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A Patient’s Guide to Scalp Psoriasis

The human immune system is a highly specialized and usually very delicately balanced weapon against pathogens that can cause illness and disease. But sometimes it gets a little confused and begins to attack the body’s own cells instead of viruses and bacteria that have come in from outside. When this disruption to the immune system occurs, it can cause a person to develop an autoimmune disease, and there are a wide variety of ways autoimmune conditions can make you feel less than fantastic.

One of the more visible and uncomfortable ways autoimmune disease can manifest itself is as a condition called psoriasis. Psoriasis leads to unsightly and very itchy, sometimes painful, patches of dry, red, raised and irritated skin that builds up in patches that may be silvery in appearance. These plaques can form anywhere on the body, but a common place is the scalp.

[See: On a Scale From 1 to 10: Most Painful Medical Conditions.]

What Is Scalp Psoriasis?

As the name suggests, scalp psoriasis occurs on the scalp. “Scalp psoriasis is an autoimmune condition that results in thickened, red, flaky skin on the scalp and ears,” says Dr. Vanessa Johnson, a dermatologist with Health First Medical Group in Viera, Florida. Though it may be confined just to the scalp, in some people, it extends onto the forehead and neck.

“It typically presents as itchy, very flaky skin on the back of the scalp and around the hairline. It can cause hair loss, bleeding, a burning sensation, itching and silvery scale” on the skin of the scalp, Johnson says. “For some patients, these symptoms are severe and can cause extreme discomfort, difficulty sleeping and a decrease in quality of life.”

Scalp psoriasis is “caused by elevated levels of particular chemicals in the skin, called cytokines,” Johnson says. These proteins generated by the immune system “cause new skin cells to form in days, rather than weeks.” This buildup of excess skin can be painful and embarrassing for some people.

What’s the Difference Between Scalp Psoriasis and Dandruff?

Scalp skin that becomes dry, itchy and flaky is called dandruff. Also referred to as seborrheic dermatitis, dandruff results “from an irritation of the scalp that causes generalized fine flaking and itching,” Johnson says. Although its exact cause is unknown, it may be related to an overreaction of the immune system to a certain kind of fungus that’s commonly found on the scalp. Dry winter air and using harsh shampoos, hair dyes, styling gels and other personal products that dry out the skin of the scalp may exacerbate symptoms.

Dandruff is a common, harmless condition that may cause embarrassment for sufferers but can often be cleared up by switching to an antidandruff shampoo or using other over-the-counter treatments. On the other hand, clearing up a case of scalp psoriasis will likely require the assistance of a doctor and possibly prescription medications.

Because these two conditions both feature dry, flaky and itchy skin, “sometimes it’s a tough call” to distinguish between garden-variety dandruff and scalp psoriasis, says Dr. Howard Bruce Pride, a dermatologist with Geisinger in Danville, Pennsylvania. But often, it can be a question of the severity of symptoms. “As opposed to just being flaky, as happens with dandruff, the plaques of psoriasis are very thick. The scale is thick and sometimes described as silvery. It’s a good adjective that does conjure up an image of an inflamed plaque with a silvery scale. That’s much more an indication of psoriasis” than dandruff, he says.

Johnson adds that “psoriasis typically has well-defined borders and oval-shaped areas of involved skin, whereas dandruff has ill-defined borders without thickened skin, and occurs all over the scalp.”

How Common Is Scalp Psoriasis?

Johnson says scalp psoriasis is “very common in patients with psoriasis. Researchers estimate that at least 50 percent of people who have plaque-type psoriasis (the most common type of psoriasis), will have psoriasis in their scalp at some point.” Roughly 2 percent of Americans have some form of psoriasis.

Pride says sometimes, the scalp is the only part of the body that’s impacted by psoriasis “or it may be the first location where psoriasis develops.” The Mayo Clinic reports that scalp psoriasis is often the first place where psoriasis develops in children.

[See: 6 Reasons You’re Procrastinating on Your Health Goals — and How to Stop.]

What Are the Risk Factors for Scalp Psoriasis?

“People who have other forms of psoriasis are more likely to develop scalp psoriasis,” Johnson says. A family history of psoriasis also increases the chances that you’ll develop scalp psoriasis, she says.

Scalp psoriasis can develop in anyone at any age, but women do seem somewhat more likely to develop the condition. Certain ethnicities seem to have higher incidence rates than others. “In one U.S. study, researchers found that 3.6 percent of whites, nearly 2 percent of African Americans and 1.6 percent of Hispanics had psoriasis,” Johnson notes.

Although it’s not known exactly what triggers someone to develop scalp psoriasis, smoking and stress are thought to be two of the biggest culprits. A genetic predisposition is also likely a major driver of scalp psoriasis.

How Is Scalp Psoriasis Diagnosed?

A doctor can typically diagnose a case of scalp psoriasis by taking a thorough medical history and conducting a physical exam. In some cases, a skin biopsy — in which a small sample of affected skin is removed and sent to a lab for additional testing — may be conducted to confirm a psoriasis diagnosis.

How Is Scalp Psoriasis Treated?

Today, there is a much wider range of treatment options available to people dealing with psoriasis than there used to be. This is thanks to breakthroughs in our understanding of how psoriasis develops and which agents can help calm an overactive immune system. “Depending upon the severity, treatment can include a topical foam or solution, oral medications or even an injectable medication for patients with severe scalp psoriasis,” Johnson says.

For some people, an itchy scalp can be comfortably cooled by a shampoo that contains menthol. Tar shampoos — yes, literally coal tar that’s used in roofing and roadway construction — may also be effective in relieving itching. “The time-honored approach is to use tar,” Pride says. “It’s been around for many, many decades and it works well. It’s quite safe, but as the name implies, it’s pretty messy and there’s not much cosmetic appeal. It stains, is dirty and smells,” like pavement or a hot roof on a summer day.

When it comes to more modern treatments, these tend to fall into two major categories. The first is topical medications that are applied directly to the scalp as a cream, ointment or shampoo. These medications usually aim to slow down excessive cell growth and reduce inflammation and may contain steroids or other drugs to achieve these ends. The National Psoriasis Foundation reports that common topical treatments for scalp psoriasis include:

Anthralin. Also known as dithranol, this medication is a synthetic substance similar to a natural compound found in goa powder from the araroba tree that slows the growth of cells.

Dovonex. Also known as calcipotriol or calcipotriene, this synthetic derivative of vitamin D slows cell growth and has been available for nearly 30 years as a long-term psoriasis treatment.

Taclonex. This drug features a combination of steroids and calcipotriene to slow cell growth, reduce inflammation and itch and flatten plaque lesions.

Tazorac. Also called tazarotene, this medication is a vitamin A derivative that slows cell growth.

Patients with a full head of hair may find treating their psoriasis with these topical medications somewhat challenging, as “it can be a mess to get lotions and creams into the scalp,” Pride says. Therefore, “we try to use medicines in shampoo form,” as much as possible when dealing with scalp psoriasis.

For more severe cases or symptoms that don’t improve with topical treatments, systemic treatments that are taken either orally or as an injection or IV infusion may be more effective. Systemic medications may include:

Methotrexate. Originally developed to treat cancer, methotrexate has proven quite effective in treating a variety of rheumatic and autoimmune diseases, including scalp psoriasis.

Oral retinoids. The term retinoid refers to a synthetic form of vitamin A. These drugs can slow cell growth and a retinoid called Soriatane, or acitretin, can be used to treat psoriasis.

Cyclosporine. This immunosuppressant medication that slows cell growth was originally developed to help prevent organ rejection in transplant patients.

Biologics. These new drugs are usually delivered via injection or IV infusion, and are powerful and highly targeted immunosuppressants that are used in a variety of autoimmune disorders. Biologics used to treat psoriatic diseases (psoriasis and psoriatic arthritis) include tumor necrosis factor-alpha inhibitors, interleukin 12 and 23 inhibitors, interleukin 17 inhibitors, T-cell inhibitors and interleukin 23 inhibitors. Each type of drug targets a specific component of the immune system to calm inflammation and reduce excessive cell growth. Trade names for these drugs that you may see advertised on TV include Cosentyx, Enbrel, Humira and Taltz, among others.

The NPF reports that “hair loss is a common problem experienced by those with scalp psoriasis. Often this hair loss is the result of damage to the hair shaft or hair follicles and not a result of the psoriasis itself. This damage can occur from rubbing, scratching or excessive combing, and from chemicals or ingredients in treatments and products.” The good news is that these hair losses are almost always temporary, and gaining better control over your psoriasis symptoms may help you regrow lost hair.

How Can I Better Manage Scalp Psoriasis?

In addition to following whichever medication treatment protocol your doctor prescribes, Pride says it’s also important to consider making some lifestyle changes that may help alleviate symptoms.

Eating right. Some doctors and patients believe that diet can impact the severity of symptoms, so talk to your doctor about which foods you might want to avoid. Many people say that nightshade vegetables, such as tomatoes, and processed foods exacerbate symptoms. On the flip side, adding certain foods may help. It’s thought that foods rich in omega-3 fatty acids, such as are abundant in salmon and sardines, might help calm symptoms. Other foods that are thought to reduce inflammation in the body, such as turmeric — an orange spice common in Indian cuisine — may also improve symptoms.

Avoiding stress. “Stress is without question a trigger for most people with psoriasis,” Pride says, and this stress can feed on itself. If your psoriasis is triggered by stress, that may make you feel more stressed out as symptoms become exacerbated. To help break the cycle, Pride recommends making sure you eat right and get plenty of sleep, as both can help you feel in better control and less stressed.

Losing weight. If you’re carrying around some extra weight, that could be making your psoriasis symptoms worse, says Dr. Jessica Kaffenberger, assistant professor of dermatology with The Ohio State University Wexner Medical Center in Columbus. “Psoriasis can improve with weight loss. This is because fat is a metabolically active tissue that can increase inflammation” throughout the body. People with psoriasis may be more likely to be overweight or obese, and Kaffenberger says she counsels these individuals on weight loss and weight management.

[See: 9 Ways to Boost Your Immune System.]

What Are the Complications of Scalp Psoriasis?

Although scalp psoriasis may only affect a small amount of your skin’s surface area, it can have a lot of consequences in other parts of the body that may be harder to see. Autoimmune disorders such as scalp psoriasis feature high levels of inflammation in the body, and this can take a toll on various internal organs and body systems aside from just the skin. Over time, it can cause a range of complications, including:

Diabetes. People with psoriasis have an increased risk of developing diabetes, and the chronic inflammation that’s associated with both issues may be the connection.

Heart disease. The American Academy of Dermatology reports that “long-lasting inflammation inside your body may affect your heart and blood vessels, putting you at greater risk of developing heart disease or having a stroke.” Seeking appropriate treatment may reduce your risk of heart failure.

Arthritis. About 30 percent of all patients with psoriasis develop a condition called psoriatic arthritis, a type of inflammatory arthritis that makes the joints painful, stiff and swollen.

Thyroid disease. The thyroid manufactures and regulates certain hormones, and this delicate gland can be damaged by autoimmune conditions such as scalp psoriasis.

Kidney disease. Chronic, systemic inflammation is bad for the kidneys and their function, and uncontrolled psoriasis can lead to nephritis and other kidney problems.

Depression. Some people with psoriasis struggle with how their condition looks to other people and makes them feel different.

Inflammatory bowel syndrome. Inflammation in the digestive tract can lead to IBS, a common condition that causes cramping, diarrhea and constipation.

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A Patient’s Guide to Scalp Psoriasis originally appeared on usnews.com