Scalp, nail and inverse psoriasis can complicate everyday grooming and leave you wondering how to get certain areas clean, trimmed or hair-free — and looking good — without flaring your condition.
Whether you’re aiming for soft, shiny hair that doesn’t smell medicinal, a shave that doesn’t leave skin rougher than when you started, manicured nails, or simply to get delicate areas of inverse psoriasis such as armpits clean and odor-free, the best approach is to proceed with caution and a gentle touch to avoid worsening psoriasis, said Abrar Qureshi, M.D., MPH, chief of the Department of Dermatology at Rhode Island Hospital, chairman of the Department of Dermatology at the Warren Alpert Medical School of Brown University in Providence, Rhode Island, and NPF Medical Board member.
“Anything you apply to inflamed skin [besides psoriasis-specific topicals] is going to inflame it more, and trauma to the skin, whether it’s physical, chemical or extreme temperatures, can cause psoriasis to worsen in a process called Koebnerization,” he said. “Although psoriatic skin can often appear thicker than normal skin, the opposite is true, and it can damage and bleed easily.”
That means effective dermatological care for inflamed psoriatic skin needs to precede many cosmetic tasks. Here, Qureshi and other experts offer advice for looking your best without inflaming your skin.
Hair and scalp
The scalp, not the hair, is where the biological process of scalp psoriasis occurs, said Katherine Flanagan, M.D., a dermatologist in private practice at Shades Valley Dermatology in Birmingham, Alabama.
“That means you can go with whatever style works for you — and any hair product or process that doesn’t irritate your skin,” she said. “The strategy for care and grooming that promotes healing and decreases flakes is generally a combination of medications to reduce inflammation and a product applied to the scalp to encourage gentle exfoliation of psoriatic scales to cut down on itching and flaking.”
Flanagan, Long Island-based aesthetician Fran Klapow and Jason S. Reichenberg, M.D., vice chair of the Department of Dermatology at the University of Texas Southwestern Medical Center in Austin, offer this advice for good hair days:
Apply prescription or over-the-counter medicated shampoos, which dermatologists often suggest for scalp psoriasis, directly to the scalp. “Think of them as scalp treatments, not shampoos,” said Reichenberg. “Separate sections of hair so you can work them gently into the scalp and let them sit for about five minutes before rinsing.”
After rinsing, use your favorite shampoo and conditioner on hair starting an inch away from the scalp. This won’t disrupt the work of medicated products and can add shine, softness and a pleasant scent.
Find a stylist who understands — or is willing to learn — how to work with your scalp psoriasis.
Avoid styling processes that deliver intense heat directly to the scalp.
Don’t pick, scratch or roughly brush your scalp, as this can make psoriasis worse.
Qureshi calls inverse psoriasis — which shows up as red lesions in body folds under breasts, in the armpit or groin area, and elsewhere on the body — “hidden psoriasis” and notes many patients are reluctant to call attention to it, even to their dermatologists.
“We have good ways to treat it, but we have to know it’s there,” he said.
Areas of inverse psoriasis, which are often marked by tiny skin fissures and splits, are also prone to bacterial and fungal infections, making it even more critical to discuss them with your dermatologist. He offers these tips for addressing inverse psoriasis:
Cleanse inverse psoriasis gently with running, tepid water and a mild cleanser without abrasives or fragrance. Qureshi often advises people to use a preservative- and fragrance-free facial cleanser made for sensitive skin in these areas.
Pat skin dry and apply prescribed medications.
Don’t treat inverse psoriasis with topical medications prescribed for other areas of your skin unless your dermatologist specifically gives you the go-ahead. “The skin in body folds is thinner and more delicate than in other areas,” he said. “Using full-strength topicals in these areas can thin skin and cause permanent damage.”
If inverse psoriasis is flaring in your armpits, use a fragrance-free, aluminum chloride-based antiperspirant without an added deodorant.
Avoid shaving, waxing or using chemical depilatories in these areas until skin is healed.
Removing unwanted hair — whether from your face, armpits, legs or elsewhere — isn’t always a straightforward process for people with psoriasis.
“Active psoriasis disrupts the skin’s normal barrier function — it’s no longer intact — and some treatments, like shaving and waxing, cause more damage and can flare disease,” said Qureshi.
The bottom line, he said, is that when psoriasis is actively inflamed, it’s important to avoid any kind of hair removal (other than a gentle trim with scissors) to avoid making skin disease worse.
Qureshi said that once skin is healed:
Avoid close shaves. “Shaving causes micro-nicks, and the closer you shave, the more damage you do,” he said, noting close shaving also increases the likelihood of ingrown hairs.
Don’t grow out beards, which can trap oils and create an infection-friendly environment.
Learn what method works best for you. “It takes trial and error, but when skin is healed, you can experiment with different hair removal methods -- shaving, waxing and chemical depilatories -- to see which is least irritating to your skin,” he said.
“Just as skin psoriasis can display a Koebner reaction — the worsening of psoriasis in response to injury or trauma — psoriatic nails can also be worsened by any type of nail damage or injury,” said Phoebe Rich, M.D., adjunct professor of dermatology and director of the Nail Disorder Clinic at the Oregon Health & Science University in Portland. “Even minor repetitive trauma, such as typing or using your nails as tools, exacerbates nail psoriasis.”
The good news, said Rich, is that treatment for nail psoriasis is improving.
“Newer biologic medications often are effective in clearing severe nail psoriasis,” said Rich, who also notes that, no matter how severe nail psoriasis is, it doesn’t leave permanent scars.
“It takes six months to grow a new fingernail and 12 months for a new toenail, so progress is not quick even with the most effective treatments, but there’s always the hope of clear nails in the future.”
Rich offered the following recommendations for those with psoriatic nails:
Keep nails short to minimize trauma from everyday tasks such as typing and texting. Short nails, even when lifted away from the nailbed (a process called onycholysis) collect less moisture underneath. Keeping these areas dry makes bacterial or yeast infection less likely.
Don’t probe or clean aggressively under nail tips; instead use a soft nail brush to remove debris gently.
Disguise nails pits with layers of ridge filler and cover discolored nails with polish, but check with your doctor first. “Your safest bet is a simple at-home manicure,” said Rich. “Don’t trim cuticles or file the nail surface, as this can damage the nail and slow healing.”
If you visit a salon, make sure it’s licensed and that it has good sanitary practices, and educate your nail technician about nail psoriasis. “Make sure they understand what they need to avoid, which also includes using any kind of motorized tool on your nails,” said Rich.
Skip acrylic and gel nails and shellacs. “These treatments, especially the removal process, can damage the natural nail plate,” she said.
If you have psoriatic toenails, consider asking your dermatologist to check for nail fungus. “About a third of people with toenail psoriasis also have nail fungus,” said Rich, who notes this is more likely in those with chronic athlete’s foot or who have family members with toenail fungus.
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