ARTICLE SUMMARY: Scalp psoriasis is highly bothersome, and hair makes it harder to treat; but there are a number of prescription treatments in a variety of formats – including sprays, foams, gels, and shampoos – to help treat the scalp effectively, as well as treatments for the whole body that have demonstrated strong success in treating scalp psoriasis.
Psoriasis of the scalp is very common. Nearly 80% of psoriasis patients develop plaques on the scalp at some point in their life with psoriasis.
Scalp psoriasis is especially distressing to many patients. It can be extremely itchy, and when psoriasis extends beyond the hairline onto the face and around the ears or down the back of the neck, it is highly visible. In some cases, it can also cause temporary loss of hair in places where the psoriasis patches are thick on the scalp. Add to this the difficulty in applying medicine only to psoriasis patches, often covered by hair, without also treating the healthy skin – and it’s not surprising that patients are eager for effective treatments.
Fortunately, there are a variety of medications that when applied directly to scalp psoriasis, are able to reduce or resolve it for a period of time; and many of the newest psoriasis treatments, designed to treat psoriasis all over the body, have demonstrated excellent clearance of scalp psoriasis as well. Over-the-counter products can play an important supporting role.
Our message for those suffering with the frustration, itch, and pain of scalp psoriasis is: don’t lose hope, as there are options available today that will likely provide you substantial relief from your scalp psoriasis.
Treatments designed with hair in mind
In recent years, pharmaceutical companies have worked not just on making scalp psoriasis treatments more effective, but on making them easier and more pleasant to apply. (Research has found that when treatments are easier to apply, patients do a better job following their doctor’s specifications, which further improves treatment effectiveness.)
This gives health care providers and patients options that now include shampoos, lotions, creams, sprays, gels, foams/mousses, and ointments. For more severe scalp psoriasis or when it also appears elsewhere on the body, there are also daily pills, occasional injections, and periodic infusions available that are effective on the scalp. UV light therapy is also appropriate in select cases (most obviously, when the patient has little or no head hair).
A brief introduction to the many options follows, so you can make the most of your doctor visits and get on track to improve the condition of your scalp – and give you a sense of peace that scalp psoriasis so often disrupts.
Topical medications – those rubbed directly into the skin – are still the most common treatments for scalp psoriasis, particularly corticosteroids and combination products that combine a steroid along with a vitamin D analog (calcipotriol, calcipotriene, calcitriol). The variety of formulations gives you options that can reflect your personal preference, your insurance coverage or what you are willing to pay, and the extent or severity of the psoriasis on your scalp or elsewhere on your body.
Other factors to keep in mind as you and your doctor select a topical scalp psoriasis treatment: how many times a day or week must you apply it? How long must it be kept on your scalp? Will it stain your towels or bedsheets? How quickly will it work? Can it be used for a long period of time? Could it impact your hair color? Are there side effects?
While some scalp psoriasis medications can be applied for as little as 15 minutes and then rinsed out, others must be left on the scalp for at least several hours. Most are used once or twice daily for several weeks, or for months at a time. For overnight applications, some people will be able to cover their scalp with a plastic shower cap to keep the medication from rubbing off during sleep (but check with your physician first, as this has the effect of increasing the dose of medicine reaching your system).
Topical corticosteroids, both high potency (e.g. clobetasol and betamethasone) and medium/low potency (e.g. hydrocortisone and fluocinolone acetonide), are commonly used to treat scalp psoriasis. Traditionally, the strategy was to use the least powerful steroid that would give the patient adequate results, as stronger steroids naturally bring greater potential for side-effects. Steroid use generally can lead to the development of spider veins and thinning of the skin. Overuse of topical steroids can also lead to suppression of the body’s own steroid production system (the Hypothalamus-Pituitary-Adrenal [HPA] Axis), which can, among other things, cause a worsening of psoriasis due to flare or rebound.
But thinking has evolved on these issues, as potent (powerful) steroids can better and more quickly clear the scalp, which can have thick build-up of dead skin cells plus hair interfering with absorption of the medicine. Also, the cover of hair makes some side effects less of an issue on the scalp than areas of the body that are more visible.
In cases where psoriasis is limited to the scalp, the amount of steroid reaching the system can be low enough to allow for longer use of strong steroids. Conversely, if you are using steroids also on large portions of your body, then this has to be more closely watched by your health care provider.
Corticosteroid preparations are normally applied 3-4 times a week and work quickly, producing results in about 3-4 weeks. When ending steroid use, it is typically safest to “wean” off the products, rather than eliminating their use abruptly; but again, check with your physician.
Vitamin D Analogs
Since their introduction in the 1990’s, Vitamin D analogs have proved to be safe and effective treatments for scalp psoriasis. Part of their appeal is that they are not steroids, so they do not raise concerns noted above that can arise through the extensive use of steroids. The most common side effect is irritation or a burning sensation at the site of application.
Calcipotriol does not work as quickly as corticosteroids do, taking up to 8 weeks to reach maximum effectiveness. And a large review of studies found that potent steroids perform better overall than vitamin D analogs. That said, when steroid reduction is a goal, calcipotriol is an effective alternative for scalp psoriasis.
Calcipotriol + Corticosteroids: A Powerful Combination
Simultaneous use of calcipotriol and corticosteroids has been found to be more effective than either therapy alone, and the combination appears to minimize the side effects of both. The combination works as quickly as the faster acting corticosteroid component, producing good results in about four weeks.
Combination products are available in a variety of formulations, though they can be far more expensive than some of the generic steroids that are available. (Again, differences in insurance coverage make it impossible for us to predict your particular out-of-pocket costs. But keep it in mind as a factor to consider.)
One option when cost is a factor is to be prescribed the two products separately and use them, for example, on alternating days. Some doctors, noting that the combination products are only modestly more effective, and recognizing that complexity in a treatment regimen reduces compliance, simply start off with a topical corticosteroid for scalp psoriasis.
Patient-to-patient tips for scalp psoriasis treatment:
1) Resist the temptation to fib to, or withhold information from, your doctor. If you know there is no way in creation you are going to do the twice-a-day scalp treatments she or he is about to prescribe for you, just say so. Find an option that fits with your lifestyle and your reality.
2) Don’t assume your health care provider knows how severely something is affecting you. If the itch is making it difficult to sleep, or the appearance of the psoriasis is causing you grave embarrassment, or it seems to others to be a minor case but is making you miserable, speak up. The impact of scalp or other psoriasis is not always apparent just from looking at it. Your treatment plan can be customized to focus on itch, emotional impact and/or other considerations that are most important to you.
3) Sometimes switching from a lotion to a spray, or to a foam, or vice versa, can improve your compliance – and treatment effectiveness. If you are not happy with your treatment regimen, ask your physician to allow you to experiment with alternatives.
For those with hair covering their scalp psoriasis (and who don’t want to shave their head), traditional UVB lamp therapy is not very effective for it. However, some specialized UVB products have shown success with scalp psoriasis in appropriate cases.
One such product is the physician-supervised XTRAC laser, which provides a very specific narrowband UVB directly to scalp psoriasis lesions. The laser generates a small spot of UVB light that can be precisely aimed, with various ways to get hair out of the way including a device similar to a blow dryer.
A typical course of treatment might require short visits to your dermatologist twice a week for six to ten weeks. Interestingly, many patients get months of remission in the spots treated with the XTRAC.
Systemic Treatments and Biologics
Patients who have troublesome scalp psoriasis that does not respond to scalp-targeted medications might consider the wide range of treatments that work on the entire body: the pills, injections, and infusions typically used for moderate to severe plaque psoriasis.
Most of the biologics have clinical data demonstrating their effectiveness in treating psoriasis of the scalp, and the others have extensive anecdotal evidence of effectiveness. Many of the latest biologics, in fact, have been able in clinical trials to obtain total resolution of scalp lesions for many psoriasis patients over a period of weeks or months. Read more about biologics for treating psoriasis.
Other systemic treatments can also improve scalp psoriasis. Data from a clinical trial of the PDE4-inhibitor pill Otezla (apremilast) show it improved scalp psoriasis for almost half of patients after four months.
There are other topical treatments for scalp psoriasis that are sometimes used when it does not respond to the most commonly used methods.
Coal tar has been used to treat skin diseases for hundreds of years, making it one of the oldest remedies for psoriasis. There are several over-the-counter lotions and shampoos containing coal tar available for the treatment of scalp psoriasis, including popular brands like T-Gel. Although coal tar seems to reduce the itch and flaking that many scalp psoriasis patients battle, coal tar has a strong odor that many find objectionable, even after pleasant-smelling masking ingredients are added. It can also stain clothing, although that is not typically a problem if a coal tar shampoo is used and then washed off after a matter of minutes.
There has been concern in some quarters about the possibility that coal tar may be cancer-causing; this is a significant concern of governments in the European Union and in the state of California, for example. That said, a follow-up of a couple hundred coal tar users after 25 years, found no larger-than-expected cancer rate. For what it’s worth, Johnson & Johnson is going to stop selling its iconic Baby Powder after more than 100 years, due to lawsuits over its safety … but they continue to sell T-Gel. (Don’t tell the trial lawyers!)
Dithranol (also known as anthralin) is another old remedy for psoriasis, in use now for a century. Dithranol treatment is usually administered at a clinic or an in-patient setting. A dithranol cream formulation is applied to the scalp for a short period of time (5-60 minutes) and then washed off. Prolonged exposure to dithranol can irritate the skin and dithranol will also stain clothes and temporarily discolor skin and hair. Despite these drawbacks, some patients who have not responded to other topical medications find that dithranol works well (although dithranol treatment is becoming rare in the United States).
Salicylic Acid and Urea
Scalp psoriasis is often highly scaly, which can block the penetration of medications into the skin, limiting their effectiveness. Therefore, patients with scalp psoriasis may benefit from an initial course of treatment with an agent that reduces scaling, such as salicylic acid ointment. There are also shampoos with salicylic acid, including T/Sal. Products with urea are also used by some to reduce psoriasis scales. Both are available in different strengths, and in prescription and over-the-counter variants.
Other over-the-counter products
If your scalp psoriasis includes thick patches, or plaques, of dead skin cells, it can be difficult for topical medications to make it deep enough to improve your psoriasis. Over-the-counter products, and home remedies, offer many ways for you to reduce the thickness, or scaling, of scalp psoriasis plaques. Some people, for example, apply products in the evening to soften the scalp, and then wash it out before bed or in the morning, rinsing out much of the dead skin along with it. Let us know your strategies for scalp psoriasis and we will share some of them in future updates to our website.
Scalp psoriasis is common and for many patients, is one of the more troubling places to have psoriasis. Fortunately, there is a robust arsenal of treatment options available to help people defeat their scalp psoriasis. It may take someone a few tries to find the right mix of effectiveness, simplicity, cost, and safety for their scalp psoriasis treatment, but partial relief to complete clearance is possible with some persistence.
Selected references and further reading:
Kim Blakely and Melinda Gooderham, “Management of scalp psoriasis: current perspectives.” Psoriasis: Targets and Therapy, Dove Press, March 2016.
van de Kerkhof, PCM and Franssen MEJ. “Psoriasis of the Scalp: Diagnosis and Management.” American Journal of Clinical Dermatology. 2001; 2(3): 159-165.
The great Ben Franklin battled psoriasis, beginning in the years preceding the American Revolution. Scalp psoriasis was a recurring problem. (“[In the early 1770’s] I first observ’d a kind of Scab or Scurff on my head, about the Bigness of a Shilling. … It slowly left that Place but appear’d in other Parts of my Head.”)
[Last updated 5-25-2020]