Psoriasis of the scalp: principles in diagnosis and treatment

According to the materials of the International Conference “Actual Issues of Modern Plastic Surgery, Aesthetic Medicine and Dermatology” 

It is known that up to 80% of patients with psoriasis have lesions of the scalp to a greater or lesser extent. In some cases, the scalp is the only localization of psoriatic rashes. Given the special "social significance" of the scalp, the presence of a chronic disease in this area significantly impairs the quality of life of 80% of patients.

 In a recent study, the impact of psoriasis on patients (n=723) was noted, 97% noted a violation of the daily lifestyle. 28% of psoriasis patients in a 2005 study reported problems accessing beauty salon services. Patients with psoriasis have low self-esteem, which negatively affects social communication. Psoriasis was significantly correlated with mental health status in one study (p < 0.01).

Specific features that may contribute to susceptibility to HPCH

• Along with the presence of a long terminal hair and a high level of sebum production, the scalp is characterized by increased desquamation of keratinized non-nucleated cells. High concentration of follicles, lack of sunlight, limiting exposure to UV, which usually reduces the development of psoriatic lesions.
• Inflammatory-causing organisms (Malassezia globosa type fungus has been isolated from HPCH patients and a relationship with disease severity has been suggested).
• Repeated rubbing and injury of the scalp (Koebner phenomenon) from combing or using styling tools).

Scalp Psoriasis Clinic

Psoriasis of the scalp is accompanied by the appearance of a characteristic rash on the skin, represented by spots or more often plaques from pale pink to brown-red. In most cases, the elements of the rash are infiltrated from a minimally palpable elevation above the level of healthy skin to a pronounced infiltration of more than 1 mm.

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Discussable questions:

• psoriasis and/or seborrheic dermatitis;
• psoriasis and hair loss;
• psoriasis and scarring;
• psoriasis and hair growth;
• psoriasis – inverse Koebner or Renbeck phenomenon

Psoriasis and/or seborrheic dermatitis (SD)

When making a diagnosis, certain difficulties may arise when the pathological process is localized exclusively on the scalp. Many patients with psoriasis were initially diagnosed with DM.

Differential diagnostic features of psoriasis and DM:

• for psoriasis, in contrast to DM, a more pronounced infiltration of rash elements due to acanthosis and hyperproliferation of the epidermis is characteristic;
• psoriasis rashes often extend beyond the scalp, onto the forehead (the so-called «psoriatic crown»), neck, auricles;
• flaking in psoriasis is dry, with DM the scales are more oily;
• more pronounced itching is observed in diabetes;
• it is also necessary to carefully examine and question the patient for damage to the nails and joints, the presence of which may speak in favor of psoriasis and significantly affect further treatment tactics.

Despite certain differences in the clinic, it is far from always clinically possible to distinguish between these two diseases. Dermoscopy is of great help in this.

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This is a useful tool for assessing scalp psoriasis, especially mild to moderate forms that are difficult to clinically assess. Dermoscopy facilitates early diagnosis, differential diagnosis, follow-up and screening. It takes into account the area of ​​the scalp affected by psoriasis, the presence and morphology of the vascular pattern, erythema and desquamation.

Dermatologically, psoriatic rashes without peeling are characterized by the appearance of "red dots", which are loops of vessels of the papillary dermis, dilated against the background of acanthosis and psoriatic inflammation.

One should also remember about the possibility of a combination of psoriasis and DM in the same patient, some authors even combine this condition with the general term "sebopsoriasis". In some cases, DM may precede psoriasis, or these conditions may coexist. The appearance of psoriasis can also be observed due to the Koebner phenomenon against the background of skin lesions with DM.

Scalp psoriasis and hair loss

A hair loss is a common complaint among people with scalp psoriasis, but hair loss caused by trauma caused by scratching itchy lesions (traction alopecia) is believed to be the cause of most of these cases.

Thus, the condition of 47 patients with psoriatic alopecia was analyzed: the follow-up period in 41 patients was 7 years, in 34 patients (83%) hair regrowth was observed when the psoriatic lesions were eliminated. Reports of telogen effluvium are not directly related to psoriasis.

Dermatological status:

• there was a decrease in the density and thinning of the hair with areas of baldness, more pronounced in the central parietal region of the scalp;
• absence of follicular orifices;
• erythematous-infiltrative lesions with peeling.

Dermatoscopic signs of psoriatic cicatricial alopecia are usually the following: it is the presence of interfollicular twisted red loops, characteristic of PVCH, against the background of the absence of follicular openings. Pustulization or hair growth in tufts was not observed.

Horizontal sections of the HPCH biopsy specimen show:

• sebaceous glands were not visualized, however, there were separate muscles that raise the hair, and perifollicular fibrosis was also observed;
• Analysis of a vertical section showed epidermal changes comparable to psoriasis and a moderate chronic inflammatory infiltrate around the vessels and sweat glands, accompanied by the formation of fibrous bundles;
• at the dermal-epidermal level, no interlayer changes or lesions of the follicular epithelium were observed.
• The results of the biopsy for PVCH were consistent with scarring alopecia accompanied by psoriasiform epidermal changes.

Psoriasis and secondary cicatricial alopecia

The most common factors associated with the development of psoriatic cicatricial alopecia are the long duration of the disease and the severity of psoriasis.

Provided that these changes are to some extent common to all lymphocytic cicatricial alopecia, we have reason to believe that psoriatic alopecia is a secondary clinical change of the primary process and is not a unique histopathological condition.

Whether the incidence of this complication is high is not yet known for certain, therefore, in order to prevent progression to the development of cicatricial alopecia, optimal control of psoriatic inflammation is necessary.

Psoriasis and hair growth

Observations show that the sequence of events in psoriasis is correlated with the activation of anagen hair growth. Striking analogies have been noted between the kinetics of epidermal cells in psoriasis and the proliferation of hair matrix keratinocytes during the anagen phase.

An analogy is drawn between the Koebner phenomenon and the resumption of anagen growth stimulated by the wound healing process. Both phenomena can have the same "trigger" mechanism.

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Clinically active psoriasis has been shown to suppress alopecia areata (AA). The spread of large-scale psoriasis on the scalp stops at the border of the HA focus. Concomitant regrowth of hair and psoriasis on the head is observed after contact immunotherapy in GA. The Renbeck Phenomenon – demonstrates normal hair growth on psoriatic lesions with concomitant GA.

Clinical case

Alopecia areata and psoriasis are considered as diseases caused by exposure to genetic factors, exogenous triggers, which are based on the formation of an autoimmune organ-specific process mediated by T-cells.

Of particular interest is the study of the Renbeck phenomenon – association of GA and psoriasis, in connection with which we present a clinical case.

Patient N., aged 23.

History of disease. Diagnosis «psoriasis» installed about 10 years ago. About 8 years ago, the patient was diagnosed with alopecia areata, total form. Within a year, hair growth was fully restored.

In April 2012, the patient experienced an exacerbation of the psoriatic process on the skin of the extremities and scalp. In June 2012, there were complaints of focal hair loss on the head, in connection with which the patient sought a consultation.

Dermatological status. There are single erymatous-squamous rashes on the skin of the trunk in the area of ​​the elbow joints. On the skin of the scalp in the occipital region, at the border of hair growth in the forehead, behind the ears, psoriasiform plaques of light pink color are observed, with unexpressed infiltration and peeling. On the skin of the parietal region, an alopecia focus 3x3 cm in size with clear boundaries, free from rashes, is determined. There is a zone of loose hair along the periphery of the focus. The hair tension test in this area is positive. Nail plates are not changed.

Diagnosis. Based on the examination, the diagnosis was made – psoriasis of the scalp, normal psoriasis of smooth skin, stationary stage; alopecia areata, focal form, active stage.

Treatment. The patient was prescribed topical clobetasol propionate 0.05% and salicylic acid 3% in the form of a lotion for psoriasis lesions; ciclopiroxolamine shampoo.

In August, recurrence of erythematous-squamous plaques in the alopecia focus was recorded, followed by restoration of hair growth in the area of ​​psoriatic elements.

Histology of the scalp. A biopsy of the skin of the scalp was performed (a fresh eruptive element with signs of hair growth was taken) using a 4 mm cylindrical punch. The biopsy specimen showed parakeratosis, acanthosis, and outgrowths into the thickness of the connective tissue, as well as dilated capillaries in the papillary dermis and a superficial perivascular lymphocyte infiltrate in the dermis.

Diagnosis. Based on clinical, dermatotrichoscopic and histological examination, recurrence of scalp psoriasis in foci of alopecia areata was established. The patient was diagnosed with important features of the Renbeck phenomenon – reduction of manifestations of psoriasis on the scalp with recurrence of alopecia areata, resumption of normal hair growth with recurrence of psoriasis in the focus of alopecia.

Discussion. Psoriasis and alopecia areata can occur in the same patient. In some patients, the development of psoriasis in the foci of alopecia may be accompanied by the phenomenon of Renbeck or a phenomenon also called "inverse Koebner"; (hair regrowth begins in psoriatic plaques that appear in alopecia areata). In psoriasis, the Koebner phenomenon occurs in the area of ​​trauma or inflammation of the skin.

The study of the Renbeck phenomenon is of interest from the point of view that the transition from psoriasis to another immune-mediated inflammatory disease can be induced by a change in the balance of cytokines. However, other potential mechanisms should be further explored as they may contribute to the understanding of new aspects of the pathogenesis of dermatoses, the development of common clinical approaches, and the optimization of existing treatment regimens for both diseases.

Factors determining the choice of therapy for psoriasis

• age;
• type of psoriasis;
• degree of damage, nature and localization of rashes;
• previous therapy;
• comorbidities.

Groups of drugs for topical therapy of psoriasis:

• topical glucocorticoids;
• vitamin D3 analogues;
• topical calcineurin inhibitors;
• keratolytics;
• others (retinoids, herbal medicines, tar preparations, combined preparations).

Treatment of scalp psoriasis

If the skin of the scalp is affected, Diprosalik lotion is prescribed (1 time per day), which has an anti-inflammatory, exfoliating effect, and Elok lotion (in the evening for 7-10 days).

Further, in the presence of peeling and signs of inflammation, it is effective to use Friderm-tar shampoo in the morning and apply Diprosalik lotion 1-2 times a day.

For moderate inflammatory manifestations and slight peeling, Friederm-zinc shampoo and Elocom lotion are recommended 1-2 times a day until the clinical manifestations disappear.

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At the moment, phototherapy methods using ultraviolet rays (UV) of the B spectrum (280-320 nm) are the most widely used in the treatment of psoriasis. The effect of phototherapy is based on its anti-inflammatory, immunomodulatory and antiproliferative effects.

Phototherapy works well with topical treatments and can also be used as monotherapy or supportive treatment.

For the most effective application of phototherapy on the scalp, there are devices optimized for this area. Such devices are equipped with a comb or light guides, which contribute to the unhindered entry of UV rays to the scalp.

PVCHP Phototherapy Algorithm

It is recommended to prepare the scalp with keratolytics before starting a course of phototherapy, as excessive scaling can significantly reduce the effectiveness of therapy.

It is important to remember that emollients should not be used immediately before phototherapy as they make it difficult for the rays to reach the skin. However, they can and should be used after each phototherapy session, as UV rays further dry out the skin.

UVB 311nm phototherapy is prescribed 2-4 times a week, 20-30 treatments per course.

After the end of an intensive course of treatment, in some cases it is advisable to prescribe maintenance phototherapy once a week.

The role of basic skin care products in patients with HPCH:

• preparation for treatment;
• increasing the effectiveness of therapy;
• reduction in the duration of treatment and the need for "active therapy" means, including the use of TCS;
• prolongation of remission periods, reduction in the number of exacerbations per year;
• improvement of the skin condition and the prognosis of the disease in general.

Optimization of therapy can be achieved by using keratolytics, emollients, antimycotics.

1. Keratolytics – an important step in the treatment of psoriasis. This is the proper preparation of the skin for therapeutic treatments. The composition of the keratolytic agent usually includes: urea (10-30%), salicylic acid (2-5%), lactic, glycolic and other organic acids, alpha-hydroxy acids and their derivatives (keluamide).

2. Emollients - capable of restructuring the water-lipid mantle and the epidermal barrier, these substances are necessary in therapy in case of constant use of drying and keratolytic agents.

3. Antimycotics – are used for the sanitation of the scalp (shampoos and lotions with ketoconazole, climbazole, zinc compounds, undecylenic acid and its derivatives.

In the treatment of psoriasis, the use of anti-psoriatic cosmeceuticals can be successful. Its success is usually based on a combination of gentle desquamation, moisturizing and debridement of the scalp.

Given the nature of the course of the disease, specific keratolytic treatments can be performed 2-3 times a week up to once a month.

After the regression of symptoms, the intensity of keratolytic therapy may be reduced.

Of moisturizers that can also be used on the scalp, it is better to give preference to gel formulations or emulsions.

For the scalp, the forms of delicate shampoos (shampoo – cream), oil and nourishing masks, balms, hair oils, lotions with low acidity (less than 5.5) are usually used.

The tactic of applying moisturizing masks after shampooing justifies itself.

Systemic therapy for HPCH

The indication for systemic therapy in psoriasis is the ineffectiveness of local treatment and phototherapy, as well as the involvement of important anatomical zones in the process, BSA  5%. The need to prescribe systemic therapy in the localization of the pathological process only on the scalp rarely occurs.

But, despite the availability of effective modern methods of external treatment and phototherapy, it is not always possible to achieve the desired therapeutic effect.

Given the very significant impact of scalp lesions on quality of life, in cases of torpid psoriasis, it is advisable to consider the possibility of systemic therapy, discussing the expected effect and possible risks with the patient.

Systemic drugs for the treatment of psoriasis include the following groups:

• retinoids (acitretin);
• cytostatic drugs (methotrexate, cyclosporine);
• immunobiological preparations.

Immunobiological preparations belong to a new group of drugs used in the treatment of psoriasis, so the question may arise: does PVCH respond to immunobiological preparations in the same way as other skin areas?

According to several studies, 79-85.5% of patients treated with infliximab had a PASI score of 75 in the scalp and neck at week 10. In the etanercept group, improvements in mean psoriasis severity score (PGA) were achieved in 58% of patients after 12 weeks of treatment. All patients with and without scalp lesions treated with adalimumab achieved a PASI score of 75 within 16 weeks.