Art & science
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Josephine G Paterson
Diagnosis and treatment of adults with scalp psoriasis Renton C (2014) Diagnosis and treatment of adults with scalp psoriasis. Nursing Standard. 28, 26, 35-39. Date of submission: September 20 2013; date of acceptance: December 10 2013.
Abstract Psoriasis is a chronic, lifelong skin condition, and scalp psoriasis is a common manifestation of this condition. Scalp psoriasis often requires separate treatment to psoriasis on other areas of the body because of the presence of hair, thinness of the skin and the visibility of this area, which may affect the person’s quality of life and wellbeing. An increased understanding of the treatment options available for scalp psoriasis, management protocols and effective application techniques may result in improved outcomes for patients.
Author Carla Renton Information and communications manager, Psoriasis Association, Northampton. Correspondence to: [email protected]
Keywords Dermatology, emollients, plaque psoriasis, psoriasis, scalp psoriasis, skin conditions, topical treatment
Review All articles are subject to external double-blind peer review and checked for plagiarism using automated software.
Online Guidelines on writing for publication are available at www.nursing-standard.co.uk. For related articles visit the archive and search using the keywords above.
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PSORIASIS IS AN immune-mediated skin condition characterised by areas of red, raised plaques and scaling. It is thought to affect around 2% of the UK population, and is equally common in males and females (NHS Choices 2013). Psoriasis can occur at any point in an individual’s life, and around one third of those affected develop the condition before the age of 16 (Raychaudhuri and Gross 2000, Augustin et al 2010). Most cases of psoriasis occur before the age of 35 (National Institute for Health and Care Excellence (NICE) 2012), with a second peak in onset occurring around the age of 55-60 (Langley et al 2005). Psoriasis is a chronic, lifelong condition that is prone to periods of flare-up and remission. Although there is a range of treatments available to manage the condition, response to treatment is unique to each individual, meaning that effective treatment can be a process of trial and error. There are several different types of psoriasis, including guttate (widespread, raindrop-like psoriasis that is often triggered by streptococcal infection), flexural (redder and less dry than guttate psoriasis, and scaly), and pustular (sterile blister-like pustules). The most common form is plaque psoriasis, which is characterised by dry, red skin lesions covered in silver scales and tends to appear on the elbows, knees, lower back and scalp (NHS Choices 2013). While different types of psoriasis may co-exist, or one may give way to another, plaque psoriasis occurs in 90% of cases (NHS Choices 2013). Any type of psoriasis may be itchy, sore or both, however plaque psoriasis affecting the scalp is often difficult to treat (NICE 2012). Scalp psoriasis is a manifestation of plaque psoriasis on the scalp, often including areas such as the hairline, forehead, back of the neck february 26 :: vol 28 no 26 :: 2014 35
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Art & science dermatology (Figure 1) and ears. It can occur in the presence or absence of other forms of psoriasis. In mild scalp psoriasis, the scalp may be dry and flaky. In moderate to severe scalp psoriasis, the plaques will be well demarcated (easily distinguished from non-psoriatic skin when running a hand over the area), red and inflamed. White or off-white plaques may be visible through the hair, or along the hairline (Figure 1), and flakes may also be present in the hair or have fallen onto the shoulders or clothes. In severe cases of scalp psoriasis, there may be hair thinning or loss because of thick plaques blocking the hair shafts. Van Onselen (2001) described three severities: Mild – dry flaking skin on areas of the scalp interspersed with normal skin. The hairline is unaffected and there is no hair loss. Moderate – dry flaking and scaling skin on most of the scalp with some normal skin. Psoriasis extends to the hairline with minimal hair loss. Severe – the entire scalp is affected with minimal normal skin. The scalp presents with thick and lumpy scales. The hairline is affected, with redness and scaling extending beyond the scalp margins. Temporary hair loss may occur.
Causes Psoriasis is an immune-mediated condition (Mason et al 2013), resulting in over-proliferation of skin cells and the development of scaly plaques on the skin. The pathogenesis of psoriasis is complex and influenced by many factors (Mason et al 2013). T-cells become activated mistakenly (NHS Choices 2013), in turn causing cytokines to trigger rapid proliferation of skin cells and inflammation (National Psoriasis Foundation 2013, Primary Care Dermatology Society 2013). Patients with psoriasis have a genetic susceptibility to the condition, which may or may not develop following an environmental trigger (Langley et al 2005). Psoriasis will not be triggered in everyone with genetic susceptibility, and
FIGURE 1
ALAMY
Scalp psoriasis affecting the back of the neck
36 february 26 :: vol 28 no 26 :: 2014
only an estimated 30% of patients have a family history of the condition (NHS Choices 2013). Therefore, while family history can form part of the supportive evidence for a diagnosis of psoriasis, it cannot either confirm or negate the diagnosis. There are several factors known to trigger a first instance of psoriasis, precipitate a flare-up or exacerbate existing psoriasis. These include periods of emotional trauma, stress or anxiety, injury to the skin (known as the Koebner phenomenon, for some this may even include friction or rubbing), certain medications (including lithium, certain antihypertension medications and certain antimalarial medications) and smoking (NHS Choices 2013). Psoriasis does not occur as the result of an allergy or contact with an irritant, and so in the case of scalp psoriasis, it is unlikely to have been caused by a particular shampoo, hair styling product or hair dye. However, it is possible that an allergy to these or similar products could exacerbate existing scalp psoriasis.
Diagnosis In most cases, the diagnosis of scalp psoriasis is clinical and is made after identifying the scalp as dry and flaky with well demarcated plaques. A personal or family history of psoriasis, or confirmed or suspected psoriasis on other parts of the body will support the diagnosis. There is no blood or laboratory test for psoriasis, but a skin biopsy can confirm the condition in cases where diagnosis is uncertain. Skin conditions can co-exist, and although psoriasis is not particularly susceptible to infection, this is a possibility with any skin condition that may be scratched. It is, therefore, important to assess whether a fungal or bacterial infection may be present on the scalp, and treat accordingly.
Treatment In some cases, psoriasis can be managed with emollients alone or without treatment. The scalp is a highly visible area, and the fact that flakes of skin can be seen in the hair and on clothes may be a source of embarrassment and may lead to avoidance coping strategies, such as avoiding dark coloured clothing or furniture. Similarly, any hair thinning or loss can be distressing for patients. Psoriasis is known to affect quality of life and emotional wellbeing (Psoriasis Association and Mental Health Foundation 2012) in a way that is comparable with other major conditions, including diabetes, arthritis and cancer (Rapp et al 1999). The effect of psoriasis does not correlate directly to the severity of disease (British Association of
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Dermatologists (BAD) and Primary Care Dermatology Society 2009), and it is important to encourage patients to discuss their feelings and how the condition affects their lives. The patient’s perception of disability as a result of the condition should be taken into account when discussing disease severity, and this can be measured using the Dermatology Life Quality Index (DLQI) (Finlay and Khan 1994). In secondary care, high DLQI scores are required for prescribing certain medications for psoriasis (NICE 2006, 2008a, 2008b, 2009). However, the DLQI is not always sensitive enough to detect low mood and depression (NICE 2012), and it is important to encourage patients to talk about their wellbeing in addition to use of the DLQI. Psoriasis affects individuals differently, and what works for one person does not necessarily work for another. Identifying a treatment or combination of treatments that is effective is often a process of trial and error, and patients require encouragement to persist with their treatment regimens. Psoriasis is a lifelong condition and many patients experience long exacerbations and remission. Therefore, effective communication between patients and clinicians is essential to ensure patients are informed about the nature of psoriasis as well as the various treatment options available (BAD and Primary Care Dermatology Society 2009). The extent, severity and effect of psoriasis should be assessed on presentation, before referral and during treatment to evaluate the efficacy of treatment interventions (NICE 2012). A record of the patient’s assessment provides an invaluable demonstration of any progress that may have been achieved before commencing a new treatment, and at each review. Because of the presence of hair, the thinness of skin on the scalp and the visibility of the area, the scalp may require different treatment to psoriasis elsewhere on the body. It is, therefore, important to treat scalp psoriasis as a distinct condition and separate site. Most scalp psoriasis is treated using topical applications (NICE 2012, Mason et al 2013) (Table 1), and it is essential to inform the patient that these treatments may need to be applied for up to eight weeks before their full effect is seen. It is also important to consider patient preference and lifestyle, because individuals have their own preferences, for example gel, ointment, lotion or shampoo, or may find it easier to use a combined application where possible, rather than applying separate formulations. Taking account of patient preference is likely to improve adherence to treatment regimens. The treatment pathway for children and teenagers may vary in terms of which applications
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and doses are suitable. Suitability of each treatment should be checked in the British National Formulary for Children, and the treatment regimen should be adjusted as required. Parents or guardians of children or young people with psoriasis should be educated on the nature of the condition and treatment application techniques.
Moisturising
Emollient use is an essential part of psoriasis treatment, and scalp psoriasis is no exception. Moisturising can help to reduce itching, skin tightness and discomfort, as well as softening scale and gently lifting plaques. Moisturising can increase the effectiveness of topical treatments with active ingredients (Green 2011, British Dermatological Nursing Group 2012). Since the scalp is a predominantly hairy area, favoured emollients are thinner and less greasy than those frequently used on other parts of the body (British Dermatological Nursing Group 2012). Lotions and oils tend to be most appropriate
TABLE 1 Topical treatments for psoriasis Topical treatment
Summary
Emollients (moisturisers)
Ease itching and dryness, reduce scaling, soften cracked areas of skin and help the penetration of other topical treatments. Use as often as needed.
Emollients containing salicylic acid
Can help reduce excessive scaling, but may irritate surrounding skin.
Topical steroids (corticosteroids)
Helpful on localised lesions. Weaker corticosteroids often do not work well on thick patches of psoriasis. Use needs to be monitored.
Tar preparations
Help to remove loose scales from patches of psoriasis, but can be messy and stain clothing. Preparations include medicated tar baths, creams, ointments or shampoos.
Dithranol (including short contact therapy)
Good for treating chronic scaly psoriasis in selected areas and can be prescribed for use at home. Short contact therapy is performed by trained nursing staff.
Vitamin D analogues
Treatment is applied either once or twice per day and is cosmetically acceptable. Not to be used while the patient is pregnant or breastfeeding. Some vitamin D analogues are combined with corticosteroid ointments for short-term use.
Vitamin A analogues
Tazarotene is a vitamin A gel that is applied once daily to patches of psoriasis. It should not be used on the face, skin folds or large areas of the body, or while pregnant or breastfeeding.
(Adapted from National Institute for Health and Care Excellence 2012, British Association of Dermatologists 2013)
february 26 :: vol 28 no 26 :: 2014 37
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Art & science dermatology for use on the scalp. If these are applied before bed, by parting the hair and massaging into the scalp, and washed out in the morning, this should help to minimise any unpleasant cosmetic effects. To reduce thick scale, BAD (2004) recommends applying coconut, olive or arachis oil at night and keeping the area occluded. Some patients also find that natural oils, such as olive or coconut oil, have additional benefits in terms of conditioning the hair.
Treatment hierarchy
Treatments for scalp psoriasis have remained the same for many years, and begin initially with topical treatments, including coal tar-based preparations and shampoos, vitamin D-based preparations, corticosteroids and dithranol applications. While phototherapy, and systemic and biologic therapies are available for people with moderate to severe psoriasis, the criteria required for these interventions means that scalp psoriasis alone is unlikely to warrant their use, unless it is particularly severe or resistant to treatment (NICE 2006, 2008a, 2008b, 2009). Some individuals with scalp psoriasis will also have psoriasis on other areas of the body, which may or may not qualify for the use of these treatments, and the scalp may respond accordingly. Mason et al (2013) found that very potent corticosteroids were the most effective topical agents for psoriasis, but NICE (2012) does not recommend their use in the initial stage of treatment because of potential side effects such as skin-thinning. It is recommended that treatment begins with a potent corticosteroid once daily. If no adequate improvement is seen in four weeks, a different potent corticosteroid formulation should be used, with possible addition of a descaling agent such as salicyclic acid. If the response continues to be inadequate, it is appropriate to consider a vitamin D and corticosteroid combination, or vitamin D alone in certain circumstances. A combined calcipotriol and betamethasone application is available, which may be preferable to patients because of ease of use (one application, rather than two applications); however, generic calcipotriol is available in a scalp solution, and so the vitamin D and corticosteroid can also be prescribed separately. If the response is inadequate after eight weeks of this therapy, NICE (2012) recommends considering a potent corticosteroid or topical coal tar application. If the patient is being treated in primary care, a referral to specialist services should also be sought. A summary of NICE (2012) guidance for the management of scalp psoriasis is provided in Figure 2. Because the evidence for coal tar shampoo benefit is limited, NICE (2012) guidance states that patients with severe scalp disease should not be offered this treatment alone. 38 february 26 :: vol 28 no 26 :: 2014
Method of application
Although it may be assumed that patients understand how to apply treatments, they are usually keen to receive demonstrations of how to use topical treatments effectively (Ersser et al 2010). Lack of adherence to treatment regimens has been linked to a lack of education on how treatments work, and the need to apply them regularly throughout the day (Ersser et al 2010). Therefore, spending time with patients to provide education and demonstrate application may lead to better treatment outcomes. The amount and frequency of use may differ depending on the treatment prescribed, and attention should be paid to the manufacturer’s information, as well as NICE (2012) guidance. In general, application of emollients and non-shampoo topical treatments involves parting the hair in sections and rubbing the treatment along the exposed area in a sequential fashion. It can be difficult to see and reach the top and back of the head, and some patients find it easier to enlist the help of relatives or carers.
Non-topical treatment
Patients with scalp psoriasis are unlikely to need non-topical treatment unless the condition is unresponsive or severe. Patients with other types
FIGURE 2 Treatment of scalp psoriasis Potent corticosteroid: use once daily for up to four weeks
Different corticosteroid formulation and/or descaling agent If response is not adequate within four weeks Calcipotriol and betamethasone combination treatment: use once daily or vitamin D once daily (only in those who cannot use corticosteroids and who have mild to moderate scalp psoriasis) If response is not adequate within four weeks Very potent corticosteroid: use up to twice daily for two weeks or coal tar once or twice daily, or referral to a specialist (Adapted from National Institute for Health and Care Excellence 2012)
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of psoriasis, or psoriasis on other areas of the body, may qualify for phototherapy, or systemic or biologic therapy. Any treatment prescribed for the scalp should take other treatments into account. For example, patients undergoing phototherapy should avoid applying topical applications to the psoriasis (including the scalp) on the morning of a phototherapy session (BAD 2012). Similarly, some medications can increase light sensitivity, and these should be avoided while undergoing phototherapy (BAD 2012). Anecdotally, patients undergoing systemic or biologic therapy for more widespread psoriasis may find that it also has a positive effect on scalp psoriasis, and if this occurs, the approach to treatment of scalp psoriasis can be reviewed as appropriate. Some patients find that the scalp will still require some form of topical or emollient therapy to help maintain results. In addition to medical treatment and support from healthcare professionals, external, independent information and support will benefit some patients. The Psoriasis Association (www. psoriasis-association.org.uk) is the leading national
charity and membership organisation for people affected by psoriasis in the UK. It provides up to date independent information, and operates a telephone and email helpline, as well as online forums for patients to share their experiences. Patients may also benefit from local psoriasis or dermatology support groups.
Conclusion Scalp psoriasis is common in those who have psoriasis in other areas of the body, although for some it may be the main problem or occur alone. Despite its prevalence, scalp psoriasis is often difficult to treat and has a profound effect on patients’ quality of life and wellbeing. Therefore, it is important that the scalp is treated as a separate site. While a variety of treatments are available for the condition, it can be a process of trial and error to find the most effective treatment or combination of treatments. Psychological and social support, as well as encouragement and education are important to promote wellbeing and improve quality of life for patients with scalp psoriasis NS
References Augustin M, Glaeske G, Radtke MA, Christophers E, Reich K, Schäfer I (2010) Epidemiology and comorbidity of psoriasis in children. British Journal of Dermatology. 162, 3, 633-636. British Association of Dermatologists (2004) Psoriasis – General Management. www.bad.org. uk/site/1119/Default.aspx (Last accessed: February 12 2014.) British Association of Dermatologists (2012) Phototherapy. www.bad. org.uk/site/1223/default.aspx (Last accessed: February 12 2014.) British Association of Dermatologists (2013) Topical Treatments for Psoriasis. www.bad. org.uk/site/865/Default.aspx (Last accessed: February 12 2014.) British Association of Dermatologists, Primary Care Dermatology Society (2009) Recommendations for the Initial Management of Psoriasis. tinyurl.com/5ukmu6m (Last accessed: February 12 2014.) British Dermatological Nursing Group (2012) Best practice in emollient therapy: a statement for healthcare professionals. Dermatological Nursing. 11, 4, s4-s19.
Ersser SJ, Cowdell FC, Latter SM, Healy E (2010) Self-management experiences in adults with mildmoderate psoriasis: an exploratory study and implications for improved support. British Journal of Dermatology. 163, 5, 1044-1049. Finlay AY, Khan GK (1994) Dermatology Life Quality Index (DLQI) – a simple practical measure for routine clinical use. Clinical and Experimental Dermatology. 19, 3, 210-216. Green L (2011) Emollient therapy for dry and inflammatory skin conditions. Nursing Standard. 26, 1, 39-46. Langley RG, Krueger GG, Griffiths CE (2005) Psoriasis: epidemiology, clinical features, and quality of life. Annals of the Rheumatic Diseases. 64, Suppl 2, ii18-ii23. Mason AR, Mason J, Cork M, Dooley G, Hancock H (2013) Topical treatments for chronic plaque psoriasis. Cochrane Database of Systematic Reviews. Issue 3, CD005028. National Institute for Health and Care Excellence (2006) Etanercept and Efalizumab for the Treatment
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of Adults with Psoriasis. Technology appraisal guidance No. 103. NICE, London. National Institute for Health and Care Excellence (2008a) Adalimumab for the Treatment of Adults with Psoriasis. Technology appraisal guidance No. 146. NICE, London. National Institute for Health and Care Excellence (2008b) Infliximab for the Treatment of Adults with Psoriasis. Technology appraisal guidance No. 134. NICE, London. National Institute for Health and Care Excellence (2009) Ustekinumab for the Treatment of Adults with Moderate to Severe Psoriasis. Technology appraisal guidance No. 180. NICE, London.
NHS Choices (2013) Psoriasis. www.nhs.uk/Conditions/Psoriasis/ Pages/Introduction.aspx (Last accessed: February 12 2014.) Primary Care Dermatology Society (2013) Psoriasis: Overview and Chronic Plaque Psoriasis. tinyurl. com/mqa9nvj (Last accessed: February 12 2014.) Psoriasis Association, Mental Health Foundation (2012) See Psoriasis: Look Deeper. Recognising the Life Impact of Psoriasis. tinyurl.com/ llavlw4 (Last accessed: February 12 2014.) Rapp SR, Feldman SR, Exum ML, Fleischer AB Jr, Reboussin DM (1999) Psoriasis causes as much disability as other major medical diseases. Journal of the American Academy of Dermatology. 41, 3, 1, 401-407.
National Institute for Health and Care Excellence (2012) Psoriasis: The Assessment and Management of Psoriasis. Clinical guideline No. 153. NICE, London.
Raychaudhuri SP, Gross J (2000) A comparative study of pediatric onset psoriasis with adult onset psoriasis. Pediatric Dermatology. 17, 3, 174-178.
National Psoriasis Foundation (2013) The Immune System and Psoriatic Diseases. tinyurl.com/ pdq9d3j (Last accessed: February 12 2014.)
Van Onselen J (2001) Psoriasis. In Hughes E, Van Onselen J (Eds) Dermatology Nursing: A Practical Guide. Harcourt Publishers, London, 133-149.
february 26 :: vol 28 no 26 :: 2014 39
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If you would like to contribute to the Art & science section, email [email protected]
The synthesis of art and science is lived by the nurse in the nursing act
Josephine G Paterson
Diagnosis and treatment of adults with scalp psoriasis Renton C (2014) Diagnosis and treatment of adults with scalp psoriasis. Nursing Standard. 28, 26, 35-39. Date of submission: September 20 2013; date of acceptance: December 10 2013.
Abstract Psoriasis is a chronic, lifelong skin condition, and scalp psoriasis is a common manifestation of this condition. Scalp psoriasis often requires separate treatment to psoriasis on other areas of the body because of the presence of hair, thinness of the skin and the visibility of this area, which may affect the person’s quality of life and wellbeing. An increased understanding of the treatment options available for scalp psoriasis, management protocols and effective application techniques may result in improved outcomes for patients.
Author Carla Renton Information and communications manager, Psoriasis Association, Northampton. Correspondence to: [email protected]
Keywords Dermatology, emollients, plaque psoriasis, psoriasis, scalp psoriasis, skin conditions, topical treatment
Review All articles are subject to external double-blind peer review and checked for plagiarism using automated software.
Online Guidelines on writing for publication are available at www.nursing-standard.co.uk. For related articles visit the archive and search using the keywords above.
© NURSING STANDARD / RCN PUBLISHING
PSORIASIS IS AN immune-mediated skin condition characterised by areas of red, raised plaques and scaling. It is thought to affect around 2% of the UK population, and is equally common in males and females (NHS Choices 2013). Psoriasis can occur at any point in an individual’s life, and around one third of those affected develop the condition before the age of 16 (Raychaudhuri and Gross 2000, Augustin et al 2010). Most cases of psoriasis occur before the age of 35 (National Institute for Health and Care Excellence (NICE) 2012), with a second peak in onset occurring around the age of 55-60 (Langley et al 2005). Psoriasis is a chronic, lifelong condition that is prone to periods of flare-up and remission. Although there is a range of treatments available to manage the condition, response to treatment is unique to each individual, meaning that effective treatment can be a process of trial and error. There are several different types of psoriasis, including guttate (widespread, raindrop-like psoriasis that is often triggered by streptococcal infection), flexural (redder and less dry than guttate psoriasis, and scaly), and pustular (sterile blister-like pustules). The most common form is plaque psoriasis, which is characterised by dry, red skin lesions covered in silver scales and tends to appear on the elbows, knees, lower back and scalp (NHS Choices 2013). While different types of psoriasis may co-exist, or one may give way to another, plaque psoriasis occurs in 90% of cases (NHS Choices 2013). Any type of psoriasis may be itchy, sore or both, however plaque psoriasis affecting the scalp is often difficult to treat (NICE 2012). Scalp psoriasis is a manifestation of plaque psoriasis on the scalp, often including areas such as the hairline, forehead, back of the neck february 26 :: vol 28 no 26 :: 2014 35
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Art & science dermatology (Figure 1) and ears. It can occur in the presence or absence of other forms of psoriasis. In mild scalp psoriasis, the scalp may be dry and flaky. In moderate to severe scalp psoriasis, the plaques will be well demarcated (easily distinguished from non-psoriatic skin when running a hand over the area), red and inflamed. White or off-white plaques may be visible through the hair, or along the hairline (Figure 1), and flakes may also be present in the hair or have fallen onto the shoulders or clothes. In severe cases of scalp psoriasis, there may be hair thinning or loss because of thick plaques blocking the hair shafts. Van Onselen (2001) described three severities: Mild – dry flaking skin on areas of the scalp interspersed with normal skin. The hairline is unaffected and there is no hair loss. Moderate – dry flaking and scaling skin on most of the scalp with some normal skin. Psoriasis extends to the hairline with minimal hair loss. Severe – the entire scalp is affected with minimal normal skin. The scalp presents with thick and lumpy scales. The hairline is affected, with redness and scaling extending beyond the scalp margins. Temporary hair loss may occur.
Causes Psoriasis is an immune-mediated condition (Mason et al 2013), resulting in over-proliferation of skin cells and the development of scaly plaques on the skin. The pathogenesis of psoriasis is complex and influenced by many factors (Mason et al 2013). T-cells become activated mistakenly (NHS Choices 2013), in turn causing cytokines to trigger rapid proliferation of skin cells and inflammation (National Psoriasis Foundation 2013, Primary Care Dermatology Society 2013). Patients with psoriasis have a genetic susceptibility to the condition, which may or may not develop following an environmental trigger (Langley et al 2005). Psoriasis will not be triggered in everyone with genetic susceptibility, and
FIGURE 1
ALAMY
Scalp psoriasis affecting the back of the neck
36 february 26 :: vol 28 no 26 :: 2014
only an estimated 30% of patients have a family history of the condition (NHS Choices 2013). Therefore, while family history can form part of the supportive evidence for a diagnosis of psoriasis, it cannot either confirm or negate the diagnosis. There are several factors known to trigger a first instance of psoriasis, precipitate a flare-up or exacerbate existing psoriasis. These include periods of emotional trauma, stress or anxiety, injury to the skin (known as the Koebner phenomenon, for some this may even include friction or rubbing), certain medications (including lithium, certain antihypertension medications and certain antimalarial medications) and smoking (NHS Choices 2013). Psoriasis does not occur as the result of an allergy or contact with an irritant, and so in the case of scalp psoriasis, it is unlikely to have been caused by a particular shampoo, hair styling product or hair dye. However, it is possible that an allergy to these or similar products could exacerbate existing scalp psoriasis.
Diagnosis In most cases, the diagnosis of scalp psoriasis is clinical and is made after identifying the scalp as dry and flaky with well demarcated plaques. A personal or family history of psoriasis, or confirmed or suspected psoriasis on other parts of the body will support the diagnosis. There is no blood or laboratory test for psoriasis, but a skin biopsy can confirm the condition in cases where diagnosis is uncertain. Skin conditions can co-exist, and although psoriasis is not particularly susceptible to infection, this is a possibility with any skin condition that may be scratched. It is, therefore, important to assess whether a fungal or bacterial infection may be present on the scalp, and treat accordingly.
Treatment In some cases, psoriasis can be managed with emollients alone or without treatment. The scalp is a highly visible area, and the fact that flakes of skin can be seen in the hair and on clothes may be a source of embarrassment and may lead to avoidance coping strategies, such as avoiding dark coloured clothing or furniture. Similarly, any hair thinning or loss can be distressing for patients. Psoriasis is known to affect quality of life and emotional wellbeing (Psoriasis Association and Mental Health Foundation 2012) in a way that is comparable with other major conditions, including diabetes, arthritis and cancer (Rapp et al 1999). The effect of psoriasis does not correlate directly to the severity of disease (British Association of
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Dermatologists (BAD) and Primary Care Dermatology Society 2009), and it is important to encourage patients to discuss their feelings and how the condition affects their lives. The patient’s perception of disability as a result of the condition should be taken into account when discussing disease severity, and this can be measured using the Dermatology Life Quality Index (DLQI) (Finlay and Khan 1994). In secondary care, high DLQI scores are required for prescribing certain medications for psoriasis (NICE 2006, 2008a, 2008b, 2009). However, the DLQI is not always sensitive enough to detect low mood and depression (NICE 2012), and it is important to encourage patients to talk about their wellbeing in addition to use of the DLQI. Psoriasis affects individuals differently, and what works for one person does not necessarily work for another. Identifying a treatment or combination of treatments that is effective is often a process of trial and error, and patients require encouragement to persist with their treatment regimens. Psoriasis is a lifelong condition and many patients experience long exacerbations and remission. Therefore, effective communication between patients and clinicians is essential to ensure patients are informed about the nature of psoriasis as well as the various treatment options available (BAD and Primary Care Dermatology Society 2009). The extent, severity and effect of psoriasis should be assessed on presentation, before referral and during treatment to evaluate the efficacy of treatment interventions (NICE 2012). A record of the patient’s assessment provides an invaluable demonstration of any progress that may have been achieved before commencing a new treatment, and at each review. Because of the presence of hair, the thinness of skin on the scalp and the visibility of the area, the scalp may require different treatment to psoriasis elsewhere on the body. It is, therefore, important to treat scalp psoriasis as a distinct condition and separate site. Most scalp psoriasis is treated using topical applications (NICE 2012, Mason et al 2013) (Table 1), and it is essential to inform the patient that these treatments may need to be applied for up to eight weeks before their full effect is seen. It is also important to consider patient preference and lifestyle, because individuals have their own preferences, for example gel, ointment, lotion or shampoo, or may find it easier to use a combined application where possible, rather than applying separate formulations. Taking account of patient preference is likely to improve adherence to treatment regimens. The treatment pathway for children and teenagers may vary in terms of which applications
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and doses are suitable. Suitability of each treatment should be checked in the British National Formulary for Children, and the treatment regimen should be adjusted as required. Parents or guardians of children or young people with psoriasis should be educated on the nature of the condition and treatment application techniques.
Moisturising
Emollient use is an essential part of psoriasis treatment, and scalp psoriasis is no exception. Moisturising can help to reduce itching, skin tightness and discomfort, as well as softening scale and gently lifting plaques. Moisturising can increase the effectiveness of topical treatments with active ingredients (Green 2011, British Dermatological Nursing Group 2012). Since the scalp is a predominantly hairy area, favoured emollients are thinner and less greasy than those frequently used on other parts of the body (British Dermatological Nursing Group 2012). Lotions and oils tend to be most appropriate
TABLE 1 Topical treatments for psoriasis Topical treatment
Summary
Emollients (moisturisers)
Ease itching and dryness, reduce scaling, soften cracked areas of skin and help the penetration of other topical treatments. Use as often as needed.
Emollients containing salicylic acid
Can help reduce excessive scaling, but may irritate surrounding skin.
Topical steroids (corticosteroids)
Helpful on localised lesions. Weaker corticosteroids often do not work well on thick patches of psoriasis. Use needs to be monitored.
Tar preparations
Help to remove loose scales from patches of psoriasis, but can be messy and stain clothing. Preparations include medicated tar baths, creams, ointments or shampoos.
Dithranol (including short contact therapy)
Good for treating chronic scaly psoriasis in selected areas and can be prescribed for use at home. Short contact therapy is performed by trained nursing staff.
Vitamin D analogues
Treatment is applied either once or twice per day and is cosmetically acceptable. Not to be used while the patient is pregnant or breastfeeding. Some vitamin D analogues are combined with corticosteroid ointments for short-term use.
Vitamin A analogues
Tazarotene is a vitamin A gel that is applied once daily to patches of psoriasis. It should not be used on the face, skin folds or large areas of the body, or while pregnant or breastfeeding.
(Adapted from National Institute for Health and Care Excellence 2012, British Association of Dermatologists 2013)
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Art & science dermatology for use on the scalp. If these are applied before bed, by parting the hair and massaging into the scalp, and washed out in the morning, this should help to minimise any unpleasant cosmetic effects. To reduce thick scale, BAD (2004) recommends applying coconut, olive or arachis oil at night and keeping the area occluded. Some patients also find that natural oils, such as olive or coconut oil, have additional benefits in terms of conditioning the hair.
Treatment hierarchy
Treatments for scalp psoriasis have remained the same for many years, and begin initially with topical treatments, including coal tar-based preparations and shampoos, vitamin D-based preparations, corticosteroids and dithranol applications. While phototherapy, and systemic and biologic therapies are available for people with moderate to severe psoriasis, the criteria required for these interventions means that scalp psoriasis alone is unlikely to warrant their use, unless it is particularly severe or resistant to treatment (NICE 2006, 2008a, 2008b, 2009). Some individuals with scalp psoriasis will also have psoriasis on other areas of the body, which may or may not qualify for the use of these treatments, and the scalp may respond accordingly. Mason et al (2013) found that very potent corticosteroids were the most effective topical agents for psoriasis, but NICE (2012) does not recommend their use in the initial stage of treatment because of potential side effects such as skin-thinning. It is recommended that treatment begins with a potent corticosteroid once daily. If no adequate improvement is seen in four weeks, a different potent corticosteroid formulation should be used, with possible addition of a descaling agent such as salicyclic acid. If the response continues to be inadequate, it is appropriate to consider a vitamin D and corticosteroid combination, or vitamin D alone in certain circumstances. A combined calcipotriol and betamethasone application is available, which may be preferable to patients because of ease of use (one application, rather than two applications); however, generic calcipotriol is available in a scalp solution, and so the vitamin D and corticosteroid can also be prescribed separately. If the response is inadequate after eight weeks of this therapy, NICE (2012) recommends considering a potent corticosteroid or topical coal tar application. If the patient is being treated in primary care, a referral to specialist services should also be sought. A summary of NICE (2012) guidance for the management of scalp psoriasis is provided in Figure 2. Because the evidence for coal tar shampoo benefit is limited, NICE (2012) guidance states that patients with severe scalp disease should not be offered this treatment alone. 38 february 26 :: vol 28 no 26 :: 2014
Method of application
Although it may be assumed that patients understand how to apply treatments, they are usually keen to receive demonstrations of how to use topical treatments effectively (Ersser et al 2010). Lack of adherence to treatment regimens has been linked to a lack of education on how treatments work, and the need to apply them regularly throughout the day (Ersser et al 2010). Therefore, spending time with patients to provide education and demonstrate application may lead to better treatment outcomes. The amount and frequency of use may differ depending on the treatment prescribed, and attention should be paid to the manufacturer’s information, as well as NICE (2012) guidance. In general, application of emollients and non-shampoo topical treatments involves parting the hair in sections and rubbing the treatment along the exposed area in a sequential fashion. It can be difficult to see and reach the top and back of the head, and some patients find it easier to enlist the help of relatives or carers.
Non-topical treatment
Patients with scalp psoriasis are unlikely to need non-topical treatment unless the condition is unresponsive or severe. Patients with other types
FIGURE 2 Treatment of scalp psoriasis Potent corticosteroid: use once daily for up to four weeks
Different corticosteroid formulation and/or descaling agent If response is not adequate within four weeks Calcipotriol and betamethasone combination treatment: use once daily or vitamin D once daily (only in those who cannot use corticosteroids and who have mild to moderate scalp psoriasis) If response is not adequate within four weeks Very potent corticosteroid: use up to twice daily for two weeks or coal tar once or twice daily, or referral to a specialist (Adapted from National Institute for Health and Care Excellence 2012)
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of psoriasis, or psoriasis on other areas of the body, may qualify for phototherapy, or systemic or biologic therapy. Any treatment prescribed for the scalp should take other treatments into account. For example, patients undergoing phototherapy should avoid applying topical applications to the psoriasis (including the scalp) on the morning of a phototherapy session (BAD 2012). Similarly, some medications can increase light sensitivity, and these should be avoided while undergoing phototherapy (BAD 2012). Anecdotally, patients undergoing systemic or biologic therapy for more widespread psoriasis may find that it also has a positive effect on scalp psoriasis, and if this occurs, the approach to treatment of scalp psoriasis can be reviewed as appropriate. Some patients find that the scalp will still require some form of topical or emollient therapy to help maintain results. In addition to medical treatment and support from healthcare professionals, external, independent information and support will benefit some patients. The Psoriasis Association (www. psoriasis-association.org.uk) is the leading national
charity and membership organisation for people affected by psoriasis in the UK. It provides up to date independent information, and operates a telephone and email helpline, as well as online forums for patients to share their experiences. Patients may also benefit from local psoriasis or dermatology support groups.
Conclusion Scalp psoriasis is common in those who have psoriasis in other areas of the body, although for some it may be the main problem or occur alone. Despite its prevalence, scalp psoriasis is often difficult to treat and has a profound effect on patients’ quality of life and wellbeing. Therefore, it is important that the scalp is treated as a separate site. While a variety of treatments are available for the condition, it can be a process of trial and error to find the most effective treatment or combination of treatments. Psychological and social support, as well as encouragement and education are important to promote wellbeing and improve quality of life for patients with scalp psoriasis NS
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of Adults with Psoriasis. Technology appraisal guidance No. 103. NICE, London. National Institute for Health and Care Excellence (2008a) Adalimumab for the Treatment of Adults with Psoriasis. Technology appraisal guidance No. 146. NICE, London. National Institute for Health and Care Excellence (2008b) Infliximab for the Treatment of Adults with Psoriasis. Technology appraisal guidance No. 134. NICE, London. National Institute for Health and Care Excellence (2009) Ustekinumab for the Treatment of Adults with Moderate to Severe Psoriasis. Technology appraisal guidance No. 180. NICE, London.
NHS Choices (2013) Psoriasis. www.nhs.uk/Conditions/Psoriasis/ Pages/Introduction.aspx (Last accessed: February 12 2014.) Primary Care Dermatology Society (2013) Psoriasis: Overview and Chronic Plaque Psoriasis. tinyurl. com/mqa9nvj (Last accessed: February 12 2014.) Psoriasis Association, Mental Health Foundation (2012) See Psoriasis: Look Deeper. Recognising the Life Impact of Psoriasis. tinyurl.com/ llavlw4 (Last accessed: February 12 2014.) Rapp SR, Feldman SR, Exum ML, Fleischer AB Jr, Reboussin DM (1999) Psoriasis causes as much disability as other major medical diseases. Journal of the American Academy of Dermatology. 41, 3, 1, 401-407.
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