How to treat and manage scalp psoriasis

| Emily Delzell

For those living with scalp psoriasis, hair care can be a pain — sometimes literally, as when chemicals used for coloring or other salon services touch open lesions under the hair. Yet, many treatment options can limit or end the snowfalls of flakes, the lingering medicated scent of shampoos and other treatments, and the itching-scratching-picking-bleeding cycle that scalp psoriasis may bring.

The first step toward good-hair days and flake-free shoulders is to get appropriate treatment, says Sylvia Hsu, M.D., professor and chair of the Department of Dermatology at the Temple University Lewis Katz School of Medicine in Philadelphia.

The range of available topicals has expanded greatly, although in most cases, the ingredients aren’t new. (Typically, topicals contain a potent steroid, though synthetic forms of vitamin D, retinoids and salicylic acid are also used.) Instead, the “vehicles,” or formats in which the active ingredients are delivered, are more user-friendly, says Hsu. Rather than lotions alone, people can now choose, for instance, a spray, oil or foam.

More good news: Scalp psoriasis doesn’t have to mean ruling out salon services. “In general, blow-drying and other types of mechanical hairstyling are safe for people with scalp psoriasis, as are processes, like coloring, that bring chemicals in contact with psoriatic lesions — as long as people don’t have sensitivities to the ingredients, which can happen with or without psoriasis,” Hsu says.

At the salon

While a trip to the salon likely won’t exacerbate scalp psoriasis, visible symptoms can wreck your confidence. To ease embarrassment or anxiety, communicate openly with your stylist before and during the appointment. If you’re looking for a new hairdresser, call salons and ask if they have someone on staff who is familiar with scalp psoriasis. Most experienced stylists are educated about the disease. If yours isn’t, use the consultation time to explain what psoriasis is not — a contagious disease or fungal infection. Then go over your individual scalp and hair issues, and discuss any known sensitivities to styling products.

And keep in mind that chemicals used in coloring, perming, or straightening services can irritate anyone, with or without scalp psoriasis, who has a sensitivity to the ingredients, says Kristina Callis Duffin, M.D., associate professor of dermatology at the University of Utah in Salt Lake City, and a member of NPF’s medical board. “It’s hard to predict which products will cause a reaction in an individual because there are so many different products, and they all have different formulations,” she says.

Talk with your stylist about the potential for irritation with specific treatments and services before going forward. If you still have questions or concerns, check with your dermatologist. “If something burns during the process, or causes irritation later, ask your stylist to try a different product,” Duffin says. “Hair dyes marketed as organic or natural may be less irritating for some individuals, although it’s important to remember that people can be sensitive to anything, whether it’s ‘natural’ or not.”

Chemicals can also cause stinging pain if your scalp psoriasis includes open, bleeding areas from scratching or picking, Hsu says. “Applying chemicals or products with alcohol to any open wound is going to sting, though it’s not otherwise dangerous and won’t generally worsen psoriatic scalp issues,” she adds.

Picking and scratching at scalp psoriasis will, however, make it worse, in a trauma-triggered process known as the Koebner effect. “Scratching and picking doesn’t spread psoriasis in a contagious process, but rather, traumatizing the skin [even with small injuries doctors sometimes call microtraumas] triggers the inflammatory process that underlies psoriatic disease,” Hsu says.

“Gentle” should be the watchword in the care of scalp psoriasis. Use caution while grooming your hair, and remind your stylist to do so, as well. Avoid burns from hot irons and trauma from firm brushes and combs, which should not rub against the scalp.

Clearing scalp psoriasis

Scalp psoriasis, along with psoriasis of the nails, genitals, palms of the hands or soles of the feet, can greatly affect your life, which is why appropriate treatment is critical.

“Scalp psoriasis impacts quality of life, including appearance where plaques are visible,” says Kiran Motaparthi, M.D., assistant professor of dermatology at the University of Florida College of Medicine in Gainesville. “Patients may feel self-conscious or distressed about scale, redness, visibility to others and even hair loss.”

Severe or undertreated scalp psoriasis can cause hair loss, which is most often temporary.

“Typically, hair loss due to psoriasis, called psoriatic alopecia, is chronic, patchy, occurs within pre-existing plaques of psoriasis and does not result in scarring or permanent hair loss,” Motaparthi says. “However, while psoriatic alopecia responds well to topical and systemic therapies, it may occasionally result in scarring or permanent hair loss if the underlying psoriasis is not adequately treated. Additionally, in some patients, psoriatic alopecia is the initial manifestation of psoriasis. Thus, patients who think their hair loss is due to psoriasis should seek prompt treatment from a dermatologist.”

Topicals work well for many people with scalp psoriasis. But they don’t always work effectively enough to give everyone the significant clearing of lesions, which should be the goal, Hsu says.

“Scalp psoriasis can affect your ability to function in your daily life,” she says. “For that reason, I am aggressive in treating it. If you aren’t being helped by the most potent topical steroid, for example, I usually move to a biologic or other systemic medication.”

Hsu says she considers treating stubborn moderate-to-severe scalp psoriasis with systemic medications even when someone’s psoriasis is mild elsewhere on the body.

“Some dermatologists stick closely to the 10 percent rule,” she says, noting many insurance companies require at least 10 percent of a person’s body surface area be affected by psoriasis before covering a biologic.

“In some cases, however, dermatologists can work with the insurance companies to prove there is a need and get the drug covered,” Hsu says. “If patients are still suffering from scalp psoriasis symptoms despite getting treatment with topicals, they should ask their dermatologist about the possibility of moving to biologics or another systemic medication.”

Motaparthi agrees. “If satisfactory improvement is not achieved within several weeks to a few months, then systemic medications should be considered,” he says. “Many effective systemic therapeutic options are available for psoriasis, including scalp psoriasis.”

Finding a physician with specialized training in psoriasis — and one who is up-to-date with the current range of available therapies — is key to successful treatment, Hsu adds.

Scalp care dos...

Use medicated scalp treatments a day or two before salon visits to maximize scale-removing properties. After you’ve applied your treatment or shampoo as directed, work a pleasant smelling conditioner into your hair, avoiding the scalp. Rinse. The leaves hair soft, minus the medicated odor.

Protect your scalp if you have sensitivities to chemicals. Apply a barrier, such as Vaseline, on affected areas of the ears, neck and temples before your hairdresser applies chemicals. This can spare sensitive skin.

Consider highlights if you’ve had sensitivity to all-over hair color. Highlights may help avoid irritation as the stylist applies color just above the scalp and wraps the treated hair in foil.

Safeguard your style. Check with your hairdresser about potential interactions among the ingredients in your own products and the salon treatment. Coal tar, for instance, can discolor bleached or tinted hair.

Ask your dermatologist about different vehicles for topical treatments. For example, foams dry quickly, leaving little residue or odor.

... and scalp care don’ts

Pick at scales, or comb or brush hair roughly. Even minor trauma can exacerbate scalp psoriasis.

Assume all of your scalp problems are psoriasis. Many hair products contain ingredients that commonly result in allergic reactions, and sensitivities can develop at any time.

Be embarrassed about scalp psoriasis. Instead, educate your stylist about psoriasis and explain your unique issues and sensitivities. If he or she isn’t sympathetic, find a professional who is.

Treat your psoriasis seriously

World Psoriasis Day is Monday, Oct. 29. This year, as we stand together across the globe, we're asking you to treat your psoriasis seriously. How does your disease affect your health? Begin by taking this simple assessment. Psoriasis should not affect your ability to function in life. We can help.


Driving discovery, creating community

For more than 50 years, we’ve been driving efforts to cure psoriatic disease and improve the lives of those affected. But there’s still plenty to do! Learn how you can help our advocacy team shape the laws and policies that affect people with psoriasis and psoriatic arthritis – in your state and across the country. Help us raise funds to support research by joining Team NPF, where you can walk, run, cycle, play bingo or create your own fundraising event. If you or someone you love needs free, personalized support for living a healthier life with psoriatic disease, contact our Patient Navigation Center. And keep the National Psoriasis Foundation going strong by making a donation today. Together, we will find a cure.

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