Psoriasis: scalp psoriasis

LAST UPDATED: Sep 22, 2022

Introduction

This chapter discusses the management of scalp psoriasis and is set out as follows:


History

  • Affected areas of the scalp are often itchy 

Clinical findings

  • Plaques of psoriasis are often separated by normal areas of scalp. Scalp margins and above the ears are frequently affected
  • Pityriasis amiantacea - the appearance of excessive scaling of the scalp with thick silvery or yellowish scales, which encircle the hair shafts and may bind down tufts of hair. Pityriasis amiantacea can be secondary to a number of scalp conditions including psoriasis and seborrhoeic eczema 
  • Look for signs of psoriasis elsewhere, although on occasions the scalp may be the only affected site 

Images

Please refer to notes on image rights at bottom of the page with regards to individual image ownership.


Management

Overview

Shampoo: for long-term management

  • Tar based preparations eg Polytar ® or Alphosyl ® shampoo are useful when scale is present - massage into the scalp for five minutes to allow the shampoo to penetrate the scale and then wash out
  • Some patients are not keen on the smell of tar based preparations and may wish to try an alternative such as Dermax ® shampoo

Topical applications: for flare-ups

If the shampoo alone does not suffice add in a topical application. Treatment options include:

  • Dovobet ® Gel, which has the benefit of combining a topical steroid with a vitamin D analogue, and is proven to be superior when compared to using either agent alone. The applicator will allow a precise amount of gel to be massaged on to affected areas on scalp while dry. Dovobet gel can sometimes leave the scalp feeling greasy and so it is recommended that the gel is applied in an evening and is washed out the following morning with shampoo that should be massaged in to the treated areas of the scalp before washing off with water
  • A topical steroid scalp preparation eg Betacap ® scalp application - these need to be applied to affected areas of the scalp when dry, and left on (ie the hair should be washed at the other end of the day). It is best to avoid alcohol based solutions, which are not as well tolerated
  • Etrivex ® shampoo - this needs to be massaged on to the scalp and left on for 20 minutes before washing out

Thick scale

Some patients present with thick scale and this needs to be removed before commencing the topical applications referred to above: 

  • Sebco ® scalp ointment is very effective at removing scale - massage in to affected areas of the scalp for five minutes and leave on for at least two hours, but preferably overnight (some patients cannot tolerate the treatment for more than a few hours). Sebco should be washed out with Capasal ® shampoo 
  • The treatment is messy and so if left on overnight patients should use an old pillowcase or towel, alternatively the scalp can be occluded with a shower cap. Sebco may be need to be used for a few days until the scale diminishes, and then used PRN as the scale builds up
  • Warn patients that hair loss may occur as the scale come away, but that this will recover

Hair margins 

  • Consider topical 1% Hydrocortisone or Eumovate ® BD

Severe scalp psoriasis 

  • Patients not responding adequately to treatment should for referred to a dermatologist for consideration of other treatments such as methotrexate or intralesional steroid injections, the latter may be useful for localised severe scalp psoriasis  

Disclaimer - the author PCDS cannot accept responsibility for any misleading or incorrect statements, and the management of individual patients remains the direct responsibility of the individual doctor. We do however hope that visitors to this site can contact us regarding comments that are considered misleading or incorrect so that we can continue to improve the site.

Image Rights - The PCDS would like to thank Dermatoweb, DermQuest (Galderma), and others who have contributed images. All named individuals and organisations maintain copyright for the relevant images. This website is non-profit and holds the images for educational purposes only. Any image downloaded must only be used for teaching purposes and not for publication or commercial use. Notice and credit must be given to the PCDS or other named contributors.

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