Scalp psoriasis is a chronic skin condition characterized by red, itchy, and scaly patches on the scalp. These symptoms can lead to discomfort and affect the hair's appearance and overall health. 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. Children can get scalp psoriasis too, and treatments will be much the same as those used for adults.
Psoriasis on the scalp forms in the same way as on other parts of the body, but the hair traps the scales of skin, preventing them from rubbing away as they might on other body parts. The result is that scales can quickly build up, causing thicker plaques that become 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. 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 a flare-up can occur in some cases, but the hair will normally grow back. 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. Treatments can be time-consuming, and you may find them easier if you ask someone to help you. It is important to choose a treatment that suits your lifestyle; carrying out intensive treatments over the weekend, for example, when you have more free time.
Understanding Scalp Psoriasis
Scalp psoriasis is a chronic condition that leads to red, scaly patches on the scalp, which feel itchy and dry. When the body produces new skin cells too quickly, it causes psoriasis. It can lead to thick scales after a build-up of dead skin cells.
Dandruff is the most common form of seborrheic dermatitis, appearing as flaky skin on the scalp without severe redness or irritation. Ayurvedguru knows how uncomfortable it is to live with scalp psoriasis. The itching, dryness, and white flakes due to psoriasis affect the scalp and confidence as well.
Hair Washing Frequency: Finding the Right Balance
To shampoo or not to shampoo? That might be your question each time you head into the shower. Dr. Dawn Davis, a Mayo Clinic dermatologist, says that when it comes to the scalp and hair, there's a new trend online where shampooing less is preferred.
"We oftentimes think about shampooing as being beneficial for the hair. But we forget that we also have to address the scalp as well," says Dr. Everyone's hair texture and needs are different.
For persons of color, the typical recommended shampooing regimen is once to twice a week, separated by a couple of days, so that there is not dryness if you shampoo day to day. And for people who are not of color, we recommend shampooing every second or third day at a minimum. Some patients can shampoo up to daily.
There is no single rule that fits everyone. Avoid washing your hair too much because it can remove natural oils that protect the scalp, but also washing your hair too little can cause a build-up of flakes on your scalp. So, it is important to maintain balance.
At DCSI Dermatology, we recommend washing your hair every 2 to 3 days with a gentle, sulfate-free shampoo. Avoid over-washing and hot water, and consider incorporating natural remedies like coconut oil or oil treatments.
Medicated Shampoos for Scalp Psoriasis
There are two main types of over-the-counter medicated shampoos for psoriasis: those with coal tar and those with salicylic acid. Both are approved by the Food and Drug Administration for psoriasis.
Coal Tar Shampoos
Coal tar shampoos can slow skin cell growth, reduce scaling, and help with redness, inflammation, and itchiness. The downside is that they’re a bit messy and can stain clothing, and they tend to have a particular smell.
Salicylic Acid Shampoos
Shampoos with salicylic acid are used to exfoliate skin and soften and remove the patches. "It makes it easier for any topical medication to penetrate into the scalp," says Dr. Green. That can make medications more effective. These shampoos typically contain 3 percent salicylic acid.
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 jewelry 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.
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 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.
Scalp Care Routine and Treatments
To make a big difference in scalp psoriasis, follow a proper routine for better scalp health. Choose herbal and sulfate-free shampoos and avoid using harsh products to protect your scalp.
Pre-Wash Treatments
Before washing your hair, apply coconut, sesame, or almond oil to your scalp for 30 minutes. Ayurveda says that scalp psoriasis is caused due to imbalances in the Vata and Kapha doshas.
Emollients and Oils
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. Oil (olive or coconut) 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.
WARNING: Studies have shown that emollient creams that become dried on clothing, dressings, and other material can catch fire if exposed to a source of ignition (this could include a spark from a naked flame, whilst smoking, using cigarette lighters, or any other methods where the product could be exposed to a potential flame source).
Prescription Treatments
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.
- Potent corticosteroid: Once daily for up to 4 weeks as the initial treatment. If there is no improvement after 4 weeks, you may be offered a different formulation of corticosteroid.
Topical steroids come in various formulations, and some are specifically designed as scalp products. These tend to be lotions, gels, foams, sprays, or shampoos, so they can be used more easily in hair-covered areas, are more cosmetically acceptable, and are easier to wash out. Corticosteroids come in different strengths, ranging from mild to very strong potency. Potent steroids are usually prescribed for scalp treatment but are not suitable for the face or around the ears. They should not be used continuously for long periods. 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.
When 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 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 (i.e., do not need to be washed out). They do not smell or stain clothing and are relatively easy to use, although not all are specifically designed for use on the scalp. They can be used to bring 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.
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.
Other Considerations
If a bacterial or yeast infection is present, scalp psoriasis can become worse. Mild scalp psoriasis can also mimic or coincide with a yeast infection and so may respond well to treatment with antifungal shampoos.
Successful outcomes for using UV light treatments are 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.
A lot of product treatments will contain salicylic acid, known as a keratolytic. This ingredient aims to break down 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.
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, systemic treatment may be considered.
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, colorings, 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.
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. Some treatments should not be used during pregnancy or breastfeeding, so before you use them, always check their suitability with your doctor.
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.