Scalp Psoriasis Treatment

What is Scalp Psoriasis?

Psoriasis of the scalp can be seen as dry, itchy, reddish scales or patches and lesions on the scalp. When it comes to psoriasis disease the scalp stands as a favorable site. 80 percent of the patients living with psoriasis have scalp psoriasis.

It can be a single patch as in mild psoriasis or can cover the entire scalp or several areas depending on the severity. In this condition, the skin cells of the head pile up to build patches with itchy and dry scales.

It may be mistaken for dandruff, but the patches appear with a silvery hive. Scalp psoriasis is the most common skin disorder in our country. The recorded cases exceed more than 10 million in India every year.

Specific treatment is not up for this disease, yet certain medications and treatment plans are going on the stream to control the outbreaks of psoriasis effectively, and most of the cases have been reverted. Also, the treatment and management of the disease are completely personal. It is discussed by the doctor based on the preferences, sensitivity, approach, and lifestyle of the patients.

The cause for psoriasis is not exemplified but it is thought to be the response to a problem in the immune system. Psoriasis often causes colds, infections, inflammation, stress and lessens self-confidence. 

Scalp psoriasis emerged as a patch and may spread all over the scalp, forehead, all over and inside the ears and neck. It is not contagious and does not spread from one person to another. Many types of research put forth that it is an immune reaction in which the cells divide and pile to form patches and scales. 

Of all the kinds of psoriasis existing, scalp psoriasis is the most frequently occurring disease, with half of the psoriasis cases falling under it. The scale of scalp psoriasis can be from unnoticeable to severely evident.

Scalp psoriasis may look similar to dandruff because of its appearance, but its silvery nature makes it different.

There is an existing myth that scalp psoriasis results in hair loss, which is a false belief.

Itching caused by this can result in lots of scratching and sleepless nights.

Stress, harsh scratching, repeated rubbing, and treatment with various chemicals can be the reason for temporary hair fall.

Scalp Psoriasis Images

Symptoms of scalp psoriasis:

  • Scalp psoriasis represents the most difficult treatment type of psoriasis. It requires prompt treatment and fast relief whereas it acts the opposite. 
  • As it affects the most visible part of the body, the irresistible itch, the severe discomfort, it alters the quality of life. 
  • Scalp psoriasis is marked by lesions that are individual or associated with other types of psoriasis. 
  • Symptoms for a starting stage of scalp psoriasis is just a mild little scaling or often looking like dandruff. That is why many mistake it for dandruff. Fine scales form on the scalp gradually along with plaques. 
  • Dryness of the scalp, redness, discomfort, silvery scales, patches, severe itching, temporary hair loss, falling of dandruff-like flakes, burning, red bumps etc., are noticeable in severe disease conditions. 
  • Pruritus is the most bothersome symptom of scalp psoriasis as complained by the patients. It is a relentless itch in the scalp with or without flaked appearance.
  • In severe cases, different types of alopecia that are patterns of hair loss can occur in scalp psoriasis.

Scalp psoriasis treatments:

Scalp psoriasis treatment is selected depending on various factors such as disease severity, age, other health issues, pregnancy, breastfeeding, etc…

The clinical treatment plan for scalp psoriasis is stipulated in a way the mind to severe cases gets treated as the plan is laid up and above. 

Before anything else to assess the severity of the disease, certain tools have opted. Physician’s global assessment and body surface area, psoriasis symptom inventory, and pruritus assessment, psoriasis area severity index, and dermatology life quality index. 

  • Topical treatments are the baseline, to begin with, in the case of mild psoriasis. A skin biopsy may be needed before prescribing any. Topical agents to be first used are the keratolytic agents such as Salicylic acids, urea, sulfur, coal tar, etc. 
  • As the disease goes from moderate-severe, topical corticosteroids come on the board. From lighter to highly potent corticosteroids which are used only topically they range depending on the disease. They are combined with topical corticosteroid-sparing agents like vitamin D analogues, tazarotene, and calcineurin inhibitors. They are either combined or given as monotherapy. 
  • These are said to reduce the high risks that come with the use of steroids and also potentially replace them as an alternate use for long-term treatment.
  • Biologics and non-biologics are used to treat moderate to severe psoriasis. 

Prescribed and approved medications used for scalp psoriasis treatment

Apart from this prescribed treatment, there are also non-prescribed therapies existing. 

Non-prescribed treatments for scalp psoriasis

Traditional Chinese practices, herbal treatments with aloe vera, and herbs are other options.

In India, Ayurveda offers the big arm in treating psoriasis rather than the other. Most people rely on ayurvedic benefits as the steroids and supplements on the other way may cause complicated side effects.

As Ayurveda stresses the balance of elements it suggests medication to balance the doshas. The pranayama which is a breathing controlling practice is also a way to reduce psoriasis by reducing stress levels. [Read Ayurvedic Treatment for Psoriasis]

The dietary changes and the preparation in Ayurveda have a notable impact on treating psoriasis. Exfoliation is recommended by ayurvedic practitioners. [Ayurvedic Diet for Psoriasis]

Neem, turmeric, frankincense, aloe Vera, black nightshade, garlic, guggul, etc, herbs are picked up in their preparations national psoriasis foundation stipulated 0.5% aloe in the creams while prescribing treatment options and widely appreciated therapies and methods.

Conventionally prescribed treatment for scalp psoriasis

  • The first line of defense for topical medications, where the medicine in the form of preparation, ointments, gels, balms, foams, liquids, and soaps are applied to the affected areas. The mild and initial stage of psoriasis gets effectively healed by this. 
  • Salicylic acid and coal tar are used in preparing those oils, shampoos, gels, and ointments. Ayurvedic medicine uses turmeric in its topical preparations, which is made as a paste as applied to the infected areas of the skin. 
  • Vitamin A is involved in the form of tazarotene. A thin layer of this must be applied on the scalp as a night regime before going to sleep. It should be washed off thoroughly with a warm shower the next day as in calcipotriene usage. This clears off the scalp if tried regularly.  
  • Coal tar shampooing is widely and best adopted as a way to treat scalp psoriasis. Using the shampoo for at least four to eight weeks can Mark the results. About ten to fifteen percent of coal tar is used in many products. Continuing the usage thereafter can maintain a well-conditioned scalp. 
  • Some softeners for the scalp are available that contain salicylic acid which deals effectively with the hard patches. The scales get softened and fall off easily.  Regardless topical applications of salicylic acid may cause hair breakage. 
  • Whatever the shampoo or softener may be, the usage must be stopped and reviewed after 2-4 weeks without delay.

Keratolytic agents:

Keratolytic agents are the class of drugs that break down the peripheral layers of the skin. So they are potent in decreasing the formation of plaques in psoriasis. It has many efficient treatment options under this category. Salicylic acids, coal tar, anthralin, sulfur, lactic acid, etc.

These agents are also utilized in treating skin diseases, acne,  hyperpigmentation, chemical peels, etc. for now, let us discuss a few keratolytic agents being used in treating scalp psoriasis. They are more efficient as clearing agents.

Still using complex regimens using multiple products can lower the adherence to the treatment. The purpose of keratolytic agents is safe to use once a day daily. It is also limited to a short span and short areas alone.

Coal tar shampoo:

The coal tar shampoo has been in use to treat scalp psoriasis for a long time. The ingredients are the distilled hydrocarbons from coal. It has non-proliferative and anti-inflammatory properties. Also, it is a potent antipruritic agent.

A concentration of not less than 5 percent to as high as 20 percent of coal tar is recommended to use. However, its extensive usage of it has been stopped until recently, due to its carcinogenic properties.

When prescribed, it is formulated as a shampoo or a lotion along with a corticosteroid. It has shown efficacy in improving and clearing the scalp but has a paucity regarding its use in treating scalp psoriasis.

The use of coal tar has been banned in a few countries because of its cancer-causing properties. Also, it has left staining, hair thinning and hair dryness, discoloration of the scalp, and staining of the clothes used. Which interferes with the appearance concerns of the patient.

Nonetheless, coal tar formulated with topical corticosteroids is being used yet again although there is no such research supporting it directly. As far the cosmetically appealing treatment using coal tar is shampooing that has 5 percent of it, in gel formulation or foams.

There are indeed great contraindications for its use. It should be avoided directly on inflamed skin, in sunlight, and eyes. It is meant for over-the-top applications only.

Anthralin: 

It is one of the oldest drugs used in treating scalp psoriasis. The systemic studies on its usage are lacking. As it has the potent nature to induce free radical production, it is said to inhibit the further pathogenesis of psoriasis.

It is prescribed in people with resistant scalp psoriasis. It acts as an antimitotic substance, hence its usage is avoided in pregnancy, children, and breastfeeding moms. Also, later on, it has been replaced by other cosmetically appealing treatments.

It is formulated as 0.5 percent scalp cream or 1 percent rub cream on the scalp. It is started at lower concentrations and gradually rises until it is tolerated. 

Salicylic acid:

The most extensively utilized keratolytic agent, in treating various skin diseases. From callus, corn to psoriasis, and dermatitis. Systematically it acts similar to aspirin with anti-inflammatory story and analgesic properties.

In general treatment plans for scalp psoriasis, they come after the scale softening agents. salicylic acid acts as a peel. This causes piles-used up cells to swell, soften, and desquamate.

It does not leave the surface easily, so that’s a drawback complained by the patients. This is why a clarifying shampoo is applied before putting on the salicylic acid.

A 5 percent salicylic acid is used to formulate the shampoos and rub in creams onto the scalp. Until 6 percent it acts as a keratolytic. Above 6 percent of the same damages the tissue so increased concentration is used to treat corn and callus.

As known shampoo containing a good amount of salicylic acid alongside coal tar is taken as a good one. In combination with shampoo,  salicylic acid is also formulated with sulfur and also coal tar. The perfect combination being used is the salicylic acid alongside the coal tar.

Generally used in combination with sulfur for other skin diseases than in scalp psoriasis. The keratolytic agents are used before all other medications for better penetration. They can be left on the scalp overnight for better absorption.

Although salicylic acid ointments are not meant for use on the face. Decent usage of salicylic acid on the scalp for four weeks has shown tremendous results and a decrease in psoriasis in research. 

The adverse effects of using the salicylic acid again would be because of unprescribed usage, and prolonged and consecutive applications of the products.

Skin burning, tingling sensation, peeling of the skin, increased scaling from the scalp, dizziness, headache, tinnitus in which there is a running noise in the ears, anxiety and heavy breathing are identified in the patients. 

Sulfur for scalp psoriasis:

As spoken above sulfur is formulated with salicylic acid for better results. It is used as an additive to describe precisely. It is similarly a keratolytic agent and stops the bacteria from spreading further. It reduces dandruff, and dermatitis also. two per content percent sulfur is sulfur-based based preparations. 

Corticosteroids: 

Topical corticosteroids, the therapy based on topical corticosteroids is considered the first line of therapy. If the psoriasis is mild to severe, the use of topical corticosteroids comes necessary for the treatment plan.

Corticosteroids have a wide range of responsibilities. They act on the target tissues, release edema, prevent the accumulation of fluid, stop the accumulation of fibroblasts, prevent inflammation, inhibit the action of histamine and permeability, and destroy acids from leukocytes.

A minimum of one percent is absorbed on the skin after application. Almost 3 percent of the corticosteroids are absorbed after 8 hours on the normal skin and 7 percent of the same are absorbed systemically on the plaques of the basis. 

Fluocinolone

It is applied in lotions, creams such as body oil, topical solutions, and foams with 0.025 to 0.5 percent formulated in them. It inhibits the release of the destructive acids by leukocytes, and reduces the inflammation of the skin cells and also itchy scales. For scalp psoriasis in particular it is applied as an oil on the scalp and left overnight.  

Clobetasol propionate:

This topical treatment option for scalp psoriasis comes under corticosteroids. It is an important component in all topical lotions, gels, foams, shampoos, ointments, sprays, and solutions.

The concentration being used from as long as 0.025 to 0.05 percent of the medications, it is a direct counter drug on the mild to moderate inflammations of the scalp psoriasis.

The aim is to relieve the inflammatory symptoms. Yet, the dosages differ for every product. In the case of shampoos using clobetasol.

They are advised to not be used for more than four weeks, as it has the potential to interfere with the HPA axis.

Foams containing Creams also are limited to 2 weeks of usage as in the case of the foams, and also the quantity is restricted to 50gms per week.

The lotions and foams should be given extra care while using them. Like they should not come in contact with other sensitive parts of the body. If Shampoo with clobetasol, they should be rinsed with water thoroughly.  

Not just a Hpa axis, but also the adverse usage or prolonged utility of these medicated products beyond can result in skin atrophy, dryness, and discomfort.

Clobetasol is prescribed not more than 50 grams of it for a week, and also is limited for two consecutive weeks only. 

The clobetasol propionate usefulness, when tested for a research study, shows a clearer scalp in four consecutive weeks. Also, clobetasol propionate has lowered the risks of relapses in the patients.

When compared to the clobetasol propionate solutions to that of foams of the same formulation, which are applied twice daily and once respectively. The usage of clobetasol propionate has shown much efficacy.

It is mainly used in primary treatments. It helps in the maintenance of the scalp after the treatments are done. Almost every product with this propionate is approved by the United States Food and Drug Administration.

As per new upgrades, low molecular weight corticosteroids are proven efficient. Fluocinolone acetonide is a synthetic corticosteroid containing fluorine. It has potency in reducing inflammation, and the itch and inhibits proliferation.

But it has limitations such as the need for high doses to be absorbed into the skin. That is why, the peptide drug conjugates which facilitate cell uptake, and penetration into the cells are used alone. This criterion has been put forth to lessen the side effects and improve the therapeutics. 

Betamethasone dipropionate

It is another corticosteroid, formulated into gels, foams, and sprays with 0.05 percent concentration. This topical medication is sprayed onto the affected areas and left overnight. 

Halobetasol propionate cream is another high potency corticosteroid formulated with 0.05 percent cream and acts on lowering the inflammation, although the mechanism is not clear. 

Hydrocortisone and Fluocinolone acetonide:

They belong to mild to lighter potent corticosteroids. Using high potency corticosteroids should be only under the prescription of a dermatologist because they are almost 1000 times stronger than class 7 steroids. 

Vitamin D analogues:

Vitamin D analogues come under the sparing agents. These are formulated alongside corticosteroids for enhanced absorption and efficacy. They lower the risks of the potential side effects caused by corticosteroid usage.

They are added to the treatment plan when the disease is moderate and needs long-term treatment. They have proven to render more efficient results in combination with topical corticosteroids than individually. 

Calcipotriene 0.5 percent synthetic vitamin D analogue used as a topical agent, alongside betamethasone 0.05 percent is used topically for long-term use as long as up to eight weeks. 

Before using these formulated gels, a clarifying shampoo should be used for the effective removal of the product. 

Calcitriol is another vitamin D analogue utilized for scalp psoriasis. 

Calcipotriene is used as a thin layer on the scalp before bed and washed off the next morning. Along with corticosteroids, the results will be more effective. 

Systemic medications:

Systemic medications or oral system therapy is a rare option taken into consideration only if the disease is severe and if a recalcitrant is needed. Non-biological medications include methotrexate, apremilast, cyclosporin, acitretin, etc.

The apremilast showed efficacy in treating severe to moderate scalp psoriasis. Other non-biologics used are tofacitinib, hydroxyurea, mycophenolate mofetil, tacrolimus, leflunomide, etc.

Biologics and small molecules used in systemic therapy are the etanercept, infliximab, and adalimumab which are TNF inhibitors. secukinumab and ixekizumab, brodalumab being IL 17 inhibitors, guselkumab,risankizumab which are IL 23 inhibitors.

Phototherapy:

Before the times, UV therapy on the scalp with hair was not easy, later on with many advancements later phototherapy stands as one reliable treatment option for scalp psoriasis.

Narrowband UVB, Broadband UVB, targeted UVB using laser excimer, excimer light, topical PUVA, oral PUVA, Grenz ray, and pulsed dye laser is the option available for phototherapy. 

Limitations of Scalp psoriasis Treatments

Though there is no permanent cure for psoriasis medications and treatments can help to manage scalp psoriasis effectively. One should note that these treatments and medications have some limitations. They are as follows

  • some medications such as coal tar has cancer-causing properties.
  • can not use pregnancy, children, and breastfeeding moms.
  • you can not use for the long term.
  • side effects of the medications.

Conclusion:

A needful effective solution is being used at its full usefulness to treat scalp psoriasis. Since scalp psoriasis has no permanent cure, the following tips, plans, treatments, and medications honestly can work better in curing the ailment. Controlling the outbreak, and preventing the comeback of the disease is also important.  Ayurvedic Scalp psoriasis treatments can help to treat scalp psoriasis naturally.

Also Read

  1. Scalp Psoriasis Case Study
  2. Ayurvedic Treatment for Scalp Psoriasis

References:

  1. scalp psoriasis: a review of current treatment options
  2. psoriasis
  3. scalp psoriasis / American academy of dermatology
  4. scalp psoriasis shampoos
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