The Impact of Scalp Psoriasis and Topical Treatments

Scalp Psoriasis

Psoriasis is a chronic skin condition that is thought to be caused by the body’s own immune system. Psoriasis is an inflammatory condition and appears on the skin with plaques covered in silvery scales over different parts of the body.^[1]

The term “scalp psoriasis” means that the condition is affecting the scalp, and in over 25% of people with psoriasis, scalp psoriasis is the first sign of the condition.^[2] Furthermore, 80% of psoriasis patients have scalp psoriasis.^[2] The severity and distribution can vary from mild to severe. Psoriasis can reach beyond the scalp to the face or neck and can sometimes be itchy.^[3] It is usually not associated with hair loss unless the disease becomes severe or prolonged.^[3]

Treatments for Scalp Psoriasis

Treatment for scalp psoriasis can be tricky and frustrating. It is complicated with problems of getting medications through the hair. The psoriasis treatment plans can be time-consuming, long-term, messy, and need to be cosmetically acceptable.^[4]

Generally, scalp psoriasis treatment involves the use of topical medications. These can be provided in a range of formulations that include psoriasis shampoos, lotions, gels, creams, ointments, and/or oils.^[2] Only a few of the therapies used for scalp psoriasis have been evaluated for efficacy in clinical studies.^[2] The general classes of medication to treat scalp psoriasis include keratolytics (a peeling agent that can soften and shed excess dead skin), tars, dithranol, steroids, and Vitamin D-like medications. Of these classes, only steroids and Vitamin D analogs have long-term data of efficacy. For example, treatment of scalp psoriasis with a gel containing betamethasone propionate (a steroid) plus calcipotriol (a Vitamin D analog) used once daily was found to be effective and safe.^[2]

Phases to treatment

Treatment can be divided into four phases.^[4] The first phase involves smoothening the scaly plaques using salicylic acid or urea preparations if the skin is thickened. Second is the clearing phase which can include topical corticosteroids, Vitamin D analogs, and others. The third phase is stabilization using a combination of Vitamin D analogs and topical corticosteroids. The fourth phase is the maintenance phase. Frequently, this involves the use of a Vitamin D analog alone, occasional use of a topical steroid, or psoriasis based shampoo such as a tar shampoo.^[4] The phases of treatment are frequently overlapped, and in some cases, are altered based on the availability of medications. 

In a study by Koo, the investigators used a three-phase approach detailed below:^[5]: 

The Topical Medication Formulation Matters

The formulation of topical medications varies widely and different topical formulations are better suited for use on the scalp, especially when trying to treat through hair. Here is a summary of the different common formulations and whether they are a good option for a scalp full of hair.

Scalp Psoriasis on Quality of Life

Scalp psoriasis can be frequently itchy, cosmetically embarrassing, and affect the quality of life.^[4]

• Those suffering from scalp psoriasis can feel an emotional toll because the visible lesions may affect one’s self-esteem and desire to socialize.^[3]
• Scalp psoriasis results in continual shedding onto clothes and can add to the emotional burden of social stigma and personal interactions.^[2]
• Topical therapy affects hair conditions cosmetically which can result in oily, brittle, or dry hair.^[3]
• Scalp psoriasis can be itchy, sting or even burn and can be a burden and distraction throughout the day.^[2]

In addition to the medical treatment for psoriasis, quality of life needs to be taken into account and can be addressed along with therapy. To be treated most effectively, both the physical and emotional effects should be discussed with a patient seeking treatment.