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Connect. Control. Cure.
scalp psoriasis
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What is psoriasis?
Psoriasis is a noncontagious, genetic disease of the
immune system affecting the skin and/or the joints.
According to the National Institutes of Health, as
many as 7.5 million Americans have psoriasis. The
most common form, plaque psoriasis, results in raised,
red lesions covered by silvery white scale. Psoriasis can
be limited to a few lesions or can involve moderate to
large areas of skin.
Having 3 to 10 percent of the
body affected by psoriasis is
generally considered a moderate
case. More than 10 percent is
considered severe. (For most
individuals, the palm of the
hand is about the same as 1
percent of the skin surface.)
However, the severity of psoriasis
can also be measured by how
psoriasis affects a person’s quality
of life. Psoriasis can have a
serious impact even if it involves
a small area, such as the palms
of the hands or soles of the feet.
From 10 to 30 percent of individuals with psoriasis
also develop psoriatic arthritis, which causes pain,
stiffness and swelling in and around the joints. To
learn more about the types of psoriasis or psoriatic
arthritis, visit the National Psoriasis Foundation Web
site at www.psoriasis.org.
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calp psoriasis is very common. In fact, at least
half of all people who have psoriasis have it on
their scalp. As with psoriasis elsewhere on the body,
skin cells grow too quickly on the scalp and cause red
lesions covered with scale.
Scalp psoriasis can be very mild, with slight, fine
scaling. It can also be very severe with thick, crusted
plaques covering the entire scalp. Psoriasis can extend
beyond the hairline onto the forehead, the back of the
neck and around the ears. Most of the time, people
with scalp psoriasis have psoriasis on other parts of
their body as well. For some, the scalp is the only
affected area.
Other skin disorders, such as seborrheic dermatitis,
may look similar to psoriasis. However, there are
differences. Scalp psoriasis scales appear powdery with
a silvery sheen, while seborrheic dermatitis scales often
appear yellowish and greasy. Despite these differences,
the two conditions can be easily confused.
How is scalp psoriasis treated?
Many treatment options can help control scalp
psoriasis and its symptoms. Sometimes scalp psoriasis
will clear on its own, or it can remain on the scalp for
long periods.
It is important to select scalp treatments that are
agreeable to you. Treatments should never be worse
than the psoriasis itself. Consider your lifestyle,
available time and the cost to help you decide among
the options.
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Tar products and salicylic acid are generally sufficient
for treating very mild scalp psoriasis. More severe scalp
psoriasis may require persistence and experimentation
to find an effective treatment plan. Treatments
include topical medications (applied to the skin)
and, occasionally, ultraviolet (UV) light. Treatments
are often combined and rotated because a person’s
psoriasis may become less responsive to medications
after repeated use. Systemic (oral or injected) psoriasis
treatments are not commonly used just for scalp
psoriasis. They may be tried if psoriasis is present
elsewhere on the body and/or the psoriasis is
moderate to severe.
Treatment schedules
Scalp treatments must be repeated until you get
adequate control of your lesions. This can take up to
eight weeks or longer.
Once you achieve an acceptable level of clearing, you
may be able to keep psoriasis from coming back by
using a tar shampoo or other medicated shampoo daily
or twice a week. Moisturizing the scalp may also help.
OVER-THE-COUNTER PRODUCTS
Salicylic acid
Salicylic acid is approved by the Food and Drug
Administration (FDA) to treat psoriasis. It softens
scale and makes it easier to remove. It can be used in
combination with tar or other products. Its popular
nickname is “sal acid,” and you will find it both in
over-the-counter (OTC) and prescription products,
mostly in over-the-counter shampoos and soaps.
Treatments with high concentrations of salicylic acid
can cause irritation. The body may absorb salicylic
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acid if used over large areas of the skin. Salicylic acid
may also weaken hair shafts and make them more
likely to break, causing temporary hair loss. This is
not permanent; hair should return to normal after
stopping treatment.
Tar
Tar products, usually available without a prescription,
are widely used to treat scalp psoriasis. You will be
able to find over-the-counter tar shampoos, creams,
gels, oils, ointments and soaps. Your doctor also can
prescribe tar in a variety of strengths. It may be used
as a sole treatment or in combination with other
treatments.
While tar is an effective medication, it can stain
bedding and gray or white hair, and has a strong odor.
There are two kinds of tars: coal tar and wood
tar. Coal tar is approved by the Food and Drug
Administration (FDA) to treat psoriasis. It is the more
common form for treating psoriasis, but some wood
tar products are used to treat scalp psoriasis.
Coal tar is available in OTC products in
concentrations from 1% to 5%, although higher
concentrations are sometimes prescribed. Refined coal
tars, such as liquor carbonis detergens (LCD), have less
of an odor and may cause less staining. Unfortunately,
refined tars are not as effective and may be harder to
find.
California requires OTC coal tar products that contain
more than 0.5% coal tar to be labeled with cancer
warnings. However, the FDA maintains that OTC
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products with coal tar concentrations between 0.5%
and 5% are safe and effective for psoriasis and that no
scientific evidence suggests that the coal tar in OTC
products is carcinogenic.
To allow for maximum absorption of the tar, massage
tar shampoo into the scalp and leave it on for about
five minutes before rinsing it off. Using a nonmedicated conditioner after shampooing with tar
products can reduce the smell of the tar shampoo.
Avoid using a non-medicated shampoo after treatment
as this may remove tar from the scalp.
Tar gels, creams, solutions, and lotions can be
massaged into the scalp and left on overnight. These
tar products are used for psoriasis on other parts of the
body as well.
Effectiveness will vary for each person. Tests have
shown tar shampoos to be superior to shampoos
without tar in treating scaling.
Medicated shampoos
Many coal tar and non-coal tar medicated shampoos
for treating scalp lesions are on the market. Leave
shampoos on the scalp as directed and rinse them out
thoroughly.
Remember, medicated shampoos are designed for
the scalp, not the hair. You may want to use a regular
cosmetic conditioner after your scalp treatment to
reduce the smell of the medicated shampoo and make
your hair more manageable.
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PRESCRIPTION PRODUCTS
Anthralin
Anthralin is an older prescription medication that may
work for some people with scalp psoriasis. The typical
use of anthralin for scalp treatment is 30 minutes with
a concentration of either 0.25% or 0.5% anthralin.
This medicine can be left on the scalp for as little as 10
minutes and then washed off. With a treatment called
Short Contact Anthralin Therapy, or SCAT, higher
concentrations are applied for shorter periods.
Anthralin can stain the skin and cause skin irritation
in some people. Remove anthralin from the scalp by
rubbing the shampoo toward the back of the head to
avoid getting anthralin on your forehead or in your
eyes.
Psoriatec is the brand name of a 1% anthralin cream
that may limit staining because the medication is
released from tiny capsules only at skin temperature.
Rinse Psoriatec from the scalp, clothing, towels or
bathroom fixtures with cool or lukewarm water to
prevent these capsules from breaking down; this may
prevent the staining and irritation usually associated
with anthralin.
Antimicrobial therapy
Scalp psoriasis can get worse if the scalp becomes
infected with bacteria or yeast. If crusting of the scalp
along with scaling occurs and/or the lymph nodes in
your neck are enlarged, your doctor may prescribe
antimicrobial treatment.
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Calcipotriene
Calcipotriene (also known by its brand name
Dovonex) is a prescription topical vitamin D3
derivative that comes in solution form. After applying
Dovonex at night, cover the scalp with a shower cap
or plastic bag before going to bed. Confine Dovonex
to the scalp because it may irritate unaffected skin,
particularly the face. You may wish to test a small area
before applying it to the entire scalp. Avoid contact
with your eyes.
cyclosporine and biologic medications. They may
help clear scalp psoriasis, and are only appropriate for
moderate to severe cases.
Systemic psoriasis medications have side effects that
must be weighed in relationship to their benefits.
Mild hair loss can be a side effect of oral retinoids.
Ordinarily, the hair will grow back when the
medication is stopped.
Tazarotene
Calcipotriene and betamethasone dipropionate
Calcipotriene and betamethasone diproprionate
(also known by its brand name Taclonex Scalp) is the
combination of the vitamin D3 derivative calcipotriene
and the potent steroid betamethasone dipropionate. It
is applied once daily for two weeks or until clearing is
achieved. It shouldn’t be used longer than eight weeks.
Avoid contact with your eyes.
Intralesional steroid scalp injections
Sometimes doctors inject scalp lesions with steroid
medications. This is done only when the scalp psoriasis
is mild and involves a few areas. It would not be
appropriate to inject many plaques. Steroid injections
are given sparingly because the medication can be
absorbed into the system.
Systemic treatments for psoriasis
If moderate to severe psoriasis is present on other
skin sites in addition to the scalp, your doctor may
prescribe systemic psoriasis medications (medications
that are taken by mouth or by injection). The most
common include methotrexate, oral retinoids,
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Tazarotene (also known by its brand name Tazorac) is
a topical vitamin A derivative that comes in a cream or
gel form for the treatment of psoriasis. The gel absorbs
more rapidly than the cream, while the cream may
be less irritating for people with dry or sensitive skin.
Tazarotene may be more effective if used in addition to
a topical corticosteroid.
Apply tazarotene in a thin film to lesions on the scalp
or hairline. The medication may dry out the skin. To
reduce irritation, apply moisturizers 30 minutes before
tazarotene is used. However, the skin should be dry
when treated. Tazarotene is safe to use on your face,
but it should not be applied around the eyes. Do not
cover treated skin.
Overnight application of tazarotene is recommended.
Let the medication air dry on the scalp before going to
bed, so you don’t spread it on your pillow and face as
you sleep.
Topical steroids
Topical corticosteroid medications (steroids) can be
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effective against scalp psoriasis. These prescription
medications come in solutions, gels, creams, lotions,
sprays, ointments and foam.
Topical steroids range from very mild to potent.
Normally, strong steroids can be used safely for scalp
psoriasis, but they should not be used continuously
for long periods. A two-week cycle of treatment is
commonly recommended for strong steroids. In
addition, they should not be used under a dressing or
covering (occlusion). Follow your doctor’s instructions
carefully.
Abruptly stopping steroid treatments can sometimes
cause psoriasis to worsen (called a rebound flare).
Work with your doctor if you plan to stop using
steroids. Do not use steroid preparations on your face
and other sensitive skin areas, such as under the breasts
or on genitals, unless directed by your doctor. Avoid
getting steroids in your eyes.
Several topical steroid prescription medications are
designed specifically for treating scalp psoriasis. These
formulas are water- and alcohol-based, which makes it
easier to wash them out after treatment.
Sometimes scalp psoriasis can become less responsive
to topical steroids. If this happens, you can switch to
other scalp treatments, such as anthralin, calcipotriene,
tazarotene or tar. It can take five to seven days before
topical steroid medications will work again for skin
that has become less responsive.
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Ultraviolet light
Hair blocks UV light treatments from reaching
the scalp. However, better results can be achieved
with conventional UV units if you part your hair in
many rows, if you have very thin hair or if you shave
your head. Hand-held devices called UV combs are
available to deliver a higher intensity of UV light.
Natural sunlight may also help if the hair is very thin
or the head is shaved.
PRACTICAL TREATMENT TIPS
Scale softening and removal
The first step in treating scalp psoriasis is to remove
(lift) any scale on psoriasis plaques. Scale lifting is
necessary to make it easier for topical medications to
penetrate the plaques and clear them.
Scale softeners contain active ingredients such as
salicylic acid, urea, lactic acid or phenol. They are
usually applied to the scalp, left on for a prescribed
length of time (sometimes overnight) and shampooed
off. The loosened psoriasis scales are washed away. You
may avoid some of the messiness by applying softeners
at night and covering your head with a shower cap.
Scale softeners can be purchased over the counter.
Soaking the scalp in warm (not hot) water can help
loosen scales. Soaking with water “plumps up” scales
and makes them easier to remove.
Another way to soften and loosen scales is to apply
oils, lotions, creams or ointments to a damp scalp.
Some people report that lubricants work better with
a hot towel wrapped around the head. You can also
apply heated olive oil to the scalp and wrap your head
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in a towel for several hours, or apply olive oil and sit
under a hair dryer.
Once the psoriasis scale has been softened, it needs to
be removed. People generally use round or fine-tooth
combs or brushes. One of the best methods is to comb
the scalp gently in a light circular motion, holding the
comb almost flat against the scalp. Once the scale is
loosened, you may shampoo to flush the scale from the
scalp and out of the hair.
Removing scales too vigorously can break the skin and
lead to an infection. It can also break hair off at the
scalp, causing temporary hair loss. The Koebner [kebner] response, a tendency for psoriasis to appear on
damaged skin, can occur at the site of rough scratching
or scraping. If treatments worsen your psoriasis or
irritate your scalp, use plain oils and water until the
irritation subsides. Great care should be taken when
removing scales and applying topical medications to
avoid triggering this response.
Effective application of medications
• Part your hair and hold it in place while you
drip or pat oils or lotions directly onto your
scalp. Make a new part about a half-inch away
and repeat. If you use a cream or ointment,
rub it right into the psoriasis. All preparations
should be used sparingly.
• Treat all of the affected areas, including those
around the ears and hairline. Products such as
anthralin and tazarotene may irritate the folds
behind the ears. Protect those areas by covering
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them with a thin layer of petroleum jelly
before applying medications. Avoid getting any
medication in the eyes.
• Pre-treat the scalp lesions with scale-softening
agents or oils to soften and remove the heavy
scales and make scalp medications more
effective.
• Shampoo your hair before applying a scalp
medication.
• Apply petroleum jelly to cotton balls and insert
them gently into the ears before applying the
medications or shampoos to keep shampoos and
medications out of ears.
Occlusion and stain protection
Shower caps, towels, plastic wrap and plastic produce
bags are examples of items used to occlude (cover)
the scalp. Occlusion can enhance a treatment while
also protecting pillows, clothes and furniture from
medications and oils. Plastic produce bags are
inexpensive, if not free, and do not make the “crinkle”
sound of a regular shower cap.
To protect your bedding from stains, you can make a
“treatment” pillowcase by sewing two towels together
on three sides.
Never use a shower cap or other covering with
prescription scalp medications, unless specifically
directed by your doctor.
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Combining medications
Tips for dealing with itch
A doctor can prescribe special combinations of
medications, a process known as compounding.
Specialized preparations prescribed by a doctor can
be mixed by a pharmacist for individual cases. Be
aware that some medications may inactivate others,
so it is best to consult your doctor before combining
medications on your own.
The forehead, neck and ears
Scalp psoriasis may creep down onto the forehead
and the neck and around the ears. These areas can
be treated with the same products used for the scalp.
However, there are some specific considerations. For
example, anthralin can stain facial skin. Strong steroid
medications should never be used on the face because
they can irritate and thin facial skin. Calcipotriene is
not recommended for the face, although some people
use it there successfully. Tazarotene is considered safe
for facial use, although it can irritate the skin.
Scalp itch
Itching is often a problem for those with scalp
psoriasis. OTC tar shampoos can help reduce
itching. Topical steroids are often effective, and oral
antihistamines are occasionally prescribed. Sometimes
doctors add menthol to scalp medications; many
over-the-counter medicated shampoos contain
menthol. There are OTC products developed
specifically for scalp itch. Check your local pharmacy
or drugstore for these products.
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• Use a conditioner after every shampoo to keep
the scalp moisturized. Dry scalp can cause
itching or make it worse.
• Limit the use of hot tools to style hair, or let hair
air-dry to reduce scalp dryness.
• Press a wet towel or cold pack against the itchy
spot.
• Run cold water over your head
COMMON QUESTIONS ABOUT SCALP
PSORIASIS
Q: I know tar products are very good for treating
scalp psoriasis, but they dry my scalp and hair.
What would you recommend?
A: Conditioners and cream rinses may help combat
dry hair. Some conditioners are specially designed
for use in combination with tar shampoos. You can
do a final application of a regular (nonmedicated)
conditioner to moisturize the hair.
Q: Can I use hair dye, hair spray or permanents if I
have scalp psoriasis?
A: While a few people report scalp irritation from
hair dyes, hair spray, or permanents, many have no
problems. Test the products on a small area of the scalp
before applying them all over to see if they will irritate
the lesions. Ask your stylist about gentle products.
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Q. How many times a week can I wash my hair
without irritating my scalp psoriasis?
A: Daily shampooing is appropriate with psoriasis,
both for treatment (medicated shampoo) and removal
of excess scale.
Q: Will head lice treatments irritate scalp psoriasis?
A: Head lice shampoos are applied only briefly, so
reactions are rare. However, they can be irritating, so
you should avoid getting them in open cuts or lesions
or on extensively scratched skin.
Q: Will a hair stylist or barber object to cutting
my hair?
A: You can broach the subject when making your
appointment. If you are refused service or made to
feel uncomfortable, contact the National Psoriasis
Foundation.
Take charge of your health—
join today!
Whether you’re newly diagnosed or have been coping
with psoriasis for years, National Psoriasis Foundation
membership offers something for everyone:
• Psoriasis Advance: Keep up to date with the latest
psoriasis news in our award-winning magazine.
• Psoriasis skINSIGHTS: This twice-yearly newsletter
offers easy self-care strategies and tips.
• Money-saving coupons and discounts: Receive
exclusive coupons for skin care and other health
products.
• Treatment tips: Full access to It Works for Me, our
online database of tips from people with psoriasis
and psoriatic arthritis.
• Toll-free information line: Call between 8 a.m. and
5 p.m. Pacific Time and talk to our health educator.
• Opportunities to connect: Share information and
support with others who have the disease through
our online message board and affiliated support
groups.
• Help in finding a doctor, special invitations to
educational events and more!
To join the National Psoriasis Foundation call
800.723.9166 or go to www.psoriasis.org.
Additional resources
The National Psoriasis Foundation maintains an
extensive library of information on psoriasis and
related topics. To learn more, visit our Web site at
www.psoriasis.org or e-mail [email protected].
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NOTES
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scalp psoriasis
MISSION STATEMENT
Our mission is to improve the quality of life
of people who have psoriasis and psoriatic
arthritis. Through education and advocacy,
we promote awareness and understanding,
ensure access to treatment, and support
research that will lead to effective
management and, ultimately, a cure.
The National Psoriasis Foundation, a charitable
501(c)(3) organization, depends on your tax-deductible
donations to support the millions of people diagnosed
with psoriasis and/or psoriatic arthritis. The Psoriasis
Foundation is governed by a volunteer Board of Trustees
and is advised on medical issues by a volunteer Medical
Board. For more information, or to obtain a copy of the
Foundation’s Annual Report, call 800.723.9166.
National Psoriasis Foundation educational materials
are reviewed by members of our Medical Board and are
not intended to replace the counsel of a physician. The
Psoriasis Foundation does not endorse any medications,
products or treatments for psoriasis or psoriatic arthritis
and advises you to consult a physician before initiating
any treatment.
©2008 National Psoriasis Foundation
National Psoriasis Foundation
6600 SW 92nd Avenue, Suite 300
Portland, OR 97223-7195
Toll Free 800.723.9166
www.psoriasis.org
Connect. Control. Cure.
May 2008