Uncovering Scalp Psoriasis Transcript
“Welcome to this episode of “Psoriasis Uncovered™”, a podcast series produced by the National Psoriasis Foundation, the nation’s leading organization for individuals living with psoriasis and psoriatic arthritis. Join us to hear our guest speakers uncover topics that lead to a better understanding of the disease and management, to coping and thriving with psoriasis and psoriatic arthritis.”
Corinne: My name is Corinne Rutkowski and I'm a fourth year medical student at the New York Institute of Technology, College of Osteopathic Medicine. I'll be your moderator for today's episode. I'm here with leading dermatologist and Vice Chair of the NPF Medical Board, Dr. Ronald Prussick, who is the Medical Director of Washington Dermatology Center in Rockville and Frederick, MD, where he specializes in the treatment of psoriasis along with other diseases of the skin, hair, and nails. Dr. Prussick is also a clinical associate professor in dermatology at George Washington University in Washington, DC. We're here today to discuss dandruff or psoriasis which is a topic of interest to me since I have experienced scalp psoriasis and I know that the two can sometimes be confused, but they are definitely different. Welcome Dr. Prussick. It's a pleasure having you on Psoriasis Uncovered. Let's start with a discussion about dandruff. What is dandruff and what are the key characteristics?
Dr. Prussick: Well, thanks for inviting me today and I'm happy to discuss these topics. We'll start with dandruff and basically dandruff a lot of people have it. It's very common and patients notice that they have white scale that is on their scalp, on their hair, and can go on their clothes when they move their head. And what dandruff is, is basically the top of the skin cells, the epidermal cells, kind of peel off too quickly. So the skin moves too quickly and you get extra skin cells. And this can be caused from dry skin. So patients who have dry skin, especially in the winter, their dry skin can be on the scalp as well. It can also be caused from a normal skin yeast called malassezia, which some patients can grow too much of it, or they can have an immune reaction to it and that can cause their dandruff.
Corinne: Interesting. You did mention dandruff being characterized by these white flakes on the scalp. What are some of the treatments that can effectively treat dandruff? And are those treatments primarily over-the-counter? Would patients have to be seen by a dermatologist for a prescription?
Dr. Prussick: I think most patients actually go to the over-the-counter and try those first. So most people go for the dandruff shampoos and those have active ingredients such as things like zinc pyrithione, ketoconazole, selenium sulfide, coal tar, or salicylic acid. They'll try those over-the-counter products and if they don't feel that they're getting improvement, they'll see a dermatologist. If they tend to have just dry skin, it's probably a good idea to try a very gentle cleanser that doesn't have any strong ingredients like propylene glycol.
Corinne: Thank you for those helpful tips. Those are definitely some ingredients that patients with dandruff should be on the lookout for. Another disease that sometimes can be confused with dandruff and psoriasis is seborrheic dermatitis. What is seborrheic dermatitis and what are the characteristics of the disease?
Dr. Prussick: Sure. Well, seborrheic dermatitis is really just an extension of dandruff and one of the causes of dandruff. So the difference is that in seborrheic dermatitis there's inflammation along with the dandruff and so patients can experience some itching. The other thing about seborrheic dermatitis is it may not only be on the scalp, it can be on the eyebrows, the nasal labial folds, the ears, the chest, the upper back, in the folds of the armpits, or in the groin. So seborrheic dermatitis is an inflammatory skin disease and the scale’s a little different from dandruff in that it tends to be a yellower, more greasy scale. And that's what seborrheic dermatitis is.
Corinne: And what treatments are used to treat seborrheic dermatitis?
Dr. Prussick: Well, we tend to use the same over-the-counter dandruff shampoos. In a lot of cases
that's what patients will start with. If they're not better, they'll come in and we give them prescription shampoos or we can give them prescription topicals to apply such as a mild topical steroid or one of the new products that's available is called roflumilast foam, which is used once a day on the scalp. And these two need to be applied after someone shampoos. So they shampoo with the medicated shampoo. They have to make sure that the shampoo actually touches the skin of the scalp or it won't work. If you just put it in your hair like a regular shampoo it's not effective. So it actually has to touch the skin of the scalp for about two to five minutes, wash it out, and then when you come out of the shower, dry your hair, then use the prescription product that the dermatologist will give you. We also use other products if its on the face, or the ears, or the folds, we would use a mild topical steroid or we have some other prescription products that we can use for seborrheic dermatitis that are safe for the face. The thing that's important is that some topical steroids are too strong for the face or the folds and can damage the skin and thin the skin. So we have to make sure that we use a very mild topical steroid and you're not using it every day permanently. If not, the dermatologist will change your product that they prescribe that is a non-topical steroid. So they're anti-inflammatory eczema creams that we tend to use that don't have a steroid in them and they can be used once or twice a day. There was an interesting survey that was done from patients who have seborrheic dermatitis. And they said that it can take up to 34 minutes a day just to apply all these different creams twice a day. So it can be quite time consuming if they have it in multiple places and definitely can affect their quality of life.
Corinne: Wow, that's really interesting. Thank you for that information Dr. Prussick. Given what you just said, it may be easy for some people to mistake dandruff or seborrheic dermatitis for what really is psoriasis. I know that before I formally got my diagnosis of psoriasis, I was dealing with a lot of scalp itchiness and the white flakes like you mentioned. And I had just thought I had dandruff. I tried a lot of the over-the-counter shampoos you mentioned and I noticed that I actually wasn't getting better. So when I went and got my diagnosis, I was surprised. How is scalp psoriasis different from dandruff or seborrheic dermatitis? And what are some of the key characteristics?
Dr. Prussick: I think your story is quite common and I have seen patients that come in with scalp psoriasis and they were diagnosed as having eczema in a lot of cases. And you know they can be difficult to distinguish eczema from psoriasis. The main difference is that psoriasis has very well demarcated plaques even on the scalp. So where we see the inflammation and the scale it's very obvious, and then there's normal skin around it. Whereas in eczema it's the redness and scaly is sort of more diffuse and not well demarcated. And that's how, as clinicians, we can differentiate dermatitis from scalp psoriasis. The other thing about scalp psoriasis it tends to occur in a band behind the ears and going in the back of the scalp, where the hair is the most dense and coming around. So the distribution is often a little bit different than we see with eczema as well. And the scale is different too. So the scale in psoriasis is more of a silvery white, thicker scale, whereas in seborrheic dermatitis and eczema it's a lighter, thinner scale. So that's how we clinically can differentiate them. The other thing we do is we'll look at areas like the ears and the eyebrows, the elbows and the knees, and see if there's any psoriasis anywhere else on the body to help confirm our diagnosis. We'll check the nails for nail pits. And any areas where there could be psoriasis somewhere else to help us with the diagnosis if it's not easy by just looking at the scalp.
Corinne: That's interesting that you mentioned the distinct demarcation of the plaques, because I remember, sometimes I would go to feel my scalp and I would actually feel a raised portion of my scalp and sometimes I would think what is that? Do I have a rash on my scalp? And then when I got diagnosed with psoriasis, I pointed out those specific raised areas to the dermatologist and he was like, yeah, that's a psoriatic plaque on your scalp. So scalp psoriasis affects over 50% of people who have psoriasis and is considered a high impact site due to the effect on quality of life. It is also a risk factor for psoriatic arthritis. Given that scalp psoriasis is classified as this high impact site, how does this impact selection of treatment?
Dr. Prussick: Well, let me just start by telling you a little bit of story of how we got to this high impact sites. So what was done is it was called the MAP survey in 2014 and then another one followed up called The Uplift Survey in 2020. And basically what happened was phone calls were made to patients and patients with psoriasis would tell us about what kind of treatments they're doing, how severe their psoriasis was, and whether they thought their psoriasis was severe or not. One of the things they found in the Uplift Survey was that 65% of patients or so said that they had a very low BSA, so less than 3 palms of psoriasis on their body, but 57% of them said that they had severe psoriasis even though their body surface area was so low. And what we found when we asked these patients about their disease, we found that they often had a high impact area and that's where we got the name “high impact area” because even though patients may have just a little bit of psoriasis, it impacts them so greatly, affecting their quality of life. So we call it a high impact area. So the scalp is a high impact area. So is the face. So is the genitals. So are the folds. So are the nails. So are the palms and soles. So even though they may not be a lot of psoriasis in those areas, it really affects patients’ quality of life and that's why they're called high impact areas. What's special about the scalp is there's a couple of things. Number one is it's much more itchy than other areas of the psoriasis for most patients. And the itching is really bothersome for patients because of course it's distracting and annoying to be itchy all the time. And when you scratch your psoriasis, you actually make it worse. It's called Koebnerization. So that's what makes scalp psoriasis a little bit harder to treat, because if patients keep scratching it, it can't heal, then it can't get better. I tell my patients that psoriasis, like an abnormal response to injury. So when you injure the skin, immune cells from the blood go in there to heal the injury. But then when you have psoriasis, the immune cells stay there and won't go back into the blood. And of course, if you're scratching it, you're going to keep the immune cells there, and that's why we can't get rid of it. So the itching is a problem and also access to the scalp. Because of the hair of course it's very difficult to apply topicals to that area. Patients find it difficult to use. They have trouble because they find that they could make their hair greasy or sticky, or they can make their hair break if they have fragile hair. So these are all the reasons why scalp psoriasis is a high impact area.
Corinne: That's very interesting. I definitely am sometimes a little self-conscious of when I'm itching my scalp in public. If people see me and they think ”oh, what is this girl doing? Why is her scalp so itchy?” Also, sometimes I do try to keep myself from itching at my scalp, but it definitely is difficult. Based on current evidence in clinical trials, what is the most effective treatment option for treating scalp psoriasis?
Dr. Prussick: Luckily we have a lot of effective treatments for scalp psoriasis now. And much of the studies that were done, for example on the biologics and systemic agents we’re looking at the big trials that got the approvals and then they went back and they looked at patients who had scalp disease and then they looked to see how much of their scalp cleared over 16 weeks or 24 weeks or a year. We don't have a lot of head to head trials comparing one treatment for scalp psoriasis to another. But we do know that the medicines that are used to treat psoriasis on the body are very effective for the scalp as well. So generally, what doctors often start with are topical treatments such as topical steroids. We also have a new product that was approved, this roflumilast foam, which is phosphodiesterase inhibitor and it's a once a day and it works quite well. The trial showed that patients got clear, almost clear after eight weeks, 77% of the time. So it worked very well for a once a day topical. Patients often like foams because they're very water based. They're easy to get into a hairy area and that's a big bonus as well. And ah we do use other treatments. So some patients come in and do excimer laser. Excimer laser is a light. So it's a narrow band UVB light, but it's admitted through a laser. And the advantage of the laser, it's high power and you can do exactly the plaques. So you don't have to treat the normal skin around it. You have to come in two or three times a week to your doctor and get that done and that's another treatment that we use for scalp psoriasis if the topicals don't work. There's systemic agents called apremilast and deucravactinib. Those are oral pills for psoriasis, and they do work for the scalp as well. And the biologics that we use for psoriasis, the ones the dermatologists use the most now inhibit interleukin 17 and 23. Those are also effective for scalp psoriasis. So really your dermatologist has to evaluate your whole history. What other lesions you have on your body? How well you're tolerating topicals and if you fail topicals then they'll consider giving you an oral or systemic treatment. Based upon that data we talked about with the high impact area we used to consider biologics and systemics only for patients who had BSA’s or body surface areas more than 10 palms. But that's been changed and there was a publication in 2020 in the Journal of the American Academy of Dermatology that said that patients who are candidates for systemic treatments are patients that have, yes, BSA more than 10% or high impact areas or failure of topicals. So if patients fail some topical treatments, their dermatologist will consider a systemic or a biologic.
Corinne: So, given the discussion about high impact sites and the extent to which they affect quality of life, should people with scalp psoriasis continue to use over-the-counter products in conjunction with their prescription treatments?
Dr. Prussick: Well, many of the patients try over-the-counter and by the time they come to our office, since it's not working, we try something else. But if patients who are listening feel that their over-the-counter product is working well for them, it keeps their disease under control, there's no harm in continuing to use this. One of the tricks I tell my patients is it's good to try two different over-the-counter products that work by a different mechanism. For example, get a shampoo that has salicylic acid to remove the scale and then use an anti-yeast product like zinc pyrithione or a ketoconazole so you alternate one with the other and that sort of works better than just using the same one all the time. So as long as your skin and hair can tolerate it, for example, some products like coal tar can dry out the scalp or dry out the hair and cause breakage, and some people even find ketoconazole shampoo can break their hair and cause some breakage, so they would stop the products. It dries out their scalp too much, especially if they're prone to curly hair or hair breakage because they use hair straighteners or hair dyes and things like that. So it really depends on the patient.
Corinne: Thank you Dr Prussick for those tips and the recommendations of those effective ingredients in some of those over-the-counter products. A reminder for our listeners as you shop for over-the-counter products look for the National Psoriasis Foundation's Seal on the product label. The NPF Seal of Recognition highlights and recognizes over-the-counter products that have been created or intended to be non-irritating and safe for those living with psoriatic disease as well as for those with sensitive skin or joint mobility limitations. For a list of products visit psoriasis.org/seal-of-recognition. Dr. Prussick, hair makes it more challenging to apply treatment to the scalp like you mentioned. Do you have any tips for applying treatment that could make it easier?
Dr. Prussick: I think one of the important things is when your doctor is prescribing something topical to put on your scalp and leave it on after you shampoo, find out what the base is. So as an example, we can give a foam. We can give a lotion. We can give a cream. We can give an ointment which is very Vaseline based and sticky. The reason why I'm saying that is because I've seen patients come in and say “my dermatologist that I saw before gave me this ointment and it was too sticky. I couldn't put in my scalp, so I never used it”. Or they said that ‘they gave me a solution that had a lot of alcohol and it broke my hair”. So I think it's good to know ahead of time what your doctor is giving you and they can explain to you the different bases that these medicines come in and you could choose the one that you will use because if they give you a prescription and you won’t use it, of course you're not going to get better. So I think that's really important. It's also important to make sure, like I said, that when you use the shampoos it stays on for three to five minutes, wash it off, then when you dry your hair and scalp, when you come out of the shower, that's the best time to apply the topical right after the shower because there's still a little bit of moisture in your scalp/skin and it'll help absorb it better. You can use a comb and part your hair to put it in.
That sometimes is helpful and like I said, a lot of patients with hair on the scalp prefer the foam basis because it's a little easier to get in. It's a little watery. It's like mousse. They just find it a little bit easier to use. So it really depends on the patient. For example, I have African American patients that prefer an ointment because their scalp and hair is so dry that they can't tolerate other things because it breaks their hair more and they may not want to shampoo as often because of this problem with dry scalp and breaking of their hair. So they may tell me they want only shampoo once a week or once every other week, so I have to adjust my treatment based upon what patients can do and can't do. So it's good to make sure you talk with your doctor. Tell them how often you want a shampoo and what product do you think would work best for you because there's no point buying something and seeing, “Oh my gosh, I don't want to use this. It's not good for my scalp. I don't like it on my scalp. I don't want to use it.” So I think just keep in mind that those are all important things. The other thing that's really important that a lot of patients didn't know when I talk to them is when they have a lot of scale on their scalp, they think they're helping themselves by getting a very hard brush and trying to scrape all that scale out of their scalp and the reason why that's a bad thing to do is because that scraping is giving the Koebnerization effect to make the psoriasis worse. So instead of making it better, you're actually triggering your psoriasis to get more inflamed. This gets more scaley and it actually makes the plaques thicker and spreads them. So use a very soft brush. That's my biggest tip today. Use a very soft brush and be very gentle with your scalp. It's very inflamed and scraping it and being rough with it is a bad thing for your scalp psoriasis.
Corinne: Thank you for those insights. It's great to know that there are so many options available for patients depending on what suits their hair best.
Dr. Prussick: Do you have any tricks that you've learned that helped you that the people listening might benefit from? Were there any tricks or topicals that have helped you that you might recommend?
Corinne: Sure. So for my scalp psoriasis, a little background. I was diagnosed when I was 19. This was about a year into my undergraduate studies and being a student on the pre-medical track, I did have a lot of stress with my exams and classes and things like that. And I had noticed that my psoriasis on my scalp would kind of flare during finals week or anytime throughout my studies where I'm particularly stressed out. So a lot of the times when I know that I'm gonna be stressed out and I know that my tendencies to itch and scratch and pick at my scalp were about to happen, I would kind of be very cognizant with myself and be very aware of my actions and try to repress the urge to itch and scratch and things like that. I thankfully have been able to keep it at bay for the most part. I just use topical clobetasol 2 times a day for two weeks and then I put it to the side. That normally sometimes will help take care of the psoriasis flare. And yeah, my biggest tip to patients is just try to be aware because I found that sometimes I was picking at my scalp without even realizing I was doing it. So I think being aware and knowing that itching can make it worse. That kind of kept me from picking and scratching as much.
Dr. Prussick: That sounds good. Do you use this clobetasol solution or foam?
Corinne: Yeah, I use the solution that comes in the little dropper. It's very easy to apply. I do have particularly long, thick hair. So something that I've found helpful is taking a comb and parting my hair like you mentioned Dr. Prussick, parting the hair so that I can actually see the scalp and placing the drops directly onto the scalp.
Dr. Prussick: Great, thanks for your tips.
Corinne: Dr Prussick, when it comes to scalp psoriasis, alopecia or loss of hair can sometimes be a concern for patients. How do you address hair loss with your patients that deal with scalp psoriasis?
Dr. Prussick: Sure. Well, hair loss is fortunately not that common in psoriasis patients. The majority don't get that, and there's different types of hair loss, and we can do a whole podcast just on different types of hair loss. But just to simplify things, dermatologists kind of have to look at the scalp and see is the hair loss a scarring hair loss or a non-scarring hair loss. So what we mean by scarring is that the hair follicles were destroyed and a scar is there and hair can't grow back versus non-scarring where the hair comes out because of inflammation or scratching, but the follicles are still healthy and they can grow back hair. So that's the main thing that we're looking at when we're examining your scalp when you have hair loss. So the most common cause of hair loss in psoriasis, just from the inflammation and the scratching, the hair comes out but it's non-scarring. So if we can get you to stop scratching, and if we can get the inflammation to calm down, the hair should grow back. And so those are the most important things you need to know about that.
Corinne: I see. Are there any new innovations in the pipeline for scalp psoriasis such as excimer laser, topical methotrexate?
Dr. Prussick: Yes, there have been some. Well, we talked a little bit about the excimer laser and that's been available for a while. What they've developed that’s something new is called an excimer lamp. And so instead of a laser focusing just on the spots, a lamp is something that patients can do at home. And the advantage is it’s home use. The disadvantages is is not as powerful and with the laser you can actually just touch the scalp psoriasis, whereas with a lamp the whole area gets treated whether you have psoriasis or not. So there's been some studies with that. Methotrexate is an oral pill that was used for many years to treat psoriasis and unfortunately it caused cumulative liver toxicity and ah it doesn't work really as well as these new breakthroughs that we've had over the last 10 to 15 years. So it's, it's now in a hydro gel topical. So you don't get any of the side effects and it's been studied to see whether once a day use will improve psoriasis and there's been some preliminary studies that show that it is actually effective. There's also a new pill for psoriasis that is being studied and it blocks the interleukin 23 receptor. And what they found is that 66% of patients with scalp psoriasis achieved a clear or almost clear at 16 weeks with this pill that's not yet available, but it looks like this is going to be a really helpful medicine once it's available for our psoriasis patients.
Corinne: These new innovations sound great Dr. Prussick and I really think that they have the potential to help patients. As a medical student interested in going into the field of dermatology and a patient myself suffering from scalp psoriasis, it has been a pleasure discussing this topic with you today. I definitely am very excited for the future of these new innovations and treatment options for patients for their scalp psoriasis. Do you have any final comments you would like to share with our listeners today?
Dr. Prussick: I just want to thank you for inviting me and just you can go to npf.org. On that website, we've written a lot of articles about psoriasis. One of the things I'm passionate about is how diet and lifestyle effects psoriasis. So I've done podcasts and written some articles on that, and there's other things you can read about that might interest you. Just be aware that people with psoriasis, one third can eventually develop psoriatic arthritis. So be aware of the signs and symptoms of that so you can let your dermatologist know if you're feeling those symptoms coming up. And I think that's important as well because you want to catch that as early as possible. And I think that the most important thing I wanted to let you know about scalp psoriasis is to make sure that you don't Koebnerize it by rubbing and scratching and try to use a soft brush and I think that'll go a long way to helping you as well.
Corinne: Thank you Dr Prussick for being here today and helping us define scalp psoriasis versus dandruff and seborrheic dermatitis. You had great insights and tips, and I'm sure the listeners at home will appreciate this greatly. Knowing the difference helps to identify what the issue is and when to seek help from a dermatologist such as yourself.
Dr. Prussick: Thank you.
Corinne: For our listeners, please share this episode link with anyone you know who is in need of information about scalp psoriasis and how to treat it. For more information about scalp psoriasis, contact our Patient Navigation Center at education@psoriasis org. And finally, NPF’s work is fueled by our community. If you enjoyed this episode and want to support more great content, please visit psoriasis.org/givepodcast to donate. Thank you for listening to Psoriasis Uncovered where we uncover what you need to know about psoriasis and psoriatic arthritis.
We hope you enjoyed this episode of Psoriasis Uncovered for people living with psoriasis and psoriatic arthritis. If you or someone you love has ever struggled with psoriatic disease, our hope is that through our podcast you’ll gain information that inspires you to lead a healthy life and look to the future. Please share the episode link if the content in today’s episode will benefit someone you know.
You can find this or all future episodes of Psoriasis Uncovered on Apple Podcasts, Spotify, Amazon Music, Gaana, Pandora, iheart radio, and the National Psoriasis Foundation web page. To learn more about this topic or others please visit psoriasis.org or contact us with your questions or comments by email at podcast@psoriasis.org.
This transcript has been created by a computer and edited by an NPF Volunteer.
Return to the Episode Page
Go to episodeKeep Listening
We have tons of great content in our Watch and Listen section. Check out our latest episodes now.
Questions about psoriatic disease?
Our Patient Navigators are here to help. Connect with our Patient Navigation Center for free resources and answers to your questions.