What are the other Names for this Condition? (Also known as/Symptoms)

• Psoriasis of the Scalp

What is Scalp Psoriasis? (Definition/Background Information)

• Scalp Psoriasis may be described as a subtype of psoriasis, which is a common chronic inflammatory skin disease that develops from a genetic defect. The condition causes the skin to grow abnormally, resulting in the formation of skin lesions. Psoriasis can run in  families but is not a contagious condition
• In a large percentage of individuals with psoriasis (mostly psoriasis vulgaris) that affects the skin, the scalp is a site of very common involvement. In some cases, the scalp is the first site of psoriasis onset. However, in a small percentage, Scalp Psoriasis is observed to be a “stand-alone” condition
• Scalp Psoriasis commonly affects the back of the head and stays within the hairline. It may be seen in random sections of the scalp or involve it entirely. It is characterized by red and scaly white plaques (thickened skin patches) that are well-defined. However, a loss of hair is not generally observed
• The signs and symptoms of Scalp Psoriasis may get better and worse over a period of time. The presentations may also vary from one individual to another and even within the same individual. The condition can present severe flaky dandruff, be significantly itchy (in some individuals), and last several years or indefinitely
• The treatment of Scalp Psoriasis is generally difficult but may involve the use of medicated shampoos, topical agents, and corticosteroids for prolonged periods. Systemic therapy may be considered for severe conditions
• The prognosis of Scalp Psoriasis depends upon its severity and response to treatment. The prognosis for mild cases is generally good. However, it is potentially a lifelong, persistent condition that needs to be regularly monitored and treated symptomatically

Who gets Scalp Psoriasis? (Age and Sex Distribution)

• Scalp Psoriasis usually affects adults more than children; the condition may arise at any age
• Both males and females are affected
• The condition affects all races and ethnic groups
• Fair-skinned Caucasians have a generally higher prevalence rate for psoriasis, while dark-skinned individuals are affected to a much lesser extent

What are the Risk Factors for Scalp Psoriasis? (Predisposing Factors)

The following are the risk factors for Scalp Psoriasis:

• Scalp Psoriasis has a strong association with genetic factors. Studies have shown a correlation between psoriasis and individuals with certain types of human leukocyte antigens (HLAs). HLAs are gene complexes that form a part of the immune system
• Certain studies have also demonstrated that individuals with close relatives already affected by the condition are at a higher risk for the disease in comparison to the rest of the population. Hence, having a family member with psoriasis is a significant risk factor
• The presence of any subtype of psoriasis can greatly increase one’s risk of Scalp Psoriasis
• Caucasians who are fair-skinned, are more susceptible to psoriasis
• HIV-infected patients
• Individuals, who are smokers, alcoholics, obese, diabetic, or with heart disease, are at an increased risk for developing severe forms of the condition
• The symptoms may get worse during cold season - during fall and winter

It is important to note that having a risk factor does not mean that one will get the condition. A risk factor increases one’s chances of getting a condition compared to an individual without the risk factors. Some risk factors are more important than others.

Also, not having a risk factor does not mean that an individual will not get the condition. It is always important to discuss the effect of risk factors with your healthcare provider.

What are the Causes of Scalp Psoriasis? (Etiology)

Scalp Psoriasis may develop from an abnormal proliferation of the skin cells, referred to as keratinocytes. The exact reason behind this development is unknown. Although it is believed to be influenced by certain genetic factors.

• There seems to be an association of the skin disorder with a dysfunctional immune system (not leading to an increased risk of infections), which results in an abnormally rapid growth of epidermal  cells
• It is believed that the condition may be affected by certain environmental factors, such as colder temperatures and diminished ultraviolet light

What are the Signs and Symptoms of Scalp Psoriasis?

The signs and symptoms of Scalp Psoriasis can vary in type and severity from one individual to another. In some, the symptoms may be mild and involve only a few pockets on the scalp (localized presentation); while in others, it can be severe, involving the entire scalp. The severity of the condition varies from time to time.

• In some, the onset of psoriasis may begin in the scalp
• The back of the head is usually involved
• The affected part is characterized by thick red skin and white or silver scales
• The flaky scales resemble a “severe dandruff-like” condition
• In most cases, the region affected stays within the hairline; in some, it can move out of the scalp border
• Itching sensation may be mild, extremely severe, or even absent
• Hair loss is not usually present
• Scratching the scalp, combing the hair, or trying to remove the flaky substances may result in hair getting “pulled out” or broken off in clumps
• In severe cases, hair loss may be seen in the affected scalp; this is usually temporary, and the hair tends to grow back

In addition to the above, signs and symptoms of any of the other psoriasis subtypes (if present) may be noted.

How is Scalp Psoriasis Diagnosed?

If Scalp Psoriasis is associated with any other variant of psoriasis, it is generally easy to diagnose the condition. If Scalp Psoriasis is noted in isolation, then it may be mistaken for other scalp conditions, making for a difficult diagnosis.

A diagnosis of Scalp Psoriasis would involve the following tests and exams:

• Complete physical examination and comprehensive medical history (including evaluation of family history of the condition)
• Dermoscopy: It is a diagnostic tool where a dermatologist examines the skin using a special magnified lens
• Wood’s lamp examination: In this procedure, the healthcare provider examines the skin using ultraviolet light. It is performed to examine the change in skin pigmentation
• X-rays, CT, and MRI scan of the affected joint can help reveal the extent of damage due to inflammation in individuals with psoriatic arthritis
• Culture of scalp debris may help in ruling out bacterial or fungal infections
• Skin biopsy: A skin tissue biopsy of the lesion may be performed and sent to a laboratory for a pathological examination. A pathologist examines the biopsy under a microscope. After putting together clinical findings, special studies on tissues (if needed), and microscope findings, the pathologist arrives at a definitive diagnosis

Many clinical conditions may have similar signs and symptoms. Your healthcare provider may perform additional tests to rule out other clinical conditions to arrive at a definitive diagnosis.

What are the possible Complications of Scalp Psoriasis?

Scalp Psoriasis can cause the following complications depending on the severity of the disease activity:

• Severe itchiness can result in a loss of sleep
• Development of secondary bacterial or fungal infections
• The quality of one’s daily life may be affected
• Rarely, permanent hair loss may ensue due to psoriasis
• Social embarrassment due to dandruff, hair loss, and itchiness
• Psychological issues such as social anxiety, stress, low self-esteem, and depression
• Due to its chronic nature, some individuals may undergo severe emotional issues and psychological distress that may require counseling
• Medication side effects that may further promote hair loss

How is Scalp Psoriasis Treated?

Scalp Psoriasis is incurable with currently available treatment measures. The goal behind the treatment is to help control the symptoms, prevent skin infections, and avoid long-term complications. In general, the following medication/treatment methods are used to manage Scalp Psoriasis:

• It is usually difficult to use topical agents due to the presence of hair on the scalp and the “foul” odor of most such agents. However, scalp care applications may include the following:
  • Medicated shampoos based on coal tar or pine tar
  • Antifungal shampoos such as ketoconazole, zinc pyrithione, among others
  • Alcohol-based agents
  • Mineral oil and salicylic acid preparations
  • Coconut-oil-based medicated preparations
  • Clobetasol propionate and calcipotriene applications
  • Many topical steroids of varying potency and vehicles (solutions, ointments, aerosol sprays, and foams)
• Ultraviolet light delivered by laser or a handheld light
• Intralesional injections using corticosteroids
• Systemic therapy, using cyclosporine, methotrexate, or other biologic agents, may be considered for severe cases of Scalp Psoriasis

Medications can have significant side effects. Besides, since the medications are often needed for a long duration of time, it is recommended that combinations of medications be used to reduce side effects. This is known as rotational therapy.

How can Scalp Psoriasis be Prevented?

Currently, there are no preventative measures available for Scalp Psoriasis since it is a genetic condition. Ensuring proper self-care and regular healthcare visits are helpful in mitigating the severity and discomfort.

• Avoiding trauma (intense itching) can help prevent aggravation of the condition
• Avoid exposure to cold temperatures for prolonged periods
• Avoid triggers to the condition such as smoking, drinking alcohol, and weight gain

Active research is currently being performed to explore the possibilities for treatment and prevention of inherited and acquired genetic conditions.

What is the Prognosis of Scalp Psoriasis? (Outcomes/Resolutions)

• The prognosis for Scalp Psoriasis depends on the extent of the condition and severity of signs and symptoms. It is generally good to excellent for mild cases
• In severe cases, the prognosis depends on the set of signs and symptoms. Severe disease can significantly affect one’s quality of overall life and result in long-term stress and depression since Scalp Psoriasis symptoms may frequently recur and persist for several years
• Since the skin condition lasts a lifetime, close monitoring of the symptoms with appropriate treatment will help decrease the burden of the disease

Additional and Relevant Useful Information for Scalp Psoriasis:

• There is no evidence to prove that oily foods and chocolate-based products have an influence on the development of this condition
• Cleaning the skin too hard with strong chemicals or soaps may aggravate the skin condition. Care must be taken to avoid strong soaps and chemicals that could potentially worsen the condition

The presence of dirt on the body is not a causative factor for the condition. However, it helps to be clean and hygienic, which may help prevent the condition from getting worse