A positive approach

to psoriasis and

psoriatic arthritis

Scalp Psoriasis

What are the aims of this leaflet?This leaflet has been written to help you understand whatscalp psoriasis is, what the symptoms are, what thetreatments are and to offer some useful tips for dealing withscalp psoriasis.

What is psoriasisPsoriasis (sor-i’ah-sis) is a long-term (chronic) scalingdisease of the skin, which affects 2-3% of the UK

population. It usually appearsas red, raised, scaly patchesknown as plaques. Any partof the skin surface may beinvolved but the plaquesmost commonly appear onthe elbows, knees and scalp.It can be itchy but is notusually painful. Nail changes,including pitting and ridging,

are present in 40% to 50% ofpeople with psoriasis alone. Around 30% of people withpsoriasis will develop psoriatic arthritis. There does notseem to be any link between the severity of the psoriasisaffecting the skin and the severity of psoriatic arthritis. Formore detailed information on psoriasis see our leafletsWhat is Psoriasis? and What is Psoriatic Arthritis?

What happens in psoriasis?Normally a skin cell matures in 21-28 days and during thistime it travels to the surface, where it is lost in a constant,invisible shedding of dead cells. In patches of psoriasis theturnover of skin cells is much faster, around 4-7 days, andthis means that even live cells can reach the surface andaccumulate with dead cells. This process is the samewherever it occurs on the body. The extent of psoriasis andhow it affects an individual varies from person to person.Some may be mildly affected with a tiny patch hidden awaywhich does not bother them, while others may have large,visible areas of skin involved that significantly affect dailylife and relationships. Psoriasis is not contagious; thereforeyou cannot catch it from another person. The cause ofpsoriasis is currently unknown.

What is scalp psoriasis?As the term suggests, scalp psoriasis is psoriasis on thescalp. It is common and approximately half of all people

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with psoriasis also have it on their scalp. The reason itdeserves special mention is that it can be more difficult totreat and usually requires specifically formulatedtreatments.

Psoriasis on the scalp forms in the same way as on otherparts of the body but the hair traps the scale and so it doesnot rub away as it would, for instance, on the elbow. Theresult is that the scale canquickly build up, causing at h i c k e r p l a q u e w h i c hbecomes more difficult tot rea t . Th is d i f f i cu l ty i scompounded by the hair,which acts as a physicalbarrier obstructing the easyapplication of creams andointments to the affectedskin. Children can get scalppsoriasis too. Treatments will be much the same asthose used for adults. On rare occasions, scalp psoriasishas been known to disappear spontaneously, but it canremain on the scalp for lengthy periods of time too.

What are the symptoms?Scalp psoriasis causes redness and scaliness, which mayalso involve the hairline, the forehead, behind the ears andthe back of the neck. It can range from very mild with slightfine scaling to very severe, crusted thick scaling coveringthe entire scalp. Hair loss during the flare-up can occur insome cases, but the hair will normally grow back. Psoriasiscan be itchy, make the scalp feel tight and occasionallycause soreness, especially if there are cracks in the skin.

What is the treatmentTThere are many treatment options that can help scalppsoriasis and often a combination approach using anumber of different treatments may be required until thesymptoms have settled. It is important to remember tocontinue to treat the scalp even if hair falls out. Hair usuallygrows back once the inflammation and scale has cleared.

Treatments can be time-consuming and you may findthem easier if you ask someone to help you. It is importantto choose one that suits your lifestyle; carrying out intensivetreatments over the weekend, for example, when you havemore free time. Psoriasis is not curable, but the signs andsymptoms can be well controlled.

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It can take at least eight weeks until you gain adequatecontrol 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 ornurse for further assessment.

Once you have achievedclearance, it is important tomaintain the improvement.This can usually be donew i t h r e g u l a r u s e o f a tar shampoo and or bymois tu r i s ing the sca lpoccasionally with an oil oremollient. Some people finddaily treatment of the scalp

an advantage in keeping the scales from returning,but this would be a personal reference depending on yourcircumstances. If you have no success in controlling yourscalp psoriasis, ask your GP to refer you to a specialist.

In 2012, the National Institute for Health and CareExcellence (NICE) published a guideline on treating scalppsoriasis. It is recommended that you begin with thetreatment process below. This guidance is based on thescientific evidence available and will not always besuitable for everyone. We have included some additionalinformation on types of treatments available and how touse them.

Topical treatment for scalp psoriasis in adults, youngpeople and children

1. Potent corticosteroid once daily for up to 4 weeks asthe initial treatment. If you find it difficult or cannotuse corticosteroids on your scalp, or you have mild tomoderate scalp psoriasis, your healthcareprofessional may instead offer you a vitamin Dpreparation

2. If there is no improvement after 4 weeks you may beoffered:

� a different formulation of corticosteroid (e.g. ashampoo or mousse); and/or

� a scalp treatment to remove the scales (such as anemollient or oil) before further applications of thepotent corticosteroid.

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3. If the situation is no better after a further 4 weeks youshould be offered:

� a combined product containing a potentcorticosteroid and vitamin D applied once a dayfor up to 4 weeks; or

� a vitamin D preparation applied once a day (if youcan’t use corticosteroids and have mild tomoderate scalp psoriasis).

4. If a combined product or vitamin D preparation doesnot control your scalp psoriasis after 8 weeks, youshould be offered one of the following options:

� for adults only, a very potent corticosteroid appliedup to twice a day for 2 weeks

� a coal tar preparation applied once or twice a day

� referral to a specialist for help with topicalapplications or advice on other treatments.

Here is a l ist of topical treatments that NICE mentions and which you may find useful for scalppsoriasis:

Topical steroids (corticosteroids)Topical steroids come in various formulations and some arespecifically designed as scalp products. These tend to belotions, gels, foams, sprays or shampoo, so they can beused more easily in hair-covered areas, are morecosmetically acceptable and are easier to wash out. Whenthere is a lot of scale and soreness you may be advised toavoid topical treatments with high alcohol content as theseoften cause drying and stinging; a gel or lotion basedproduct might be more suitable.

Corticosteroids come in different strengths, ranging frommild to very strong potency. Potent steroids are usuallyprescribed for scalp treatment, but these are not suitablefor the face or around the ears. They should not be usedcontinuously for long periods of time. They are used, ideally,for a few weeks to bring the psoriasis under control, andthen gradually phased out, switching to maintenancetreatment with a coal tar shampoo and/or emollients.Sometimes the corticosteroid becomes less effective afterrepeated use and you may need to try an alternativeformulation or treatment for a while.

When you are using potent steroids on the scalp, takecare not to let the treatment run onto your face or behindyour ears, as the skin is much thinner in these areas andmore prone to damage. It’s important to wash your handsafter using these treatments so you do not spreadthetreatment to other areas by mistake.

Vitamin D analoguesVitamin D analogues are available as ointment, gel, foamor lotion depending on the brand. They are usually appliedonce or twice a day and left in contact with the scalp (ie donot need to be washed out). They do not smell or stainclothing, and are relatively easy to use, although none arespecifically designed for use on the scalp. They can beused to bring the scalp psoriasis under control and maintainthat control. One manufacturer combines the treatmentwith a potent steroid and this must therefore be avoided onthe face and behind the ears. Products without steroidcontent are safe to use on the forehead too, but cansometimes cause irritation. It is wise to test a small patchbefore applying it to the entire scalp. In all cases, avoidcontact with the eyes.

Tar productsTar shampoos, gels, ointments and creams are commonlyused to treat scalp psoriasis and can be used on thehairline, forehead and around the ears. They may becombined with other medications, such as salicylic acid orcoconut oil, to help remove scale. Tar is effective but it canstain clothing and jewellery and has a strong smell, so somepeople dislike using it. The precise instructions for use willdepend on the formulation of the product, but tar productsare usually massaged into the scalp, left in contact for aperiod of time (perhaps 1-2 hours) and then washed off.Clothes and bedding can be protected from staining bywearing a shower cap during the contact period. Make sureyou receive full instructions from your nurse, doctor orpharmacist on how to use the product safely andeffectively.

Medicated shampoosThere are several coal tar and medicated shampoos fortreating scalp psoriasis available from your local chemist.For further advice, speak to your pharmacist. You shouldbear in mind that medicated shampoos are designed fortreating the scalp rather than washing hair, so using aregular shampoo and conditioner after your scalp

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treatments will reduce any unpleasant smell and leave yourhair shiny and manageable. When using tar shampoos youshould massage the shampoo into the scalp and leave for5-10 minutes before rinsing out. Tar shampoo alone is notrecommended for treating severe scalp psoriasis (i.e. wherethere is thick scaling and redness).

Emollients/oilsSometimes emollient ointments or oils can be useful insoftening thick, adherent scale on psoriasis plaques. Other‘active’ treatments like steroids or tar will work better if thescale is removed first, because they can then betterpenetrate the area that needs treating. There are a coupleof products speci f ica l lymarketed for this purpose,but p repara t ions such as o l i ve o i l , coconut oil or softened emulsifyingointment may be used, oryour pharmacist may beable to recommend analternative emollient orlotion.

Oil can be dribbled onto the scalp andmassaged in, section by section, trying to avoid too muchgoing on the hair. The scalp can then be wrapped in atowel, shower cap or cling film and left for 30-60 minutes.The scalp and hair can then be washed with normal or tarshampoo. While the scalp is still damp, the scales shouldbe softened and looser, making them easier to remove byhand. You may find this more manageable if you havesomeone to help. Place a plastic, fine-toothed comb flatagainst 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 theskin and cause hair loss. You can then shampoo again towash away debris from the scalp and out of the hair. Thehair may need two washes if it remains oily. You can, ofcourse, use a hairdryer to dry your hair afterwards. Oncethis is done, an active treatment such as a corticosteroidlotion can be applied. Some people find that a combinationof techniques works better for them, so work out a regimethat suits your circumstances and gives you the results thatyou find most convenient

NB: Tar ointments are used in a similar way.7

Other treatments DithranolDithranol 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 tothe scaly plaques and left incontact for up to 30 minutesbefore being rinsed out. Itneeds to be applied with greatcare as it can irritate and causepurple staining of blonde orred hair. Dithranol can also

burn skin unaffected byplaques. Lipid-stabilised dithranol, if used correctly, canreduce staining. Do be aware that dithranol will stainclothing and baths, showers and wash basins. Extraattention is needed and so it is probably best reserved forsupervised use in dermatology clinics only.

Antimicrobial treatment If a bacterial or yeast infection is present, scalp psoriasiscan become worse. A crusting scalp together with scalingand/or swollen lymph nodes in the neck may indicate toyour doctor that anti microbial treatment will be necessaryas there is infection present.

Mild scalp psoriasis can also mimic or coincide with ayeast infection and so may respond well to treatment withantifungal shampoos. Antifungal shampoos may have to beused once or twice a week thereafter to maintain results.

Ultraviolet lightSuccessful outcome for using UV light treatments is poorbecause the hair blocks UV light from penetrating the scalp.It works best on shaved heads. Natural sunlight may alsohelp if your head is shaved or hair is thin. See our leafletsPsoriasis and Phototherapy and Psoriasis and the Sun.

Salicylic acidA lot of product treatments will contain salicylic acid, knownas a keratolytic. This ingredient aims to breakdown thepsoriasis scales so they can be washed away more easily.It is contained in both over the counter (OTC) andprescription products. It’s worth remembering thattreatment with high concentrations of this ingredient cancause irritation and sometimes weaken hair, resulting insome temporary hair loss. Hair should, however, return tonormal after stopping the treatment.

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Combination medications The treatment of psoriasis should be tailored to eachperson. Your doctor or nurse may try various combinationsof treatments before finding which works best for you.Make sure you ask how to use the treatments and ifpossible have some written instructions, as it can beconfusing if you are prescribed several different products.

Systemic treatmentsFor severe and recalcitrant (difficult to treat) scalp psoriasisa systemic treatment may be considered. This would beunder the care of a dermatologist.

HairdressingSome people with scalp psoriasis find it embarrassingwhen they first visit a new hairdresser or barber. Anyreputable hairdresser should have an understanding ofconditions such as scalp psoriasis and be able to adviseyou on styles, colourings and hair products. It is alwaysworth making general enquiries of friends and relativesabout local hairdressers or contacting the HairdressingCouncil for further advice. Some hairdressers are alsohappy to visit your home if you would prefer not to go to asalon.

There is no evidence to suggest the use of hair dyes, hairsprays or perms will affect your scalp, but make sure youask your hairdresser to apply patch tests before embarkingon any treatments, to see if the products will irritate yourscalp or psoriasis lesions. They may be able to use oradvise you of gentler products.

PregnancySome treatments should notbe used during pregnancy orbreast-feeding, so before youuse them, always check theirsuitability with your doctor. Asa general rule, emollients,some oils and corticosteroidf o r m u l a t i o n s ( w i t h o u tantimicrobial or salicylic acidadded) are safe to use.

RisksParaffin based skin products can be a fire hazard if theycome into contact with clothing or bedding as they can beeasily ignited with a naked flame. Keep away from nakedflames or cigarettes if clothing or bedding has absorbedparaffin.

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If you have any views or comments about this informationor any of the material PAPAA produces you can contact us v ia the deta i ls on the back page or on l ine atwww.papaa.org/user-feedback

More informationWe have produced several other particularly relevantleaflets, which you may find useful, including Treatmentsfor Psoriasis: An Overview, Emollients and Psoriasis, andPsoriasis and Sensitive Areas.

There is also a psoriasis treatment demonstration videodeveloped by St. John’s Institute of Dermatology and theBritish Association of Dermatologists you may find useful:https://www.youtube.com/watch?v=hMUPuqt-khY

Useful contactsFor information about health matters in general and how toaccess services in the UK, the following websites providenational and local information.

n NHS Choices (England): www.nhs.ukn NHS 24 (Scotland): www.nhs24.comn Health in Wales: www.wales.nhs.ukn HSCNI Services (Northern Ireland):

http://online.hscni.net

These sites are the official sites for the National HealthService and provide links and signposting services torecognised organisations and charities.

ReferencesGelfand JM, Weinstein R, Porter SB, Neimann AL, BerlinJA, Margolis DJ. Prevalence and treatment of psoriasis inthe United Kingdom: A population-based study.ArchDermatol 2005;141:1537-41.

Cohen MR, Reda DJ, Clegg DO. Baseline relationshipsbetween psoriasis and psoriatic arthritis: Analysis of 221patients with active psoriatic arthritis. Department ofVeterans A f f a i r s C o o p e r a t i v e S t u d yG r o u p o n seronegativespondyloarthropathies. JRheumatol 1999;26:1752-6.

NICE http://publications.nice.org.uk/psoriasisifp153/initial-treatment-with-topical-medication www.haircouncil.org.uk

The above list is not exhaustive. For further references usedin the production of this and other PAPAA informationcontact us or go to: www.papaa.org/resources/references

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About this informationThis material was produced by PAPAA. Please be awarethat research and development of treatments is ongoing.

For the latest information or any amendments to t h i s m a t e r i a l p l e a s e c o n t a c t u s o r v i s i t o u rwebsite: www.papaa.org The site contains information ontreatments and includes patient experiences and casehistories.Original text written by PAPAA. Fully reviewed and revisedin May 2013 and August 2015A peer review has been carried out by consultant nurseKarina Jackson, St John's Institute of Dermatology, Guy'sand St Thomas' NHS Foundation Trust, in April 2018.A lay and peer review panel has provided key feedback onthis leaflet. The panel includes people with or affected bypsoriasis and/or psoriatic arthritis.

Published: June 2018

Review date: October 2020

©PAPAA

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