By Gary M. White, MD
Psoriasis very commonly affects the scalp.
Scalp psoriasis--like seborrheic dermatitis--manifests itself as redness and scaling of the scalp However, the crust is thicker, the lesions are more well-defined, and they are often more resistant to treatment. A plaque of redness and scale encircling the scalp, extending 1-2 cm beyond the hair line is also characteristic.
Daily use of a medicated shampoo (e.g. selenium sulfide 2.5%, zinc pyrithione, ketoconazole 1-2%, tar) followed by a topical steroid liquid is often sufficient. For mild itching, fluocinonide solution or betamethasone valerate solution are good. For more severe redness and/or itching, clobetasol scalp solution may be needed. Clobetasol foam is more effective than clobetasol solution. A clobetasol spray is also available.
No scratching please as this increases the activity of psoriasis. Always remember that psoriasis Koebnerizes and repeated scratching in one area can make an isolated plaque of scalp psoriasis persist for years. (Don't hesitate to instruct a patient not to scratch.)
Calcipotriene solution 0.005% is available. It is applied BID. Alternatively, one may apply it QD followed by clobetasol solution QD. A combination foam containing calcipotriene and betamethasone (Cal foam) is available and very effective.
If significant scale remains after initial interventions, various medications may be occluded overnight under a shower cap e.g. mineral oil, a topical steroid in an oil vehicle (Derma-Smoothe/FS--fluocinolone 0.01%--wet hair and scalp thoroughly before applying, cover with shower cap), Bakers PS (a mixture of phenol and saline), 20% urea (mixed up in an aqueous cream by the local pharmacist) and shampooed off in the AM.
Rarely, methotrexate, apremilast or another systemic agent may be needed for recalcitrant scalp-only psoriasis. See systemic treatment.
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