Download Treating scalp psoriasis in general practice

Forum
Dermatology
Treating scalp psoriasis
in general practice
Johnny Loughnane details the
manifestations of psoriasis on and
near the scalp, as well as how to
best manage a condition that often
impinges on quality of life
Figure 1. Severe psoriasis can lead to alopecia. However, hair regrowth
is usual with effective treatment
Psoriasis is a common inflammatory dermatosis, affecting 2% of the population. Scalp involvement is common.
Indeed, scalp involvement may be the only manifestation
of the disease.
It may be difficult to distinguish between psoriasis
and dandruff or seborrhoeic dermatitis. Psoriasis usually
presents with more well-demarcated, erythematous plaques
covered with thick, silvery scales. Seborrhoeic dermatitis is
less well demarcated and scales are finer and have a more
greyish colour. Both conditions can itch.
Scratching a psoriasis plaque lifts the surface scales,
making their silvery colour more obvious. Picking off the
silvery scales results in bleeding points, a finding known as
the Auspitz sign.
Psoriasis is one of those skin conditions that preferentially
involves damaged skin, the so-called Koebner phenomenon.
Many patients with dandruff/seborrhoeic dermatitis scratch
their scalp. In psoriasis patients, the disease may Koebnerise to the scratched scalp. Indeed, many patients present
with features of psoriasis and seborrhoeic dermatitis: socalled sebopsoriasis.
Scalp psoriasis significantly impinges on quality of life:
• It is a highly visible disease, especially when it spreads
beyond the hair margins
• There are problems with scales falling on clothing
• There may be persistent itch
• It is traditionally difficult and messy to treat.
Treatment has to include a thick coverage of scalp hair.
This is difficult to achieve with creams, ointments and
especially pomades.
Patient compliance and tolerability can play a crucial role
in efficacy. Therefore, when it comes to treatment, choice
of vehicle can be as important as the choice of therapy
itself.
Topical corticosteroids have been widely used in
general practice. Steroids are effective thanks to their antiinflammatory action. There are two problems with steroid
applications when used as sole therapy. Firstly, they are
Figure 2 and 3. Psoriasis of the hair margin and ears before and after
treatment with Eumovate ointment in the morning an Silkis in the
evening
usually only partially effective. Secondly, continued use
over a period of time gives less and less of a response, ie.
tachyphylaxis.
Traditional tar and dithranol treatments are just not used
in general practice due to their messiness and side-effect
profile.
Two approaches have been adopted in an attempt
to improve acceptability and effectiveness of topical
treatment:
Reduce messiness of treatment
Cocois contains tar and salicylic acid. It has a bit of a
smell but is generally well tolerated. It is more effective
if left on the scalp for longer than recommended by the
manufacturers. It can be applied at night and washed out in
the morning. A shower cap helps protect bedding.
Combination treatments
• Combine steroid and salicylic acid (Diprosalic scalp application): The salicylic acid is an excellent keratolytic and
helps break down scale
• Combine steroid and tar: Cocois can be applied, as above,
at night. A steroid is applied after washing out Cocois in
the morning
FORUM February 2010 49
Scalp psoriasis-NH2* 1
28/01/2010 16:33:16
Forum
Dermatology
Treatment of scalp psoriasis
Mild
• Calcipotriol + betamethasone (Xamiol)
• Tar shampoo
• Topical steroid: betamethasone as scalp application or
mousse
• Topical steroid + salicylic acid (Diprosalic scalp
application)
Moderate
• Calcipotriol/betamethasone (Xamiol)
• Tar (Cocois) +/– betamethasone (Bettamousse/Betacap)
Figure 4 and 5. Scalp psoriasis before and two weeks after daily
Xamiol. Results with Xamiol are often much quicker than with
traditional therapies. The gel is applied to the scalp at night and
washed out in the morning. Some patients find that leaving the hair
shampoo for a few minutes, before washing out, makes removal of
the gel more effective
• Combine steroid and a vitamin D analogue: calcipotriol
(Dovonex) applied at night with a steroid in the morning
has been used for many years.
Applying even cosmetically acceptable applications to the
scalp is difficult. Understandably, regimens needing twice
daily treatments have a poor compliance record.
A recent addition to our therapeutic options combines a
Severe
• Coal tar pomade
• Refer
steroid, betamethasone with a vitamin D analogue, calcipotriol (Xamiol).
Psoriasis of the face and hair margin
The hair margin is an important dividing line between
the tougher skin of the scalp and the more delicate skin of
the face. This has implications when treating psoriasis that
extends beyond the hair margin:
• Potent steroids will cause thinning of facial skin
• Tar and vitamin D analogues may irritate facial skin. Calcitriol (Silkis) is less effective than calcipotriol (Dovonex)
but appears less irritant on delicate skin, such as on the
face.
We therefore tend to combine a moderate potency steroid,
clobetasone ointment (Eumovate), with calcitriol (Silkis).
They should be applied at different times of the day.
If this does not give an acceptable result one may try
tacrolimus (Protopic). Tacrolimus is generally ineffective on
chronic plaque psoriasis. However, on the thinner skin of
the face it is effective in up to 90% of patients.
Johnny Loughnane is in practice in Limerick
Irish College of General Practitioners
Place an advert free of charge
on the ICGP website
The ICGP Classifieds section allows members to place job adverts online, free of charge.
GPs can advertise posts in their practice (short-term and long-term) or advertise their
availability for work.
GPs looking to pass on their practice or GPs looking to take over a practice can also post adverts.
See www.icgp.ie/classifieds
50 FORUM February 2010
Scalp psoriasis-NH2* 2
28/01/2010 16:33:32