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Getting on top of scalp psoriasis

By Emily Delzell

If you have scalp psoriasis, you know the frustration of experiencing an itch that you really can't scratch. Scalp psoriasis is difficult to reach and treat, yet the flaking is visible to the public.

"Scalp psoriasis tends to itch more than psoriasis elsewhere on the body," said Dr. Jason S. Reichenberg, vice chair of the dermatology department at the University of Texas Southwestern Medical Center in Austin. "It's also hard to cover up, can leave flakes all over your clothes and, unless you have very short hair, it can be difficult to get medications to the lesions to treat them."

Alison Burbank, who has had scalp psoriasis since her initial diagnosis at age 5, said that itching is the main problem. Burbank, a 26-year-old native of Baton Rouge, La. takes Remicade (infliximab), along with methotrexate, but neither drug helped much with the thick scale and lesions on her scalp, and she began seeking an alternative.

Although scalp psoriasis can resist even systemic drugs and is tricky to access with topical medications and phototherapy, there has been an explosion of new treatments in the last 10 years, Reichenberg said.

Letting in light

"Laser treatment is one of the major additions that has really changed how we treat scalp psoriasis," Reichenberg said.

Lasers deliver ultraviolet B (UVB) light that can help clear skin with psoriasis. Unlike traditional phototherapy, dermatologists can precisely target treatment to psoriasis lesions, which can withstand higher doses of UVB light than healthy skin, said Dr. Jeffery Weinberg, associate clinical professor of dermatology at Icahn School of Medicine at Mount Sinai in New York City. Hair can still get in the way of the laser's action, but this obstacle can be partially overcome by manually parting the hair during treatment, Weinberg said.

Many dermatologists believe the laser's ability to deliver higher doses of light therapy allows people to clear more quickly and with fewer treatments than with conventional phototherapy, but there have been no head-to-head clinical trials comparing laser treatment with traditional light therapy or topical or systemic medications.

Still, research largely supports the benefits of laser therapy for scalp psoriasis. Researchers at the University of Utah, for example, reported in The Journal of Drugs in Dermatology that in a small series of patients, laser treatment, combined with a topical steroid, cleared scalp psoriasis that resisted other treatment.

In addition, a 2006 study from researchers at Johns Hopkins at Green Spring Station in Lutherville, Md., and published in Photodermatol Photoimmunol Photomed, found laser therapy improved scalp psoriasis in all 35 participants, none of whom had responded to intensive topical treatment. About half saw clearance of more than 95 percent of their scalp lesions.

Weinberg said that laser therapy comes with fewer side effects than many other medications for psoriasis, and the main issues reported by patients are redness and mild burning similar to sunburn.

Smoother delivery

In addition to lasers, which aren't the best option for everyone, Reichenberg said the surge in treatments for scalp psoriasis also includes a number of topicals. In most cases, the active ingredients aren't new but are instead delivered in more sophisticated, user-friendly mediums.

"In the past, we've pretty much been limited to liquids, but now we have sprays, oils, foams and shampoos," Reichenberg said.

This is helpful because people with different hair types often have different preferences. African-Americans, for example, often prefer an oil, while Caucasians more often want a light liquid or alcohol-based solution, he said.

Some people, including Burbank, have very thick scale on their scalp, making it difficult for medications to reach active lesions.

Patients with thick scalp scale should gently soften and remove it to allow medications to penetrate, Reichenberg said, and there are a number of products, often in the form of shampoos, that can help.

Apply the product directly on to the scalp and let it rest for five minutes so the active ingredients can do their work. Salicylic acid and coal tar are two common scale-removing ingredients in over-the-counter products, although Reichenberg cautioned that OTC products may not have much effect on anything except very mild psoriasis or sebo-psoriasis.

"Used correctly, over-the-counter products may help with mild scalp psoriasis, or the overlap of psoriasis and seborrheic dermatitis [dandruff], which is common enough that we have a name for it — sebo-psoriasis," he said.

Burbank has just started using a prescription steroid-containing shampoo. Her current dermatologist, who she's been seeing for about two years, is well-versed in newer therapies and has an optimistic outlook.

"She says we'll keep trying til we find something that works," she said.

Finding the right doctor is critical, Reichenberg said

"Finding a physician with specialized training in psoriasis — and one who is up-to-date with the current range of available therapies — is key to successful treatment," he said.

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