What is scalp psoriasis?
As the term suggests, scalp psoriasis is psoriasis on the scalp. It is common and approximately half of all people with psoriasis also have it on their scalp. The reason it deserves special mention is that it can be more difficult to treat and usually requires specifically formulated treatments.
Psoriasis on the scalp forms in the same way as on other parts of the body but the hair traps the scale and so it does not rub away as it would, for instance, on the elbow. The result is that the scale can quickly build up, causing a thicker plaque which becomes more difficult to treat . This difficulty is compounded by the hair, which acts as a physical barrier obstructing the easy application of creams and ointments to the affected skin. Children can get scalp psoriasis too. Treatments will be much the same as those used for adults. On rare occasions, scalp psoriasis has been known to disappear spontaneously, but it can remain on the scalp for lengthy periods of time too.
What are the symptoms?
Scalp psoriasis causes redness and scaliness, which may also involve the hairline, the forehead, behind the ears and the back of the neck. It can range from very mild with slight fine scaling to very severe, crusted thick scaling covering the entire scalp. Hair loss during the flare-up can occur in some cases, but the hair will normally grow back. Psoriasis can be itchy, make the scalp feel tight and occasionally cause soreness, especially if there are cracks in the skin.
What is the treatment
There are many treatment options that can help scalp psoriasis and often a combination approach using a number of different treatments may be required until the symptoms have settled. It is important to remember to continue to treat the scalp even if hair falls out. Hair usually grows back once the inflammation and scale has cleared.
Treatments can be time-consuming and you may find them easier if you ask someone to help you. It is important to choose one that suits your lifestyle; carrying out intensive treatments over the weekend, for example, when you have more free time. Psoriasis is not curable, but the signs and symptoms can be well controlled.
It can take at least eight weeks until you gain adequate control of the plaques, whichever treatment you use. Remember to try to treat psoriasis daily when it is active.
If, however, you have seen no improvement after 4 weeks’ continuous treatment, you should return to your doctor or nurse for further assessment.
Once you have achieved clearance, it is important to maintain the improvement. This can usually be done with regular use of a tar shampoo and or by moisturising the scalp occasionally with an oil or emollient. Some people find daily treatment of the scalp an advantage in keeping the scales from returning, but this would be a personal reference depending on your circumstances. If you have no success in controlling your scalp psoriasis, ask your GP to refer you to a specialist.
In 2012, the National Institute for Health and Care Excellence (NICE) published a guideline on treating scalp psoriasis. It is recommended that you begin with the treatment process below. This guidance is based on the scientific evidence available and will not always be suitable for everyone. We have included some additional information on types of treatments available and how to use them.
Topical treatment for scalp psoriasis in adults, young people and children
- Potent corticosteroid once daily for up to 4 weeks as the initial treatment. If you find it difficult or cannot use corticosteroids on your scalp, or you have mild to moderate scalp psoriasis, your healthcare professional may instead offer you a vitamin D preparation
- If there is no improvement after 4 weeks you may be offered: a different formulation of corticosteroid (e.g. a shampoo or mousse); and/or a scalp treatment to remove the scales (such as an emollient or oil) before further applications of the potent corticosteroid.
- If the situation is no better after a further 4 weeks you should be offered:
- a combined product containing a potent corticosteroid and vitamin D applied once a day for up to 4 weeks; or
- a vitamin D preparation applied once a day (if you can’t use corticosteroids and have mild to moderate scalp psoriasis).
- If a combined product or vitamin D preparation does not control your scalp psoriasis after 8 weeks, you should be offered one of the following options:
- for adults only, a very potent corticosteroid applied up to twice a day for 2 weeks
- a coal tar preparation applied once or twice a day
- referral to a specialist for help with topical applications or advice on other treatments.
Here is a list of topical treatments that NICE mentions and which you may find useful for scalp psoriasis:
Topical steroids (corticosteroids)
Topical steroids come in various formulations and some are specifically designed as scalp products. These tend to be lotions, gels, foams, sprays or shampoo, so they can be used more easily in hair-covered areas, are more cosmetically acceptable and are easier to wash out. When there is a lot of scale and soreness you may be advised to avoid topical treatments with high alcohol content as these often cause drying and stinging; a gel or lotion based product might be more suitable.
Corticosteroids come in different strengths, ranging from mild to very strong potency. Potent steroids are usually prescribed for scalp treatment, but these are not suitable for the face or around the ears. They should not be used continuously for long periods of time. They are used, ideally, for a few weeks to bring the psoriasis under control, and then gradually phased out, switching to maintenance treatment with a coal tar shampoo and/or emollients. Sometimes the corticosteroid becomes less effective after repeated use and you may need to try an alternative formulation or treatment for a while.
When you are using potent steroids on the scalp, take care not to let the treatment run onto your face or behind your ears, as the skin is much thinner in these areas and more prone to damage. It’s important to wash your hands after using these treatments so you do not spread the treatment to other areas by mistake.
Vitamin D analogues
Vitamin D analogues are available as ointment, gel, foam or lotion depending on the brand. They are usually applied once or twice a day and left in contact with the scalp (ie do not need to be washed out). They do not smell or stain clothing, and are relatively easy to use, although none are specifically designed for use on the scalp. They can be used to bring the scalp psoriasis under control and maintain that control. One manufacturer combines the treatment with a potent steroid and this must therefore be avoided on the face and behind the ears. Products without steroid content are safe to use on the forehead too, but can sometimes cause irritation. It is wise to test a small patch before applying it to the entire scalp. In all cases, avoid contact with the eyes.
Tar shampoos, gels, ointments and creams are commonly used to treat scalp psoriasis and can be used on the hairline, forehead and around the ears. They may be combined with other medications, such as salicylic acid or coconut oil, to help remove scale. Tar is effective but it can stain clothing and jewellery and has a strong smell, so some people dislike using it. The precise instructions for use will depend on the formulation of the product, but tar products are usually massaged into the scalp, left in contact for a period of time (perhaps 1-2 hours) and then washed off. Clothes and bedding can be protected from staining by wearing a shower cap during the contact period. Make sure you receive full instructions from your nurse, doctor or pharmacist on how to use the product safely and effectively.
There are several coal tar and medicated shampoos for treating scalp psoriasis available from your local chemist. For further advice, speak to your pharmacist. You should bear in mind that medicated shampoos are designed for treating the scalp rather than washing hair, so using a regular shampoo and conditioner after your scalp treatments will reduce any unpleasant smell and leave your hair shiny and manageable. When using tar shampoos you should massage the shampoo into the scalp and leave for 5-10 minutes before rinsing out. Tar shampoo alone is not recommended for treating severe scalp psoriasis (i.e. where there is thick scaling and redness).
Sometimes emollient ointments or oils can be useful in softening thick, adherent scale on psoriasis plaques. Other ‘active’ treatments like steroids or tar will work better if the scale is removed first, because they can then better penetrate the area that needs treating. There are a couple of products specifically marketed for this purpose, but preparations such as olive oil , coconut oil or softened emulsifying ointment may be used, or your pharmacist may be able to recommend an alternative emollient or lotion.
Oil can be dribbled onto the scalp and massaged in, section by section, trying to avoid too much going on the hair. The scalp can then be wrapped in a towel, shower cap or cling film and left for 30-60 minutes. The scalp and hair can then be washed with normal or tar shampoo. While the scalp is still damp, the scales should be softened and looser, making them easier to remove by hand. You may find this more manageable if you have someone to help. Place a plastic, fine-toothed comb flat against the scalp and gently rotate it in a circular motion. Loosen the scale carefully and try to comb it out of the hair. Do not remove scales too fiercely as this can damage the skin and cause hair loss. You can then shampoo again to wash away debris from the scalp and out of the hair. The hair may need two washes if it remains oily. You can, of course, use a hairdryer to dry your hair afterwards. Once this is done, an active treatment such as a corticosteroid lotion can be applied. Some people find that a combination of techniques works better for them, so work out a regime that suits your circumstances and gives you the results that you find most convenient
NB: Tar ointments are used in a similar way.
Dithranol creams may be effective in scalp psoriasis but, like coal tar, can be difficult to use and are not often prescribed for home use. Dithranol is usually applied to the scaly plaques and left in contact for up to 30 minutes before being rinsed out. It needs to be applied with great care as it can irritate and cause purple staining of blonde or red hair. Dithranol can also burn skin unaffected by plaques. Lipid-stabilised dithranol, if used correctly, can reduce staining. Do be aware that dithranol will stain clothing and baths, showers and wash basins. Extra attention is needed and so it is probably best reserved for supervised use in dermatology clinics only.
If a bacterial or yeast infection is present, scalp psoriasis can become worse. A crusting scalp together with scaling and/or swollen lymph nodes in the neck may indicate to your doctor that anti microbial treatment will be necessary as there is infection present.
Mild scalp psoriasis can also mimic or coincide with a yeast infection and so may respond well to treatment with antifungal shampoos. Antifungal shampoos may have to be used once or twice a week thereafter to maintain results.
Successful outcome for using UV light treatments is poor because the hair blocks UV light from penetrating the scalp. It works best on shaved heads. Natural sunlight may also help if your head is shaved or hair is thin. See Psoriasis and phototherapy and Psoriasis and the sun.
A lot of product treatments will contain salicylic acid, known as a keratolytic. This ingredient aims to breakdown the psoriasis scales so they can be washed away more easily. It is contained in both over the counter (OTC) and prescription products. It’s worth remembering that treatment with high concentrations of this ingredient can cause irritation and sometimes weaken hair, resulting in some temporary hair loss. Hair should, however, return to normal after stopping the treatment.
The treatment of psoriasis should be tailored to each person. Your doctor or nurse may try various combinations of treatments before finding which works best for you. Make sure you ask how to use the treatments and if possible have some written instructions, as it can be confusing if you are prescribed several different products.
For severe and recalcitrant (difficult to treat) scalp psoriasis a systemic treatment may be considered. This would be under the care of a dermatologist.
Some people with scalp psoriasis find it embarrassing when they first visit a new hairdresser or barber. Any reputable hairdresser should have an understanding of conditions such as scalp psoriasis and be able to advise you on styles, colourings and hair products. It is always worth making general enquiries of friends and relatives about local hairdressers or contacting the Hairdressing Council for further advice. Some hairdressers are also happy to visit your home if you would prefer not to go to a salon.
There is no evidence to suggest the use of hair dyes, hair sprays or perms will affect your scalp, but make sure you ask your hairdresser to apply patch tests before embarking on any treatments, to see if the products will irritate your scalp or psoriasis lesions. They may be able to use or advise you of gentler products.
Some treatments should not be used during pregnancy or breast-feeding, so before you use them, always check their suitability with your doctor. As a general rule, emollients, some oils and corticosteroid formulations (without antimicrobial or salicylic acid added) are safe to use.
Paraffin based skin products can be a fire hazard if they come into contact with clothing or bedding as they can be easily ignited with a naked flame. Keep away from naked flames or cigarettes if clothing or bedding has absorbed paraffin.
This article is adapted from the Scalp psoriasis leaflet.
Always consult your doctor or healthcare provider.