CASE 3: Scalp Psoriasis

June 1, 2003

A 30-year-old man presents with scalingand erythema of the scalp that extendspast the anterior hairline. Thepatient has a family history of psoriasis.For the past 5 years, he has experiencedwintertime flares of the diseasethat affect his scalp and the extensorsurfaces of the extremities.

A 30-year-old man presents with scalingand erythema of the scalp that extendspast the anterior hairline. Thepatient has a family history of psoriasis.For the past 5 years, he has experiencedwintertime flares of the diseasethat affect his scalp and the extensorsurfaces of the extremities.(Case and photograph courtesy of Drs Marti Jill Rotheand Jane M. Grant-Kels.)What would your managementplan include?A REVIEW OF THE OPTIONSA family history of psoriasis significantlyincreases the risk of the disease.Often a chronic manifestation ofthe disorder, scalp psoriasis usuallypresents with thick, scaly plaques inthe scalp and, occasionally, pinkplaques along the hairline. Local therapyfor scalp psoriasis-generally, acombination of topical therapies-ameliorates the signs and symptomsbut often fails to completely clear thedisorder.To lift and debride scale, recommendthat patients apply baby, olive,or mineral oil to the scalp overnightor for 20 to 30 minutes before washingthe hair with an antidandruffshampoo. For maximum efficacy,suggest that your patients periodicallyalternate the use of antidandruffshampoos that contain active ingredients,such as tar, zinc pyrithione, ketoconazole,salicylic acid, or selenium.Topical corticosteroid lotions, solutions,or gels may be applied to thewet head after the shampoo is used.Derma-smoothe/FS, whichcontains the medium-strength corticosteroidfluocinolone acetonide in apeanut-oil base, is usually appliedovernight under a shower cap. Somepatients prefer Olux, which contains the ultrapotent corticosteroid clobetasolpropionate, or Luxiq, with themedium-potency corticosteroid betamethasonevalerate; these foampreparations are used after shampooingthe hair.Generally, ultrapotent topical corticosteroidsshould not be used forlonger than 2 consecutive weeks; advisepatients to alternate between applicationsof ultrapotent and mediumstrengthcorticosteroids every 2weeks.Topical calcipotriene lotion, tazarotenegel, anthralin, tar, and salicylicacid preparations may also beprescribed for scalp psoriasis. Althoughsome patients can toleratehairline applications of calcipotriene,the agent often causes an irritant contactdermatitis when applied to theface. Topical tacrolimus and pimecrolimuscan markedly clear facialpsoriasis; reassure patients that the stinging and burning, which usuallyaccompany the first several applications,generally resolve with continueduse of these agents.Tacrolimus and pimecrolimuscan be helpful; however, they are notyet available in lotion or gel formulationsfor easy application to hair-bearingareas.CASE 3:APPROACH AND OUTCOMEOvernight applications of oliveoil to the scalp and postshampoo applicationsof betamethasone propionatesolution brought about someimprovement. After 2 weeks, the corticosteroidwas discontinued andpimecrolimus was prescribed for useon the central scalp and hairline; clinicalimprovement continued.