The scalp is one of the most common and persistent areas affected by psoriasis (occurring in about 50 percent of all patients) and can be one of the most difficult places to treat. The scales on the scalp can be thick and silvery-white, and can stick together tightly to form dense crusts that can be very itchy. Picking at the scales and scratching the scalp can worsen the psoriasis.
Scalp psoriasis can be localized, involving only a few discrete areas or can affect the entire scalp. The lesions often appear behind the ears and along the hairline, but can spread beyond the hairline. If the ear canal is affected and accumulates enough scales, hearing may be impaired. Hair loss is uncommon because psoriasis does not affect the hair root, but in severe cases hair loss can occur. Hair usually regrows once the psoriasis is controlled.
Mild outbreaks of scalp psoriasis that remain hidden by the hair might not be noticed by an observer; however, severe forms can be extremely itchy and highly visible. Silvery-white scales (resembling dandruff) flake onto shoulders and collar; which can be embarrassing and emotionally stressful for the patient. Successful treatment is important to minimize the emotional stresses and physical discomforts.
Grace is a forty-eight-year-old public relations specialist, with a bubbly, enthusiastic, humorous manner that is highly infectious. She is an active woman and married with two children, both of whom are in university. Approximately two years ago she came to see me with a history of having an "awful head." This problem involved significant itching, and constant scaling and shedding from her scalp that was visible on her clothing, particularly with darker color. This was making her self-conscious, and she was also finding the condition embarrassing as she would tend to scratch her itchy scalp. It was clear that the condition was causing her significant discomfort. She described a problem of thickening toenails, which she attributed to a "fungus," She had treated herself with multiple over-the-counter dandruff shampoos without any effect. There was no family history of psoriasis.
When I examined Grace's scalp, virtually the entire area was covered with a thick, white, adherent scale. It was evident that the scalp was quite inflamed and red. She had a number of areas that were open and bleeding due to scratching in an attempt to alleviate the itching. The nails of both big toes were yellow, thick, and discolored. Otherwise she was completely healthy.
After examining Grace, it was clear to me that she had scalp psoriasis. I suspected that her "fungal" nails were in fact also a manifestation of psoriasis. I took fungal cultures of her nails, which were negative, a result that supported a diagnosis of psoriasis.
I explained to Grace that while scalp psoriasis can be both challenging to treat and a recurrent problem, we should be able to get it under much better control, providing a reduction in her symptoms and her social concerns. I discussed with her the need to reduce the amount of scaling on her scalp and the inflammation or redness that was causing her such intense itching. For this, I used a topical lotion for the scalp, which combined salicylic acid with a topical steroid. By using this combination, we removed the scale, as well as reduced the inflammation and the itch. I also recommended that she use a tar-based shampoo on a regular basis. This can also help reduce the scaling and control her symptoms.
When I saw her a month later, she was delighted. For the first time, she had significant control of her symptoms, her "awful head" was now controlled with minimal scaling on her clothing, and there was no significant itch. At this point, I recommended discontinuing the topical salicylic acid-steroid lotion and using only a mild topical steroid as she still had some mild inflammation or redness in the scalp. Given that the scaling had been reduced, there was no need for the salicylic acid, which was initially helpful in enhancing the penetration of the topical steroid and reducing the scaling. If used after the scaling is gone, it can be irritating to the scalp. I now see her only occasionally as she is able to control her symptoms with a tar-based shampoo and with as-needed use of the topical steroid. To find out more, you can check out Psoriasis On Scalp.