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A positive approach
to psoriasis and
psoriatic arthritis
Scalp Psoriasis
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What is psoriasis?
Psoriasis (Ps) is a long-term (chronic) scaling disease
of the skin, which affects 2%-3% of the UK population.
It appears as red, raised scaly patches known as
plaques. Any part of the skin surface may be involved
but the plaques most commonly appear on the
elbows, knees and scalp. It can be itchy but is not
usually painful. Nail changes are present in 50% of
people and 10%-20% of people will develop psoriatic
arthritis.
What happens?
Normally a skin cell matures in 21-28 days and during this
time it travels to the surface, where it is lost in a constant
invisible shedding of dead cells. In patches of psoriasis
the turnover of skin cells is much faster, around 4-7 days,
and this means that even live cells can reach the surface
and accumulate with dead cells. The extent of psoriasis
and how it affects an individual varies from person to
person. Some may be mildly affected with a tiny patch
hidden away on an elbow which does not bother them
while others may have large visible areas of skin involved
that significantly affect daily life and relationships. This
process is the same wherever it occurs on the body.
Psoriasis is not contagious.
What is scalp psoriasis?As the term suggests, scalp psoriasis is psoriasis
involving the scalp. It is common and approximately half
of all people with psoriasis have it on their scalp. The
reason it deserves special mention is that it can be
particularly difficult to treat and usually requires
specifically formulated medicines.
Psoriasis in the scalp forms in the same way as in other
parts of the body but the affect of the hair is to trap the
scale and stop it being rubbed away as it is, for instance,
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with psoriasis 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 also
acts as a physical
barrier obstructing
t h e a p p l i c a t i o n
o f c r e a m s a n d
ointments to the
affected skin.
The net result can be stubborn thick scaly plaques
which require specifically formulated scalp treatments.
Other things affecting the scalp
These can include scalp acne, infestations, fungal
infections and alopecia. Make sure you get a correct
diagnosis before starting any treatments. your doctor or
healthcare provider will provide appropriate advice.
What are the symptoms?
Scalp psoriasis causes redness and scaliness w h i c h
m a y a l s o involve the hairline, the forehead, behind the
ears and the back of the neck. It can range from very
mild w i th s l igh t f i ne s c a l i n g t o v e r y severe
crusted thick scaling covering the entire scalp which can
in some cases cause hair loss during the flare, but will
normally grow back.
A correct diagnosis of scalp psoriasis is essential in
treating the condition as there are other skin disorders
which may look similar such as seborrhoeic dermatitis.
The difference being that scalp psoriasis scales appear
fine with a silvery colour, whilst seborrhoeic dermatitis
scales often are yellowish and greasy. One of the most
frustrating symptoms is the constant shower of scale on
to your collar and shoulders.
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What is the treatment?
There are many treatment options that can help scalp
psoriasis and they all need to be used regularly.
Treatments can be time consuming and it is important to
select one that fits in with your lifestyle. On rare occasions
scalp psoriasis has been known to have spontaneous
remissions but can also remain on the scalp for lengthy
periods of time too. Bear in mind however, that the
treatments used should never be worse than the psoriasis
itself. If this is the case consult your doctor for further
advice or alternative treatment options.
It is also important to realise that good patient
compliance and experimentation to find an effectivetreatment plan which may include treatments such as
topical medications and
ultra violet UV light can
often be combined and
rotated depending onpsoriasis resistance to
repeated medicinal use.
With all treatments it
can take at least eightweeks until you get
adequate control of the
plaques. Once you have achieved this it is important to
maintain any improvement, and this can usually be done
with regular use of a tar shampoo.
It should be mentioned that children can get scalp
psoriasis too. Treatments will be much the same as used
for adults.
Here is a list of topical treatments that you may find
useful for scalp psoriasis:
Tar products
Tar shampoos, gels, ointments and creams are commonly
used to treat scalp psoriasis. They may be combined with
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other medications such as salicylic acid, to help remove
scale, or coconut oil, to moisturise the skin. Tar is effective
but it can stain clothing and jewellery and has a strong
smell. As a result, some people dislike using it. The
precise instructions for use will depend on the formulation
of the product but tar products are usually massaged into
the scalp, left in contact for a period of time, and then
rinsed off. Clothes and bedding can be protected from
staining by wearing a shower cap during the contact
period.
Topical steroids
These scalp products are usually formulated as liquids,
gels, oils, foams, sprays or shampoo. They range frommild to very strong potency. They should not be used for
long periods of time. Ideally, they should be used regularly
for a few weeks to bring the psoriasis under control, and
then gradually phased out, giving way to maintenance
with a coal tar shampoo. Abrupt stopping of steroids canresult in a rebound or worsening of psoriasis. It is not
advisable to use steroid preparations on your face, other
areas of sensitive skin such as under the breast and
genitals and around the eyes, unless directed by your
doctor. Most topical steroid medications are designedspecifically for treating scalp psoriasis. These formulations
are usually water and alcohol based which make them
easier to wash out after treatment. You can become
resistant to some topical steroids used in the treatment of
scalp psoriasis. If this happens consult your doctor foralternative medications. It should also be noted that it can
take several months before such topical steroid
medications will work again for skin that has become
resistant.
Vitamin D analogues
Vitamin D analogues are available in water and oil based
scalp formulations. They are usually applied once or twice
a day and left in contact with the scalp. They do not smell
or stain clothing, and are relatively easy to use. They can
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be used to bring the scalp psoriasis under control and
maintain that control. Such medications should be
confined to the scalp region only as it can irritate
unaffected skin particularly the face. It may be advisable
if you think you are prone to sensitivities to test a small
patch before applying it to the entire scalp. Avoid contact
with the eyes.
Vitamin A derivative (topical retinoids)
These can be applied as creams or gels for the treatment
of psoriasis and can be used in the treatment of scalp
psoriasis too. These medications may be less irritating for
the people with dry or sensitive skin. To avoid the drying
out of skin too much and to reduce irritation, applying amoisturiser 30 minutes before these are used may help.
These medications can be used on the face but should
never be applied around the eye region and treated skin
should not be covered.
Antimicrobial treatment
If bacterial or yeast infections are present scalp psoriasis
can become worse. A crusting scalp together with scaling
and/or swollen lymph nodes in the neck may indicate to
your doctor that antimicrobial treatment will be necessary
as there is infection present.
Mild scalp psoriasis can respond well to treatment with
anti fungal shampoos that will help to reduce the yeast
infection. Anti fungal shampoos may have to be used
once or twice a week thereafter to maintain results.
Ultra violet light
Successful outcome for using UV light treatments can bevariable on the scalp because the hair blocks UV light
from penetrating the scalp. It works best on shaved
heads. Natural sunlight may also help again if your head
is shaved or hair is thin. It is therefore not surprising that
this is not a first line treatment.
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Dithranol
Dithranol creams are effective in scalp psoriasis but like
coal tar can be difficult to use. Dithranol is usually applied
to the scaly plaques and left in contact for up to 30minutes before being rinsed out. It needs to be applied
with great care as it can irritate and cause purple staining
of blonde or red hair. Dithranol can burn non affected skin.
Lipid stabilised dithranol, if used correctly, can
reduce staining.It should also
be noted that
dithranol will
stain clothing
a n d b a t h s ,showers and
wash basins.
Extra attention
is needed.
Medicated shampoos
There are many coal tar and non coal tar medicated
shampoos for treating scalp psoriasis available from your
local chemist. For further advice ask your pharmacist whomay be able to give you further guidance. You should also
bear in mind that medicated shampoos are designed for
the scalp not the hair so the use of a regular shampoo and
conditioner after your scalp treatments will reduce the
smell of any unpleasant medicated shampoo and leaveyour hair shiny and manageable. Scalp psoriasis can get
worse if it becomes infected with bacteria or yeasts and
sometimes medicated shampoos with antifungal
medicines can be useful in reducing the plaques. The
choice of which of these treatments is best for you is apersonal one. It is a good idea to shop around and try
different treatment options. In this way you can discover
which one suits you best.
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Some useful tips
Scalp psoriasis may progress down onto the forehead,
neck and around the ears. These areas can be treated
with the same products you use for your scalp only if
indicated to use on such areas. Be careful about your
face. Strong steroids should not be used on the face and
dithranol can stain and burn facial skin. Avoid getting
medication in the eyes.
A lot of product treatments will contain salicylic acid,
known as a keratolytic. This ingredient aims to loosen
psoriasis scales so they can be washed away more easily.
This ingredient will be contained in both over the counter(OTC) and prescription products mostly found in
shampoos and soaps. It should be noted that treatment
with high concentrations of this ingredient can cause
irritation and used over large areas of skin the body may
absorb it leadingto the weakening
of ha i r shaf ts ,
causing them to
break and leading
to temporary hairloss. Hair should
return to normal
after stopping
the treatment.
Such productsmay be easier to apply at night and the head covered
with a shower cap to avoid messiness and more
convenient as they can be time consuming at the
beginning of the day before going to work.
Softening and loosening thick scale makes it easier for
topical medications to penetrate plaques and clear them.
Soaking the scalp in warm water can help loosen scales
which can then be removed using a comb. But be gentle
do not break the skin.
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Round or fine tooth combs or brushes are generally
used to remove psoriasis scales. Comb or brush the scalp
gently with a light circular motion holding the comb or
brush flat against the scalp. Loosen the scale gently then
you can shampoo to flush the scale from the scalp and
out of the hair. A hairdryer can be used to blow additional
scales away from the scalp and the hair. Do not remove
scales too fiercely as this can break the skin leading to
infection. The Koebner (name given to the development
of psoriasis on damaged skin) response can occur, this
can also occur if you scratch or scrape your scalp roughly.
If any treatments you use aggravate your psoriasis and
scalp always consult your doctor. Care should be taken
when removing the scales and applying topical
medications so as to avoid the Koebner response.
Never use a shower cap or other occlusion method
when using prescription scalp medications unless
specified by your doctor.
Scalp itch As mentioned refraining from scratching and
picking of psoriatic scales will reduce infection and the
Koebner response. Over the counter medicated
shampoos can help in alleviating itching. Please speak to
your pharmacist about this.
Combination medications The treatment of psoriasis
should be tailor made to each person. A doctor may try
various combinations of medications before finding what
works for you. Good communication between you and
your doctor and good compliance will ensure optimum
results for you. Always be aware that when medications
are combined they may activate adverse reactions. By
being aware of this and consulting your doctor if you are
unsure will reduce the likelihood of further discomforts.
Another alternative is to soften and loosen the scales is
to use oils, lotions, creams or ointments applied to a
damp scalp providing they do not cause you irritation.
To add to their effectiveness a hot towel placed around
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the head to act as an occlusion will also help loosen and
soften the scales. The heating of olive oil and application
to the scalp and wrapping your head in a towel for a long
period of time may also help or to speed the process up
applying the olive oil and then sitting under a hairdryer. Be
careful not to
burn the scalp
with too much
intensive heat.
If you are
prone or suffer
from dry hair
conditioners and
cream rinses
may help to
minimise and moisturise the hair and scalp. There is no
evidence to suggest the use of hair dyes, hair sprays or
perms will affect your scalp, however please advise your
hairdresser before embarking on any treatments so that
they can apply patch tests to see if any of their products
will irritate your scalp or psoriasis lesions. They may be
able to use gentler products. If you have the need to use
head lice shampoo preparations it is unlikely you will have
a reaction but they can be irritating and great care should
be taken not to get the solution into open cuts or lesions
or extensively scratched skin.
It can be highly embarrassing for you finding or going to
a new hairdresser or barber. If they are reputable and
understanding they should have a knowledge of
conditions such as scalp psoriasis and therefore will be
able to best advise you on styles, colourings and hair
products. It is always worth making general enquiries of
friends and relatives about local hairdressers or contacting
the Hairdressers Council for further advice that may be
useful. Some hairdressers are also happy to visit your
home if you would prefer not to go to a salon
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When applying scalp products part the hair and hold
it in place while you drip the oil or lotion directly onto
your scalp. Repeat this process until the whole of
the affected area has been treated.
Conditioners and cream rinses to help combat dry
hair can be used after you have completed using
your medication
Hair dyes and sprays do not usually irritate the scalp
in scalp psoriasis. However, it may be sensible to
test a cosmetic product on a small area of your
scalp before committing to it.
Please note:
This leaflet is one of many produced by PAPAA as a guide.
Material produced by PAPAA should not be used as a
replacement for medical advice.
Always consult your own doctor or medical healthcare
provider.
This material was produced by PAPAA 2008. Please be
aware that treatments and research is ongoing. For the
latest and up to date information or any amendments to
this material please contact us our visit our website.
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The Charity for Peoplewith psoriasis andpsoriatic arthritis
PAPAAthe new single identity of the PsoriaticArthropathy Alliance and Psoriasis Support Trust
The organisation is independently funded and
aims to be a definitive source of information and
educational material for people with psoriasis and
psoriatic arthritis in the UK.
To be a support to both patients and professionals
by providing material that can be trusted
(evidence based), which has been approved and
contains no bias or agendas.
We will be looking to provide positive advice that
enables people to be involved as they move
through their healthcare journey in an informed
way, which is appropriate for their needs
and any changing circumstances.
Psoriasis and Psoriatic Arthritis Alliance is a company limited by guarantee
registered in England and Wales No. 6074887
Registered Charity No. 1118192
Contact:
PAPAAPO Box 111 St Albans Herts AL2 3JQ
Tel: 0870 770 3212
Fax: 0870 770 3213
Email: [email protected]
www.papaa.org
9 781906 143152
ISBN 978-1-906143-15-2