scalp that my head was shaved in order to treat it. It was just a thick mass that covered my whole head.
What Is Scalp Psoriasis?
Of the estimated 7.5 million Americans with psoriasis, about half have it on their scalp, which, as Diane’s experience shows, can be devastating. “Psoriasis is a chronic inflammatory disease that causes your skin to grow 65 percent faster in certain areas,” explains Rachna Bandhari, MD, PhD, a board-certified dermatologist at the Bucay Center for Dermatology and Aesthetics in San Antonio, TX. It happens when a glitch in the immune system prompts infection-fighting cells to attack healthy skin cells by mistake.
When you have scalp psoriasis, you may notice patches, or plaques, of scaly skin not only on the scalp but also around its margins, so your forehead and the skin behind and inside the ears and on the neck may also be affected. “Symptoms include scaling, flaking, itching, discomfort, and pain,” says Dr. Bandhari.
And while it may sometimes look like dandruff and itch like dandruff, telltale signs that it’s not dandruff include persistence — “Scalp psoriasis lasts longer than dandruff,” says Dr. Bandhari — and resistance — i.e., “Dandruff treatments aren’t enough to cure it.”
In addition, people with scalp psoriasis usually have plaques elsewhere on the body, such as the elbows and knees, back, or genitals, and may have other psoriasis symptoms such as nail pitting.
However, because dandruff and seborrheic dermatitis (both caused by an overgrowth of yeast) and scalp psoriasis are on a spectrum of scalp disorders, overlap is not unusual, Dr. Bandhari says, “So if there is ever any doubt, I would always consider a biopsy to prove what it is.”
Another thing about scalp psoriasis? No two cases are exactly alike. For example, while Beth says her scalp psoriasis is “mostly very itchy and flaky,” flakes aren’t really a problem for Diane. But regardless of how a person’s scalp psoriasis may manifest, almost all people with the condition have one thing in common: Their quality of life suffers, says Dr. Bandhari. “Even though it seems like scalp psoriasis affects only a localized area, it can be very embarrassing, and most patients are very much impacted by this.”
The shame prevents some people from socializing and attending school or work. And an activity many people find relaxing — going to the hairdresser — can be downright traumatic for someone with scalp psoriasis, as Catherine O’Leary, a psychologist with psoriasis, attests: “I can’t face sitting in a busy salon with a dark towel over my shoulders. No matter how good the haircut, the embarrassment would be too much. Luckily, I have a kind and understanding hairdresser who cuts my hair in the back room of her house; but even then I cringe at the flakes that flurry onto my shoulders and the floor.”
What Does Scalp Psoriasis Look Like?
Scalp psoriasis causes raised plaques that range in color from pink and red with silvery scales (on people with lighter skin) to purple, violet, and brown with gray scales (on those with darker skin).
The appearance of scalp psoriasis may also depend on its severity. In milder cases, it may look like a gentle scaling on the scalp, with flaking similar to dandruff. As the severity increases, the plaques become thicker with more discoloration and their margins become better defined. What’s more, it may affect a greater surface area, even covering the entire scalp, as in Diane’s childhood episode. Very severe cases can even lead to hair loss.
How Can You Treat Scalp Psoriasis
“Taking scalp psoriasis seriously is important because it’s a reflection of what’s going on inside your body,” says Dr. Bandhari. “When we see the skin inflamed, we know the body inside is inflamed.”
In fact, the same inflammation underlying psoriasis can cause other problems, which explains why psoriasis is associated with a higher risk of heart disease, psoriatic arthritis, hypertension, obesity, and diabetes.
While scalp psoriasis can’t be cured, it can be controlled. Fortunately, there are many treatment options, so odds are high you’ll find a strategy that works for you.
The first step is finding a dermatologist with whom you feel comfortable, getting an accurate diagnosis, and preparing for some trial and error: “Being patient is important,” stresses Dr. Bandhari. “Sometimes people don’t respond so quickly. But if one thing doesn’t work, you don’t have to despair. The key is to keep trying.”
Treating Scalp Psoriasis
Here is an overview of psoriasis treatments now available:
Over-the-counter products
Medicated shampoos, creams, gels, lotions, foams, ointments, and soaps containing ingredients such as salicylic acid, coal tar, zinc pyrithione, or selenium sulfide may help reduce flaking, ease redness and soreness and soften scales. Note: Many of these products are available in stronger prescription-strength formulas.
Prescription topical options
- Steroids. Often the first line of prescription treatment, these are available in ointment, lotion, cream, gel, foam, spray and shampoo forms. It’s important to apply to the scalp, not the hair, to get the full benefit, which includes reduced inflammation, redness, itching and scales. Also, discuss your shampoo routine with your dermatologist, so they can take that into account when planning your treatment. “There’s no need to change the frequency of your shampooing,” says Dr. Bandhari. “Use your regular routine.” Note: Steroids may also be injected into the scalp to treat discrete patches of scalp psoriasis.
- Vitamin D analogues. A synthetic form of vitamin D available in cream, ointment, and foam form, calcipotriene can help ease inflammation, remove scales and slow skin growth. Apply to scalp at bedtime, cover with a shower cap and allow the medication to penetrate the plaques overnight.
Ultraviolet light therapy
When your scalp psoriasis doesn’t respond to topical treatments, your dermatologist may recommend light therapy, also known as phototherapy, which can help slow the growth of excess skin cells and reduce the formation of plaques. Treatments involve exposing the skin to ultraviolet light either in the doctor’s office or at home, using a special unit.
Systemic (bodywide) treatments
In severe cases of scalp psoriasis, systemic treatments may bring relief by addressing the underlying inflammation caused by psoriasis.
Oral options include disease-modifying antirheumatic drugs (DMARDs) like methotrexate, immunosuppressants like cyclosporine and newer treatments like PDE4 inhibitors, which target enzymes that cause inflammation in the first place. You may also benefit from biologic treatments, given by injection or infusion, that block immune cells from causing rapid skin growth and inflammation. For example, some biologics are IL-12, Il 12/23 IL-17 or IL-23 inhibitors while others are TNF-inhibitors, and many other pathways are currently being studied.
Deucravacitinib (Sotyktu), an oral medication that belongs to a unique class of drugs called TYK2 inhibitors, was approved by the FDA in 2022 for the treatment of psoriasis in adults with moderate to severe plaque psoriasis who are eligible for systemic therapy (like a pill or infusion) or phototherapy.
As you explore the treatments that help you best manage scalp psoriasis, it may be helpful to remember Diane’s words: “Finding a good dermatologist is the key. Just getting the proper treatment has its benefits. You must be your own best advocate.”
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