Treatment Of Psoriasis: An Algorithm
ASHA G. PARDASANI, M.D., STEVEN R. FELDMAN, M.D., PH.D., and ADELE R. CLARK, P.A.-C., Wake Forest University School of Medicine, Winston-Salem, North Carolina
Am Fam Physician. 2000 Feb 1 61:725-733.
See related patient information handout on psoriasis, written by the authors of this article.
Psoriasis is characterized by red, thickened plaques with a silvery scale. The lesions vary in size and degree of inflammation. Psoriasis is categorized as localized or generalized, based on the severity of the disease and its overall impact on the patient’s quality of life and well-being. Patient education about the disease and the treatment options is important. Medical treatment for localized psoriasis begins with a combination of topical corticosteroids and coal tar or calcipotriene. For lesions that are difficult to control with initial therapy, anthralin or tazarotene may be tried. The primary goal of therapy is to maintain control of the lesions. Cure is seldom achieved. If control becomes difficult or if psoriasis is generalized, the patient may benefit from phototherapy, systemic therapy and referral to a physician who specializes in the treatment of psoriasis.
What Are The Symptoms Of Plaque Psoriasis On The Scalp
Psoriasis symptoms can occur anywhere on a persons scalp, and the back of the head is a common place for plaques to develop. There may be just one patch on the scalp or multiple patches in different places. In some people, plaques might extend outside the area of the scalp that is covered in hair. For example, they might occur on the forehead at the edge of the persons hairline, around the ear area, or on the back of the neck at the bottom of the hairline2.
Just like other areas affected by psoriasis, symptoms on the scalp can be mild, moderate, or severe. For people with mild symptoms, psoriasis on the scalp can be relatively thin with light scales, covering only a small part of the head. For people with more severe symptoms, the plaques may become much thicker and cover a larger area of the head.3
What Are Causes And Risk Factors Of Scalp Psoriasis
It is generally accepted that scalp psoriasis, like all psoriasis, is related to genetic defects that affect certain parts of the immune system. There are undoubtedly environmental risk factors that trigger its initial development in genetically predisposed individuals. The notion that “emotional stress” plays a causal role or at least exacerbates psoriasis has been difficult to prove. There is no question, however, that psoriasis of the scalp can be an extremely stressful experience.
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Presence Of Psoriatic Arthritis
People with psoriasis should be screened for psoriatic arthritis annually. This is best achieved in primary care and specialist settings through the use of a validated tool, such as the Psoriasis Epidemiology Screening Tool . Consider a non-urgent rheumatology referral or seeking rheumatology advice if the score is > 2 .
|Consider referral to rheumatology with a score > 2|
What Are Scalp Psoriasis Symptoms And Signs Can Scalp Psoriasis Cause Hair Loss
Psoriasis appears as a small bump, a papule, surmounted by scale. When these papules coalesce, a plaque is formed that is often covered by thick layers of horny scale. When this scale is shed, it appears as dandruff, which can be quite unsightly. Scratching these plaques, either because of itching or because of the impulse to remove it, is a very poor idea because of what is called the Koebner phenomenon . This may cause psoriasis to develop in areas of inflammation and trauma. Scratching off the scale will only make things worse. Although most patients do not note hair loss, there can be extensive alopeciahair loss in severe cases.
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For Best Results Consider A Psoriasis Diet Plan
Psoriasis Friendly Diet
A psoriasis friendly diet is crucial for treating and preventing psoriasis. Some of these foods include:
- Omega-3 fatty acids: Sources include fish , pumpkin seeds, avocados, flaxseeds, olive oil, and walnuts
- Vegetables like spinach, kale, carrots, sweet potatoes, squash, and broccoli
- Fruits like mangoes, strawberries, oranges, blueberries, and figs
- White meat, legumes, and soy-based products
What Are The Complications Of Chronic Plaque Psoriasis
Approximately 742% of people with psoriasis develop psoriatic arthritis .
Comorbidities associated with psoriasis include obesity, metabolic syndrome, cardiovascular disease, malignancy, autoimmune disease , chronic kidney disease, non-alcoholic fatty liver disease , depression, and alcohol abuse .
Severe psoriasis can cause death, particularly extensive erythrodermic and pustular psoriasis .
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Scalp Psoriasis Vs Seborrheic Dermatitis
Occasionally, seborrheic dermatitis of the scalp can be confused with scalp psoriasis since both can produce excess scale and can itch. Pathological examination of the skin biopsy material occasionally may be helpful in distinguishing the two entities. As a practical matter, this is rarely necessary because most patients with psoriasis have typical psoriatic lesions present in other areas, such as the elbows, knees, or torso. In addition, both conditions generally respond to similar topical medications.
How Common Is Scalp Psoriasis
It is common and approximately half of all people with psoriasis also have it on their scalp. The reason it deserves special mention is that it can be more difficult to treat and usually requires specifically formulated treatments.
Psoriasis on the scalp forms in the same way as on other parts of the body but the hair traps the scale and so it does not rub away as it would, for instance, on the elbow. The result is that the scale can quickly build up, causing a thicker plaque which becomes more difficult to treat . This difficulty is compounded by the hair, which acts as a physical barrier obstructing the easy application of creams and ointments to the affected skin. Children can get scalp psoriasis too. Treatments will be much the same as those used for adults. On rare occasions, scalp psoriasis has been known to disappear spontaneously, but it can remain on the scalp for lengthy periods of time too.
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Ayurvedic Treatment For Scalp Psoriasis
Scalp Psoriasis affects almost 50% of psoriasis patients. Scalp is the most commonplace where psoriasis is seen. Its seen more in children and adults. Itching and hair loss are the common symptoms seen in most patients.
Scalp psoriasis may appear only in the scalp or along with the other parts of the body. Most commonly seen scalp psoriasis is Plaque type scalp Psoriasis and other types such as pustular psoriasis, erythrodermic psoriasis are also can be seen in the scalp as an individual or with combinations.
Psoriasis can only involve the scalp or as a part of the body. In the initial stage, it may be unnoticed or confused with dandruff and it is covered by hairs. In the scalp, the scales build up fast causing thicker plaque, and trapped by the hair it becomes more difficult to treat.
What Are Treatment Options For Moderate Or Severe Plaque Psoriasis On The Scalp
For people with moderate or severe plaques on the scalp, over-the-counter topical treatments, and medicated shampoos may not be effective enough to treat their symptoms.2 These patients will need to work with their healthcare providers to figure out the best treatment plan for their condition. Treatment might include stronger topical treatments that require a prescription. Generally, these topical treatments work by decreasing the growth of the excess skin cells that cause psoriasis plaques. Some of them also help to flatten thickened skin and reduce the amount of scale on plaques. Topical prescription medicines that may be used to treat scalp psoriasis include:
Corticosteroids are a type of topical medication that are available as a scalp oil or foam to treat symptoms of plaque psoriasis. Typically, these products are applied with occlusion using a scalp covering such as a shower cap.
People with very severe scalp psoriasis may be advised to try a systemic medicine if their symptoms are not controlled well enough by topical medicines.3 Unlike topical medicines that are directly applied to affected areas, systemic medicines work by changing the way that the entire body functions. These types of drugs can be taken orally in a tablet, capsule, or liquid. They can also be injected through a shot or in an IV. Some of the systemic medicines that healthcare providers might suggest for treating scalp psoriasis include:
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Article Summary: Scalp Psoriasis Is Highly Bothersome And Hair Makes It Harder To Treat But There Are A Number Of Prescription Treatments In A Variety Of Formats Including Sprays Foams Gels And Shampoos To Help Treat The Scalp Effectively As Well As Treatments For The Whole Body That Have Demonstrated Strong Success In Treating Scalp Psoriasis
Psoriasis of the scalp is very common. Nearly 80% of psoriasis patients develop plaques on the scalp at some point in their life with psoriasis.
Scalp psoriasis is especially distressing to many patients. It can be extremely itchy, and when psoriasis extends beyond the hairline onto the face and around the ears or down the back of the neck, it is highly visible. In some cases, it can also cause temporary loss of hair in places where the psoriasis patches are thick on the scalp. Add to this the difficulty in applying medicine only to psoriasis patches, often covered by hair, without also treating the healthy skin and its not surprising that patients are eager for effective treatments.
Fortunately, there are a variety of medications that when applied directly to scalp psoriasis, are able to reduce or resolve it for a period of time and many of the newest psoriasis treatments, designed to treat psoriasis all over the body, have demonstrated excellent clearance of scalp psoriasis as well. Over-the-counter products can play an important supporting role.
Our message for those suffering with the frustration, itch, and pain of scalp psoriasis is: dont lose hope, as there are options available today that will likely provide you substantial relief from your scalp psoriasis.
Salicylic Acid Works As A Peeling Agent
Best for: Mild psoriasis
Why it works: Salicylic acid is a key ingredient in over-the-counter anti-dandruff shampoos, acne medicines, and callus and wart removers. Because its a keratolytic, or peeling agent, its often used to treat scalp psoriasis. Salicylic acid also helps with the itching by managing the abnormal turnover of cells in the skin, causing those excess skin cells to soften and come off.
Dr. Daveluy says that shampoos containing salicylic acid can be effective in combination with topical steroids. The salicylic acid dissolves and removes the flakes so the topical steroid can penetrate the skin instead of being absorbed into the flakes, he explains.
Be aware that strong salicylic preparations can cause irritation if left on the skin for too long.
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Calcipotriol + Corticosteroids: A Powerful Combination
Simultaneous use of calcipotriol and corticosteroids has been found to be more effective than either therapy alone, and the combination appears to minimize the side effects of both. The combination works as quickly as the faster acting corticosteroid component, producing good results in about four weeks.
Combination products are available in a variety of formulations, though they can be far more expensive than some of the generic steroids that are available.
One option when cost is a factor is to be prescribed the two products separately and use them, for example, on alternating days. Some doctors, noting that the combination products are only modestly more effective, and recognizing that complexity in a treatment regimen reduces compliance, simply start off with a topical corticosteroid for scalp psoriasis.
Cut The Itch With Apple Cider Vinegar
Some people say to use this on your scalp a few times a week. Its long been used as a disinfectant, so it may burn a bit when you put it on. You can mix it with equal parts water to cut the sting. Some people like to use it full-strength and then rinse once it dries. But dont try this one if you have cracks or open skin. Itll really hurt! It may take a few weeks to notice a difference in itchiness. In general, check with your doctor before you try natural remedies.
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Scalp Psoriasis Vs Dermatitis
Like psoriasis, dermatitis can also affect the scalp. While some of the treatments for these conditions may overlap, the conditions themselves have different causes.
Scalp psoriasis is likely caused by immune dysfunction. Dermatitis is caused by various skin irritants, such as allergens.
With scalp psoriasis, youll notice silvery-red scales that may extend beyond the hairline. Theyll cause itching, flaking, and redness. In dermatitis, scales are white or yellowish and accompanied by dandruff.
A doctor can usually tell the difference between scalp psoriasis and dermatitis by taking a look at the affected area. In other cases, it might be trickier to tell the difference.
They might perform a skin scrape or take a biopsy. An overgrowth of skin cells will be present in cases of scalp psoriasis. In dermatitis cases, there will be irritated skin and sometimes bacteria or fungi.
Dermatitis can cause dandruff. Scalp psoriasis and dandruff share many of the same symptoms, such as:
- white or yellow skin flakes on the scalp
- mild redness
Whats The Difference Between Scalp Psoriasis And Dandruff
Dr. Bhutani says it can be really tough to tell scalp psoriasis and dandruff aparteven for doctors! Although both conditions can cause those annoying flakes, which may be the only visible symptom at first for some people, they tend to pop up for different reasons. Unlike scalp psoriasis, dandruff isnt an autoimmune issue and can be spurred by various factors, like having very dry or oily skin, which can lead to an overgrowth of a yeast-like fungus that thrives on a moist scalp10.
But you may be able to pick up on subtle differences if you look a bit closer. Dandruff flakes can be white or yellow, which is not common in scalp psoriasis. With scalp psoriasis, plaques have a dry scale with more clearly defined edges, and the scales themselves are often thicker with a silvery sheen.
If your scalp is extremely itchy or you have any other scalp psoriasis symptoms, then you may want to schedule an appointment with a dermatologist, who can thoroughly assess whats going on. If youre only noticing some flaking and have tried an over-the-counter dandruff shampoo but havent noticed improvement, then you may want to see a dermatologist anyway theyll be able to take a closer look and prescribe something a bit stronger if you need it.
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Topical Steroids Reduce Psoriasis Inflammation
Best for: Mild to moderate psoriasis
Why it works: Topical steroids work by reducing the inflammation thats driving the skin changes seen in psoriasis, Daveluy says. This type of treatment for scalp psoriasis is likely to be a liquid instead of a cream. When your hair is wet, create a part and apply a small amount. Then create a new part right next to it, and apply again, and keep doing this until your whole scalp has been treated, he says. A shower cap may also be worn to keep the product from staining pillowcases.
Topical steroids can be bought or prescribed at different strengths, depending on your symptoms. Some people may also need steroid injections for short-term treatments.
Topical Treatments For Moderate To Severe Scalp Psoriasis
If your symptoms are more severe and the plaques on your scalp are thick, you will probably need prescription treatment. Your GP can recommend a topical treatment containing corticosteroids, vitamin D analogues, or dithranol. Prescription products containing these ingredients include dermovate scalp application, locoid scalp lotion, dithrocream and dovobet gel.
You should use these treatment exactly as directed by your doctor. Make sure that you apply the medicated product directly to the scalp, and not to the hair.
In addition to these medicated treatments, you might also try using emollients on your scalp, as these can help to soften thick plaques. An emollient is a rich moisturiser which can prevent itching and inflammation, and create a protective barrier on the skin, sealing in moisture. One to consider using is grahams natural psoriasis cream, which is made from manuka honey and calendula. Formulated with natural ingredients, this moisturising treatment offers effective relief will helping to normalise the skins structure.
If you are going to use an emollient on your scalp, you should try the following method:
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Ultraviolet Light Therapy Can Treat Psoriasis Plaques
Best for: Mild to moderate psoriasis
Why it works: When sunlight penetrates the top layers of the skin, the ultraviolet radiation bombards the DNA inside skin cells and injures it. This can cause wrinkles, aging skin, and skin cancers. However, these same damaging effects can destroy the skin cells that form psoriasis plaques
Light therapy involves exposing the skin to an artificial light source, either at a medical office or at home. Consistency is key to this form of treatment, which is often suggested for cases that arent responding to topical creams. For best results, you must expose the skin to the UV light or lamp for a set amount of time on a regular schedule usually three times a week for a period of six to twelve weeks.
Phototherapy works by reducing the inflammation, says Daveluy, but he cautions that its less effective with scalp psoriasis than with psoriasis elsewhere on your body. Thats because the scalp doesnt respond the same way. Hair blocks some or all of the light, but you may achieve better results if you part your hair in many rows.