34 JCN 2018, Vol 32, No 1

SKIN CARE

Managing psoriasis, which affects 2–3% of the UK population (British

Association of Dermatologists [BAD]; Dubois Declercq and Pouliot, 2013), has been the focus of this series. The National Institute for Health and Care Excellence guidelines provide the treatment pathway for this inflammatory skin condition (NICE, 2012; Figure 1), which can also have an impact on patients’ wellbeing, both psychologically and socially.

Approximately 50% of patients with body psoriasis will have a level of scalp psoriasis (National Psoriasis Foundation), which is renowned for being difficult to treat.

Scalp psoriasis: managementand treatment

Tonia Goman

Scalp psoriasis forms in the same way that it does to the body, but the hair acts as a trap retaining the scale which can build up resulting in thicker plaques (Psoriasis and Psoriatic Arthritis Alliance [PAPAA], 2013).

The scalp will be prone to feeling tight, itchy and sometimes sore. The characteristic silvery white flakes over red, thickened skin can create embarrassment due to the level of ‘dandruff’ that covers clothes, (Stanway, 2004). This can influence what people choose to

wear and can impact

Tonia Goman, dermatology specialist nurse, (inflammatory skin conditions) and lead phototherapy nurse, Bristol Dermatology Centre, Bristol Royal Infirmary; joint-chair of British Dermatology Nurse Group (BDNG) phototherapy sub-group; skin camouflage practitioner

This fourth article in a seven-part series looks at scalp psoriasis.

intense itching, which can be embarrassing for patients. Finding suitable treatments can be life-changing to some. This piece focuses on treatment options, from bland and simple techniques through to the variety of treatments available on prescription. This should enable community nurses to facilitate patients in managing their scalp psoriasis when asked

KEYWORDS:Dermatology Psoriasis Scalp Treatments

THE SCIENCE — WHAT IS PSORIASIS?

Approximately 2–3% of the UK population is affected by the chronic inflammatory skin condition, psoriasis (Dubois Declercq and Pouliot, 2013). There are various forms of psoriasis, but it generally presents as red plaques that can become thick and scaled. It may start as small red lesions that eventually increase and coalesce (join together). Often starting at the

knees and elbows, for many it can be limited only to these areas, whereas for others it can affect other parts of the body, such as the scalp. Men and women are equally affected, as are children (Van Onselen, 2011).

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Figure 1.The psoriasis treatment pathway (adapted from NICE [2016]).

Person with psoriasis

Principles of care

Assessment

Topical therapy

Specialist referral

Systemic biologic therapy

Phototherapy Systemictherapy

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Directions: Adults, the elderly and children from 1 year of age. For generalised all-over application to the skin. Apply three times daily or as often as needed. Adex Gel can be used for as long as necessary either occasionally, such as during fl ares, or continuously if the added anti-infl ammatory action is benefi cial. Seek medical advice if there is no improvement within 2-4 weeks.

Contra-indications, warnings, side effects etc: Do not use if sensitive to any of the ingredients. Keep away from the eyes, inside the nostrils and mouth. Temporary tingling, itching or stinging may

occur with emollients when applied to damaged skin. Such symptoms usually subside after a few days of treatment, however, if they are troublesome or persist, stop using and seek medical advice. Rarely skin irritation (mild rashes) or allergic skin reactions can occur on extremely sensitive skin, these tend to occur during or soon after the fi rst few uses and if this occurs stop treatment. As safety trials have not been conducted during pregnancy and breast-feeding, seek medical advice before using this product. Care should be taken as emollients which soak into clothing, pyjamas, bedlinen etc. can increase the fl ammability of these items. Patients should avoid these materials coming into contact with naked fl ames or lit cigarettes etc. As a precaution, dressings and clothing, etc., should be changed frequently and laundered thoroughly. Ingredients: Carbomer, glycerol, isopropyl myristate, liquid paraffi n, nicotinamide, phenoxyethanol, sorbitan laurate, trolamine, purifi ed water.

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SKIN CARE

36 JCN 2018, Vol 32, No 1

heavily on a patient’s social life, as they avoid certain scenarios to prevent uncomfortable situations — for example, events that specify dark clothes, as the scale is often highlighted. A general rule for psoriatic scalp sufferers is to wear lighter coloured clothes to reduce the evidence of the scale. Hair length is often a consideration, as managing shorter hair is easier with topical therapies, although plaques can be more obvious. Hair loss can also occur, and while generally temporary, it can be distressing to patients who will need to be reassured that once the condition has been treated, the hair will normally return (Stanway, 2004). The impact on patients is often indicated in their daily living quality index (DLQI; Finlay and Khan, 1994), a questionnaire used within

itch. After massaging the chosen product into the scalp, apply a shower cap, old towel or cling film for at least 30–60 minutes. Then, wash with normal or tar-based shampoo, and gently comb out the excess scale while still damp. However, such emollients are difficult and time-consuming to wash out, which is not ideal.

Shampoos, with a variety of ingredients, are available for scalp conditions to treat mild-to-moderate scalp psoriasis. Their ease of use will directly impact whether a patient follows the treatment — shampoos are considered user-friendly and less messy (Blakely and Gooderham, 2016). Tar-based products can be effective, although the smell often puts patients off, or they use them less regularly than recommended. Some over-the-counter shampoos contain menthol, which can be beneficial in reducing the distressing symptom of itch.

A summary of these treatments for managing scalp psoriasis follows. For more information, please refer to the previous article in this series (Goman, 2017).

dermatology to assess how skin conditions affect patients’ lives.

If the flakes present more yellow tones with a greasier appearance, it may be sebopsoriasis. This is an overlap of psoriasis and seborrhoeic dermatitis, a form of eczema (Stanway, 2004).

As with body psoriasis, the principal plan of treatment should focus on topical therapies (Figure 2). Moisturising dry skin conditions is essential and is often key to managing the symptoms of psoriasis, although moisturising the scalp is not as easy as the body. Using a very greasy emollient, such as coconut oil, olive oil or Hydromol® ointment (or similar products), massaged into the scalp can ease tightness and soothe the

Table 1: Scalp severities (Van Onselen, 2011)

Mild Moderate SevereFine scale/flakesMild rednessIndividual areas of the scalp affectedNo hair loss

Thicker scaleLarger areas of the scalp affectedSome hair loss to these localised patchesHairline can be affected

Majority to whole scalp coveredMuch thicker plaquesThickened, crusted scaleHair loss, this should be temporary

Figure 2.NICE guideline plan of action for treating scalp psoriasis (NICE, 2012; PAPAA, 2012).

If combined product orvitamin D preparation does

not control symptomsafter eight weeks

If no improvementafter further four weeks

If no improvementafter four weeks

Potentcorticosteroid

For adults only, a very potent corticosteroid can be applied up to twice a day for two weeksA coal tar preparation applied once or twice a dayReferral to a specialist for help with topical applications or advice on other treatments

vitamin D applied once daily for up to four weeks; orA vitamin D preparation applied once a day (if unable to use corticosteroids and have mild-to-moderate scale psoriasis)

and/orA scalp treatment to remove the scales (such as an emollient or oil)of the potent corticosteroid

to use, or condition mild-to-moderate, a vitamin D preparation may be advised

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JCN 2018, Vol 32, No 1 37

CORTICOSTEROIDS

In clinical trials, corticosteroids have proven to be the most effective treatment for scalp psoriasis. Thus, they are the most commonly prescribed therapies (Chan et al, 2009). They are available in different formulations, i.e. creams, lotions, ointments, oils, gels, foams, sprays and shampoos. One study showed that patients tend to prefer the foam method due to convenience, (Andreassi et al, 2003).

Corticosteroids come in strengths from mild to very potent. The more potent treatments are not suitable for the face or around the ears, to prevent long-term side-effects such as thinning of the skin. Following directions from the NICE guidelines (2012), they should be used according to instructions and for no longer than four weeks. They are not ideal for long-term use and patients should be weaned off them, or switched to an alternative treatment with a coal tar shampoo and/or emollients.

VITAMIN D ANALOGUES

Various studies have proven the efficacy of this form of treatment, (Green et al, 1994; Barnes et al, 2000). This form of treatment is strongly advised in the NICE guidelines (2012). Combination forms of vitamin D analogues and corticosteroids, such as the Dovobet® range of treatments (Leo Laboratories), that come in ointments and gels, have been proven to be effective and are often a favoured option for both healthcare professionals and patients. Vitamin D analogues are effective, but can be slower to take effect, i.e. it may take up to eight weeks to note any improvement. This treatment can also be beneficial to maintain control once psoriasis has been treated and is under control (Blakely and Gooderham, 2016). Used once or twice a day, they can be left on the scalp, having been applied under occlusion, such as a plastic shower cap. They are often favoured, as they tend not to smell or stain fabrics and are generally easy to use. However, as yet, none of these products are manufactured to be specifically applied to the scalp (PAPAA, 2013).

COAL TAR TREATMENTS

These are another effective form of treatment, coming in a wide range of applications, such as shampoos, gels, ointments and creams. They are also safe to use to the hairline and behind the ears. They are often combined with coconut oil and/or salicylic acid, offering a cocktail of effective products that result in easing symptoms of itch and inflammation and removing scale (PAPAA, 2013).

The use of coal tar is renowned for slowing the development of the cells, it assists in reducing inflammation, itch and scale. Strengths can vary —the stronger the tar, the more potent it will be. It can irritate, so a lower strength may be more beneficial for the patient (National Psoriasis Foundation, 2017).

However, coal tar treatments are often not a first choice for patients, as they are prone to smell unpleasant, and are also likely to stain fabrics and jewellery. Furthermore, they can be considered time-consuming, as they should be massaged into the scalp and left in place for a directed length of time, dependent on the precise treatment. A shower cap is advised during this time to protect clothes from staining.

SALICYLIC ACID

Salicylic acid is often incorporated in other scalp treatments, such as salicylic acid 2–3%, betamethasone 0.05% (Diprosalic®, MSD), and Cocois scalp ointment, which contains three main active ingredients, coal tar, salicylic acid and precipitated sulphur. It works as an anti-keralytic, by breaking down the thickened scale. Higher concentrations equate to more potent strengths, which can result in irritation. In the author’s clinical experience, salicylic acid is effective, but can be difficult for patients to manage and, therefore, is more appropriate in combination products. A product such as Cocois scalp application can break down excessive scaling, reduce inflammation, itch and soothe the scalp as it also contains a coconut compound. Breaking down the

▼Practical advice for patients

Avoid scratching — suggest techniques such as keeping nails short. Keeping rooms cool in order not to overheat or dehydrate skin. Drink plenty of water

Brush/comb hair gently, and often

Leave treatments on scalp for as long as directed, shampoos should be left on for a minimum time period

Treat scalp directly rather than the hair

Use moisturising hair conditioner Avoid blow drying hair, as this is

prone to drying the scalp further Avoid using alcohol-based

treatments on raw, sore skin Buy pillowcase protectors or

store a supply of old pillowcases when using scalp treatments

Allow time for treatments to work — at least eight weeks, not just days

Always read instructions —products will often vary from techniques or timing

Tell your GP or dermatologist if treatments cause side-effects, or discomfort

Try hairstyles that cover the hairline

Apply oil-based treatments that soften the scalp, making it easier to lift the scale

Opt for light-coloured clothes to mask falling scale.

thickened scale is crucial for other treatments to be effective.

OTHER TREATMENTS

PhototherapyOther treatments often include ultraviolet (UV) therapy. There are UV combs available on the market, but they are not renowned for efficacy. Full-body phototherapy is not successful in treating scalps, as it does not allow the light to penetrate through the hair. Phototherapy will be discussed in more detail in the next article in this series.

SKIN CARE

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38 JCN 2018, Vol 32, No 1

SKIN CARE

the counter, not over your head. Available online: www.psoriasis.org/about-psoriasis/treatments/topicals/over-the-counter (accessed 26 November, 2017)

National Institute for Health and Care Excellence (2012) Psoriasis: assessment and management. Clinical Guideline [CG153]. NICE, London. Available online: www.nice.org.uk/guidance/cg153/chaptere/1-Guidance#topical-therapy (accessed 25 January, 2017)

Psoriasis Association. Types of Psoriasis: Scalp Psoriasis. Available online: www.psoriasis-association.org.uk/psoriasis-and-treatments/types-of-psoriasis (accessed 5 March, 2017)

Psoriasis and Psoriatic Arthritis Alliance (2013) Scalp Psoriasis. Patient Information Leaflet. Available online: www.papaa.org/sites/default/files/scalp_ps913.pdf

Stanway A (2004) Scalp psoriasis. DermNet, NZ. Available online: www.dermnetnz.org/topics/scalp-psoriasis (accessed 26 February, 2017)

Van Onselen J (2011) Psoriasis Dermatology Nursing: A Practical Guide. Churchill Livingstone: 142–3

Systemic treatmentsWhen topical treatments are not effective or managing the symptoms, a dermatologist may recommend tablet treatments. These include the systemic treatment options used primarily in dermatology for body psoriasis, such as methotrexate, acitretin or ciclosporin (and will be discussed in the sixth article in this series). Such treatments involve blood monitoring and regular appointments with both GPs and the dermatology team.

INFANTS AND CHILDREN

Managing scalp psoriasis in infants and children can be more difficult. Generally, only topical treatments are advised in the form of vitamin D analogues or corticosteroid creams. However, off-label treatments can be prescribed at a doctors’ discretion, with close monitoring.

CONCLUSION

Community nurses are often the first source of support, being asked what treatments are available to manage scalp psoriasis. Providing practical support with knowledge of what is available can make the symptoms far more manageable. The NICE guidelines (2012) provide valuable options that can be tailored to symptom severity. If these methods

are not effective, it is worthwhile referring on to community dermatology services or secondary care, as systemic treatments may need to be prescribed.

REFERENCES

Andreassi L, Giannetti A, Milani M, Scale Investigators Group (2003) Efficacy of betamethasone valerate mousse in comparison with standard therapies on scalp psoriasis: an open, multicentre, randomised, controlled, cross-over study on 241 patients. Br J Dermatol 148(1):134–8

British Association of Dermatologists. Psoriasis — An overview. Available online: www.bad.org.uk/shared/getfile.ashx?id=178&itemtype=document(accessed 6 August, 2016)

Barnes L, Altmeyer P, Forstrom L, Stenstrom MH (2000) Long-term treatment of psoriasis with calcipitriol scalp solution and cream. Eur J Dermatol 10(3): 199–204

Blakely K, Gooderham M (2016) Management of scalp psoriasis: current perspectives. Psoriasis: Targets and Therapy6: 33–40

Chan CS, Van Voorhees AS, Lebwohl MG, et al (2009) Treatment of severe scalp psoriasis: from the Medical Board of the National Psoriasis Foundation. J Am Acad Dermatol 60(6): 962–71

Dubois Declercq S, Pouliot R (2013) Promising new treatments for psoriasis. Scientific World J article ID 980419, 9 pages. Available online: www.hindawi.com/journals/tswj/2013/980419/

Finlay AY, Khan GK (1994) Dermatology Life Quality Index (DLQI) — a simple practical measure for routine clinical use. Clin Exp Dermatol 19: 210–16

Goman T (2017) Use of topical treatments in psoriasis management. J Community Nurs31(4): 58–67

Green C, Ganpule M, Harris D, et al (1994) Comparative effects of calcipitriol (MC903) solution and placebo (vehicle of MC903) in the treatment of psoriasis of the scalp. Br J Dermatol 130(4): 483–7

National Psoriasis Foundation. Scalptreatment. Available online: www.psoriasis.org/about-psoriasis/specific-locations/scalp (accessed 5 March, 2017)

National Psoriasis Foundation (2017) Over

KEY POINTSScalp psoriasis forms in the same way that it does to the body, but the hair acts as a trap retaining the scale which can build up resulting in thicker plaques.

Moisturising dry skin conditions is essential and is often key to managing the symptoms of psoriasis, although moisturising the scalp is not as easy as the body.

This article provides a brief outline of topical treatments, which will enable community nurses to better guide patients through the complexities of the different products available.

Providing practical support with knowledge of what is available can make the symptoms far more manageable.

Managing scalp psoriasis in infants and children can be more difficult.

Having read this article,

Your knowledge of the NICE treatment pathway for psoriasis

Why scalp psoriasis can be difficult to treat

The advice you would give patients with scalp psoriasis to help relieve symptoms.

Then, upload the article to the free JCN revalidation e-portfolio as evidence of your continued learning: www.jcn.co.uk/revalidation

RevalidationAlert

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