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scalp psoriasis
calp psoriasis is very common. In fact, at least half of all people who have psoriasis have it on their scalp. As with psoriasis elsewhere on the body, skin cells grow too quickly on the scalp and cause red lesions covered with scale. Scalp psoriasis can be very mild, with slight, fine scaling. It can also be very severe with thick, crusted plaques covering the entire scalp. Psoriasis can extend beyond the hairline onto the forehead, the back of the neck and around the ears. Most of the time, people with scalp psoriasis have psoriasis on other parts of their body as well. For some, the scalp is the only affected area. Other skin disorders, such as seborrheic dermatitis, may look similar to psoriasis. However, there are differences. Scalp psoriasis scales appear powdery with a silvery sheen, while seborrheic dermatitis scales often appear yellowish and greasy. Despite these differences, the two conditions can be easily confused. How is scalp psoriasis treated? Many treatment options can help control scalp psoriasis and its symptoms. Sometimes scalp psoriasis will clear on its own, or it can remain on the scalp for long periods. It is important to select scalp treatments that are agreeable to you. Treatments should never be worse than the psoriasis itself. Consider your lifestyle, available time and the cost to help you decide among the options.

What is psoriasis? Psoriasis is a noncontagious, genetic disease of the immune system affecting the skin and/or the joints. According to the National Institutes of Health, as many as 7.5 million Americans have psoriasis. The most common form, plaque psoriasis, results in raised, red lesions covered by silvery white scale. Psoriasis can be limited to a few lesions or can involve moderate to large areas of skin. Having 3 to 10 percent of the body affected by psoriasis is generally considered a moderate case. More than 10 percent is considered severe. (For most individuals, the palm of the hand is about the same as 1 percent of the skin surface.) However, the severity of psoriasis can also be measured by how psoriasis affects a persons quality of life. Psoriasis can have a serious impact even if it involves a small area, such as the palms of the hands or soles of the feet. From 10 to 30 percent of individuals with psoriasis also develop psoriatic arthritis, which causes pain, stiffness and swelling in and around the joints. To learn more about the types of psoriasis or psoriatic arthritis, visit the National Psoriasis Foundation Web site at www.psoriasis.org.

Tar products and salicylic acid are generally sufficient for treating very mild scalp psoriasis. More severe scalp psoriasis may require persistence and experimentation to find an effective treatment plan. Treatments include topical medications (applied to the skin) and, occasionally, ultraviolet (UV) light. Treatments are often combined and rotated because a persons psoriasis may become less responsive to medications after repeated use. Systemic (oral or injected) psoriasis treatments are not commonly used just for scalp psoriasis. They may be tried if psoriasis is present elsewhere on the body and/or the psoriasis is moderate to severe. Treatment schedules Scalp treatments must be repeated until you get adequate control of your lesions. This can take up to eight weeks or longer. Once you achieve an acceptable level of clearing, you may be able to keep psoriasis from coming back by using a tar shampoo or other medicated shampoo daily or twice a week. Moisturizing the scalp may also help. OVER-THE-COUNTER PRODUCTS
Salicylic acid

acid if used over large areas of the skin. Salicylic acid may also weaken hair shafts and make them more likely to break, causing temporary hair loss. This is not permanent; hair should return to normal after stopping treatment.
Tar

Tar products, usually available without a prescription, are widely used to treat scalp psoriasis. You will be able to find over-the-counter tar shampoos, creams, gels, oils, ointments and soaps. Your doctor also can prescribe tar in a variety of strengths. It may be used as a sole treatment or in combination with other treatments. While tar is an effective medication, it can stain bedding and gray or white hair, and has a strong odor. There are two kinds of tars: coal tar and wood tar. Coal tar is approved by the Food and Drug Administration (FDA) to treat psoriasis. It is the more common form for treating psoriasis, but some wood tar products are used to treat scalp psoriasis. Coal tar is available in OTC products in concentrations from 1% to 5%, although higher concentrations are sometimes prescribed. Refined coal tars, such as liquor carbonis detergens (LCD), have less of an odor and may cause less staining. Unfortunately, refined tars are not as effective and may be harder to find. California requires OTC coal tar products that contain more than 0.5% coal tar to be labeled with cancer warnings. However, the FDA maintains that OTC

Salicylic acid is approved by the Food and Drug Administration (FDA) to treat psoriasis. It softens scale and makes it easier to remove. It can be used in combination with tar or other products. Its popular nickname is sal acid, and you will find it both in over-the-counter (OTC) and prescription products, mostly in over-the-counter shampoos and soaps. Treatments with high concentrations of salicylic acid can cause irritation. The body may absorb salicylic

products with coal tar concentrations between 0.5% and 5% are safe and effective for psoriasis and that no scientific evidence suggests that the coal tar in OTC products is carcinogenic. To allow for maximum absorption of the tar, massage tar shampoo into the scalp and leave it on for about five minutes before rinsing it off. Using a nonmedicated conditioner after shampooing with tar products can reduce the smell of the tar shampoo. Avoid using a non-medicated shampoo after treatment as this may remove tar from the scalp. Tar gels, creams, solutions, and lotions can be massaged into the scalp and left on overnight. These tar products are used for psoriasis on other parts of the body as well. Effectiveness will vary for each person. Tests have shown tar shampoos to be superior to shampoos without tar in treating scaling.
Medicated shampoos

PRESCRIPTION PRODUCTS
Anthralin

Anthralin is an older prescription medication that may work for some people with scalp psoriasis. The typical use of anthralin for scalp treatment is 30 minutes with a concentration of either 0.25% or 0.5% anthralin. This medicine can be left on the scalp for as little as 10 minutes and then washed off. With a treatment called Short Contact Anthralin Therapy, or SCAT, higher concentrations are applied for shorter periods. Anthralin can stain the skin and cause skin irritation in some people. Remove anthralin from the scalp by rubbing the shampoo toward the back of the head to avoid getting anthralin on your forehead or in your eyes. Psoriatec is the brand name of a 1% anthralin cream that may limit staining because the medication is released from tiny capsules only at skin temperature. Rinse Psoriatec from the scalp, clothing, towels or bathroom fixtures with cool or lukewarm water to prevent these capsules from breaking down; this may prevent the staining and irritation usually associated with anthralin.
Antimicrobial therapy

Many coal tar and non-coal tar medicated shampoos for treating scalp lesions are on the market. Leave shampoos on the scalp as directed and rinse them out thoroughly. Remember, medicated shampoos are designed for the scalp, not the hair. You may want to use a regular cosmetic conditioner after your scalp treatment to reduce the smell of the medicated shampoo and make your hair more manageable.

Scalp psoriasis can get worse if the scalp becomes infected with bacteria or yeast. If crusting of the scalp along with scaling occurs and/or the lymph nodes in your neck are enlarged, your doctor may prescribe antimicrobial treatment.

Calcipotriene

Calcipotriene (also known by its brand name Dovonex) is a prescription topical vitamin D3 derivative that comes in solution form. After applying Dovonex at night, cover the scalp with a shower cap or plastic bag before going to bed. Confine Dovonex to the scalp because it may irritate unaffected skin, particularly the face. You may wish to test a small area before applying it to the entire scalp. Avoid contact with your eyes.
Calcipotriene and betamethasone dipropionate

cyclosporine and biologic medications. They may help clear scalp psoriasis, and are only appropriate for moderate to severe cases. Systemic psoriasis medications have side effects that must be weighed in relationship to their benefits. Mild hair loss can be a side effect of oral retinoids. Ordinarily, the hair will grow back when the medication is stopped.
Tazarotene

Calcipotriene and betamethasone diproprionate (also known by its brand name Taclonex Scalp) is the combination of the vitamin D3 derivative calcipotriene and the potent steroid betamethasone dipropionate. It is applied once daily for two weeks or until clearing is achieved. It shouldnt be used longer than eight weeks. Avoid contact with your eyes.
Intralesional steroid scalp injections

Tazarotene (also known by its brand name Tazorac) is a topical vitamin A derivative that comes in a cream or gel form for the treatment of psoriasis. The gel absorbs more rapidly than the cream, while the cream may be less irritating for people with dry or sensitive skin. Tazarotene may be more effective if used in addition to a topical corticosteroid. Apply tazarotene in a thin film to lesions on the scalp or hairline. The medication may dry out the skin. To reduce irritation, apply moisturizers 30 minutes before tazarotene is used. However, the skin should be dry when treated. Tazarotene is safe to use on your face, but it should not be applied around the eyes. Do not cover treated skin. Overnight application of tazarotene is recommended. Let the medication air dry on the scalp before going to bed, so you dont spread it on your pillow and face as you sleep.
Topical steroids

Sometimes doctors inject scalp lesions with steroid medications. This is done only when the scalp psoriasis is mild and involves a few areas. It would not be appropriate to inject many plaques. Steroid injections are given sparingly because the medication can be absorbed into the system.
Systemic treatments for psoriasis

If moderate to severe psoriasis is present on other skin sites in addition to the scalp, your doctor may prescribe systemic psoriasis medications (medications that are taken by mouth or by injection). The most common include methotrexate, oral retinoids,

Topical corticosteroid medications (steroids) can be

effective against scalp psoriasis. These prescription medications come in solutions, gels, creams, lotions, sprays, ointments and foam. Topical steroids range from very mild to potent. Normally, strong steroids can be used safely for scalp psoriasis, but they should not be used continuously for long periods. A two-week cycle of treatment is commonly recommended for strong steroids. In addition, they should not be used under a dressing or covering (occlusion). Follow your doctors instructions carefully. Abruptly stopping steroid treatments can sometimes cause psoriasis to worsen (called a rebound flare). Work with your doctor if you plan to stop using steroids. Do not use steroid preparations on your face and other sensitive skin areas, such as under the breasts or on genitals, unless directed by your doctor. Avoid getting steroids in your eyes. Several topical steroid prescription medications are designed specifically for treating scalp psoriasis. These formulas are water- and alcohol-based, which makes it easier to wash them out after treatment. Sometimes scalp psoriasis can become less responsive to topical steroids. If this happens, you can switch to other scalp treatments, such as anthralin, calcipotriene, tazarotene or tar. It can take five to seven days before topical steroid medications will work again for skin that has become less responsive.

Ultraviolet light

Hair blocks UV light treatments from reaching the scalp. However, better results can be achieved with conventional UV units if you part your hair in many rows, if you have very thin hair or if you shave your head. Hand-held devices called UV combs are available to deliver a higher intensity of UV light. Natural sunlight may also help if the hair is very thin or the head is shaved. PRACTICAL TREATMENT TIPS
Scale softening and removal

The first step in treating scalp psoriasis is to remove (lift) any scale on psoriasis plaques. Scale lifting is necessary to make it easier for topical medications to penetrate the plaques and clear them. Scale softeners contain active ingredients such as salicylic acid, urea, lactic acid or phenol. They are usually applied to the scalp, left on for a prescribed length of time (sometimes overnight) and shampooed off. The loosened psoriasis scales are washed away. You may avoid some of the messiness by applying softeners at night and covering your head with a shower cap. Scale softeners can be purchased over the counter. Soaking the scalp in warm (not hot) water can help loosen scales. Soaking with water plumps up scales and makes them easier to remove. Another way to soften and loosen scales is to apply oils, lotions, creams or ointments to a damp scalp. Some people report that lubricants work better with a hot towel wrapped around the head. You can also apply heated olive oil to the scalp and wrap your head

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in a towel for several hours, or apply olive oil and sit under a hair dryer. Once the psoriasis scale has been softened, it needs to be removed. People generally use round or fine-tooth combs or brushes. One of the best methods is to comb the scalp gently in a light circular motion, holding the comb almost flat against the scalp. Once the scale is loosened, you may shampoo to flush the scale from the scalp and out of the hair. Removing scales too vigorously can break the skin and lead to an infection. It can also break hair off at the scalp, causing temporary hair loss. The Koebner [kebner] response, a tendency for psoriasis to appear on damaged skin, can occur at the site of rough scratching or scraping. If treatments worsen your psoriasis or irritate your scalp, use plain oils and water until the irritation subsides. Great care should be taken when removing scales and applying topical medications to avoid triggering this response.
Effective application of medications

them with a thin layer of petroleum jelly before applying medications. Avoid getting any medication in the eyes. Pre-treat the scalp lesions with scale-softening agents or oils to soften and remove the heavy scales and make scalp medications more effective. Shampoo your hair before applying a scalp medication. Apply petroleum jelly to cotton balls and insert them gently into the ears before applying the medications or shampoos to keep shampoos and medications out of ears.
Occlusion and stain protection

Part your hair and hold it in place while you drip or pat oils or lotions directly onto your scalp. Make a new part about a half-inch away and repeat. If you use a cream or ointment, rub it right into the psoriasis. All preparations should be used sparingly. Treat all of the affected areas, including those around the ears and hairline. Products such as anthralin and tazarotene may irritate the folds behind the ears. Protect those areas by covering

Shower caps, towels, plastic wrap and plastic produce bags are examples of items used to occlude (cover) the scalp. Occlusion can enhance a treatment while also protecting pillows, clothes and furniture from medications and oils. Plastic produce bags are inexpensive, if not free, and do not make the crinkle sound of a regular shower cap. To protect your bedding from stains, you can make a treatment pillowcase by sewing two towels together on three sides. Never use a shower cap or other covering with prescription scalp medications, unless specifically directed by your doctor.

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Combining medications

Tips for dealing with itch

A doctor can prescribe special combinations of medications, a process known as compounding. Specialized preparations prescribed by a doctor can be mixed by a pharmacist for individual cases. Be aware that some medications may inactivate others, so it is best to consult your doctor before combining medications on your own.
The forehead, neck and ears

Use a conditioner after every shampoo to keep the scalp moisturized. Dry scalp can cause itching or make it worse. Limit the use of hot tools to style hair, or let hair air-dry to reduce scalp dryness. Press a wet towel or cold pack against the itchy spot. Run cold water over your head

Scalp psoriasis may creep down onto the forehead and the neck and around the ears. These areas can be treated with the same products used for the scalp. However, there are some specific considerations. For example, anthralin can stain facial skin. Strong steroid medications should never be used on the face because they can irritate and thin facial skin. Calcipotriene is not recommended for the face, although some people use it there successfully. Tazarotene is considered safe for facial use, although it can irritate the skin.
Scalp itch

Itching is often a problem for those with scalp psoriasis. OTC tar shampoos can help reduce itching. Topical steroids are often effective, and oral antihistamines are occasionally prescribed. Sometimes doctors add menthol to scalp medications; many over-the-counter medicated shampoos contain menthol. There are OTC products developed specifically for scalp itch. Check your local pharmacy or drugstore for these products.

COMMON QUESTIONS ABOUT SCALP PSORIASIS Q: I know tar products are very good for treating scalp psoriasis, but they dry my scalp and hair. What would you recommend? A: Conditioners and cream rinses may help combat dry hair. Some conditioners are specially designed for use in combination with tar shampoos. You can do a final application of a regular (nonmedicated) conditioner to moisturize the hair. Q: Can I use hair dye, hair spray or permanents if I have scalp psoriasis? A: While a few people report scalp irritation from hair dyes, hair spray, or permanents, many have no problems. Test the products on a small area of the scalp before applying them all over to see if they will irritate the lesions. Ask your stylist about gentle products.

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Q. How many times a week can I wash my hair without irritating my scalp psoriasis? A: Daily shampooing is appropriate with psoriasis, both for treatment (medicated shampoo) and removal of excess scale. Q: Will head lice treatments irritate scalp psoriasis? A: Head lice shampoos are applied only briefly, so reactions are rare. However, they can be irritating, so you should avoid getting them in open cuts or lesions or on extensively scratched skin. Q: Will a hair stylist or barber object to cutting my hair? A: You can broach the subject when making your appointment. If you are refused service or made to feel uncomfortable, contact the National Psoriasis Foundation.

Take charge of your health join today! Whether youre newly diagnosed or have been coping with psoriasis for years, National Psoriasis Foundation membership offers something for everyone:
Psoriasis Advance: Keep up to date with the latest psoriasis news in our award-winning magazine. Psoriasis skINSIGHTS: This twice-yearly newsletter offers easy self-care strategies and tips. Money-saving coupons and discounts: Receive exclusive coupons for skin care and other health products. Treatment tips: Full access to It Works for Me, our online database of tips from people with psoriasis and psoriatic arthritis. Toll-free information line: Call between 8 a.m. and 5 p.m. Pacific Time and talk to our health educator. Opportunities to connect: Share information and support with others who have the disease through our online message board and affiliated support groups. Help in finding a doctor, special invitations to educational events and more!

To join the National Psoriasis Foundation call 800.723.9166 or go to www.psoriasis.org.

Additional resources

The National Psoriasis Foundation maintains an extensive library of information on psoriasis and related topics. To learn more, visit our Web site at www.psoriasis.org or e-mail education@psoriasis.org.

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scalp psoriasis

MISSION STATEMENT Our mission is to improve the quality of life of people who have psoriasis and psoriatic arthritis. Through education and advocacy, we promote awareness and understanding, ensure access to treatment, and support research that will lead to effective management and, ultimately, a cure.

The National Psoriasis Foundation, a charitable 501(c)(3) organization, depends on your tax-deductible donations to support the millions of people diagnosed with psoriasis and/or psoriatic arthritis. The Psoriasis Foundation is governed by a volunteer Board of Trustees and is advised on medical issues by a volunteer Medical Board. For more information, or to obtain a copy of the Foundations Annual Report, call 800.723.9166. National Psoriasis Foundation educational materials are reviewed by members of our Medical Board and are not intended to replace the counsel of a physician. The Psoriasis Foundation does not endorse any medications, products or treatments for psoriasis or psoriatic arthritis and advises you to consult a physician before initiating any treatment. 2008 National Psoriasis Foundation

National Psoriasis Foundation

6600 SW 92nd Avenue, Suite 300 Portland, OR 97223-7195 Toll Free 800.723.9166 www.psoriasis.org Connect. Control. Cure.
May 2008