Scalp Psoriasis: The Basics
Psoriasis in the scalp can be isolated or a part of a bigger picture of psoriasis elsewhere on the body. The characteristic features of well defined red inflamed plaques with associated scaling and even crusting or scabbing can be seen throughout the scalp or isolated to certain areas. It is best distinguished from routine dandruff because of the well defined red raised plaques that are classic of psoriasis as opposed to just flaking or dryness.
Scalp psoriasis can be all over the scalp but is classically found along the back of the scalp and involve the posterior neck, front of the scalp and extend onto the forehead, and in isolated discrete patches throughout scalp.
I break down treatment options to patients as based on a few factors: how extensive is it, is there involvement of psoriasis elsewhere on the skin, how much does it affect your day to day life.
Three big approaches:
Systemic medications (oral or injecta
Under topical therapies we have topical steroids as the most effective with or without a vitamin D analogue topical called calcipotriene and with or without a peanut oil extract to help loosen scale. Benefit here is mostly for isolated lesions to help control the flaking and itching. If there’s lots of flaking we can also add in a salicylic acid containing topical to help resolve the flaking. For those that struggle to apply these or feel like they just are not effective enough, we can supplement with intralesional injections of steroids locally in the skin to speed up resolution. I do remind people that there tends to be a strong stress correlation to flares and it’s important to know this to help control symptoms too!
Phototherapy through narrow band UV light can be used to treat scalps as well in the office with a UV comb that permits the light to get directly to the scalp or an excimer laser.
Light therapy for psoriasis has been around for decades as it has been shown to help treat psoriasis by reducing certain inflammatory cells in the skin. The benefit is that it can work well, downside is that it can require 2-3 trips a week to the office for treatment for weeks.
Lastly there are systemic medications. These are immunosuppressive or biologic medications that work by altering the immune system to control psoriasis. These medications do work well to treat and control psoriasis.
There is no real threshold as to when it makes sense to start these other than a personal decision as to when you decide to get more aggressive. Many times people choose these with more extensive disease however there is no hard and fast rule that says this is necessary to wait for. With these we need to bear in mind that we take on the side effect profile of these medications.