Coping with The Anxiety of Having Scalp and Nail Psoriasis

Why Hair Makes Scalp Psoriasis Difficult to Treat

Dr. McMichael:

Scalp psoriasis is the same as psoriasis on any area the body. It's all part of the same disease which is scaly, flaky, red skin that can cause itching, pain, irritation, and embarrassment. When it's on the scalp it's particularly hard to treat because there is hair on the scalp. The areas of scalp that are affected commonly are the posterior scalp just above the neck where there is usually fairly thick hair. Most people don't see it, but unfortunately as the psoriasis worsens, you get lots and lots of scaling, and it comes down onto your clothing. It can be anywhere on your scalp or involve the entire scalp onto the face. It can also be in the ears, behind the ears, and even in front of the ears.

We use mostly topical agents – ointments and solutions and foams – when we are treating a localized area of psoriasis. We typically design them for use on the body. So you can put them on, rub them in, and they work where you put them. Unfortunately, the rubbing is not very easy when you have hair in the way. You have to think about things that you can put on the scalp that can get through the hair, so we tend to use a lot of solutions and foams on the scalp. But even that doesn't always work. It's one of those areas that you can't get to easily, so it's very difficult to apply medications.

Scalp Psoriasis - Signs, Symptoms and Complications

Dr. McMichael:

Maybe two to three percent of psoriasis patients get infections. But that's serious because if they don't get them treated right away, that can cause systemic illness, fevers and chills, and then eventually potentially spread of the psoriasis.

I think a lot more people lose hair than really notice. I have a lot of patients who have localized hair loss, and when they get their psoriasis treated, they actually have regrowth of that hair.

Most patients who have scalp psoriasis have a thick, scaly, red plaque, just as you would see maybe on an elbow or a knee. There are a few patients who will have big, large sheets of scales with very severe disease, but they almost always have the same kind of disease on their bodies. You may also have patients who have small, little pustules. Those are little, tiny bumps that look like acne. And those can be a bit hard to figure out if you are not thinking about psoriasis, but I do have a very small number of patients that will come up with pustules, and that's the form psoriasis takes on their scalp.

Sometimes people come in very early and the psoriasis on their body is not very well formed, and the scalp is one of those areas we check. If it's in the scalp, then I know it's psoriasis. It's usually quite easy to diagnose psoriasis, but every now and again it gives us a little bit of trouble. So you can have it isolated on your scalp, you can have it isolated on one area of the body. It's just really not all that uncommon.

You could have a lot of hair loss associated with psoriasis if you are having a lot of inflammation. You can get a superficial infection. So in addition to having the psoriasis, from scratching and getting normal bacteria that live on our skin into the open areas where you scratch, you can have a bacterial infection or a yeast infection, and that complicates the treatment even more.

Successful Treatment of Scalp Psoriasis Begins with a Proper Diagnosis

Dr. McMichael:

Most dermatologists are aware of the many different forms that psoriasis can take when we look at the skin. We put your complaints together with what we see, and at times when there is a lot of infection over the top of the psoriasis or somebody has scratched a lot, or the lesions are new or just don't look quite right, we will biopsy, which means we take tiny piece of skin and look at it under the microscope to make the diagnosis.

It can be misdiagnosed. A lot of patients have seborrheic dermatitis of the scalp, which is another scaly, itchy kind of scalp problem, usually isolated to the scalp, although you can have involvement of the face and the chest in these patients. Some people put it on a continuum with psoriasis, thinking that seborrheic dermatitis may be a mild form of psoriasis. There are two very distinct camps: One believes that seborrheic dermatitis is on a continuum with psoriasis, and one believes that it is a totally different disease. So depending on what you believe, you may diagnose this as seborrheic dermatitis and not treat it as aggressively as we treat psoriasis, or you might think about it as eczema, which is more of a scaly, itchy, problem that doesn't have the discrete plaques that we see with psoriasis.

Bald Is Beautiful - Especially When Treating Scalp Psoriasis

Dr. McMichael:

When patients have scalp psoriasis and they have hair loss, such as men who have balding, or male pattern baldness, they won't have the psoriasis on the bald part of the scalp. They will have it where they still have hair. So it seems to be intimately involved with the follicles that are still producing hair when we see it on the scalp. But we still don't understand everything about scalp psoriasis, so we don't know why that happens.

As a matter of fact, it's easier to treat. So it usually gets a lot better because you don't have to put on as much goo, all these ointments and solutions that I was talking about. You can use a lot of the different shampoos, and it penetrates a lot better, so it tends to actually improve things. But most patients are not willing to shave their heads for the disease, and we don't want them to have to do that either.

Treating Scalp Psoriasis with Camouflage and Medications

Dr. McMichael:

A lot of people with psoriasis will wear hats. And some women wear scarves and wigs and those sorts of things. But we really try to help patients because we don't want them to have to be forced to wear a head covering if they don't want to.

We'll layer treatments. We will start out with a shampoo, and then we will add on a topical medication that may be put on daily or twice daily, and we use some of the corticosteroid medications and some vitamin D derivatives. And then we will maybe spot treat with something very strong, or we will use oils that help lift the scales up and also treat at the same time. So we really get a regimen for the patient that is very specific to their needs.

There are a lot of home remedies available to people on the Internet. But you have to be really careful about these things because they are not tested in scientific studies, and perhaps they are not exactly what you need or they may make things worse. As long as they are not harmful, they don't make the psoriasis worse, and they make you feel better, I think it's okay. But you do need to talk to your doctor about them so that they know that you are using them, and they can build your regimen along with that particular treatment.

Most of the topical medicines that we use for psoriasis are topical corticosteroids. Corticosteroids reduce inflammation. But they can also thin the skin a bit, so we like to keep them to a mid-level potency. Other things that we use topically, such as anthralin (Dritho-Scalp, Psoriatec) and salicylic acid, go on the scalp and thin the skin, so it takes the top layer of skin off. So you have a couple of different approaches - taking down the inflammation or trying to take the scales off. And sometimes we use them in combination.

The oral medications that are most commonly used are a vitamin A derivative called etretinate (Tegison), and we also use a medication called methotrexate (Rheumatrex) that we use in very severe cases of psoriasis.

Other systemic medications include biologics, which are genetically engineered to bind to a protein in the body that is responsible for causing a lot of the inflammation of psoriasis. When we bind up that protein, you don't get that inflammation, and psoriasis gets better.

We start with the treatment that we think is going to be the most effective. Patients are really ready for something to work overnight, and unfortunately we just don't have that. It takes a month to two months to really see significant improvement, to see complete clearing. We try to find the minimum amount of treatment that a patient needs to stay clear of symptoms.

What Is Fingernail and Toenail Psoriasis?

Dr. Scher:

Nail psoriasis is psoriasis that affects what we refer to as the nail unit which includes the nail plate, which is where nail polish is placed; the skin underneath the nail plate, which is called the nail bed; the growth center of the nail, which is the nail matrix; and the skin around the nails including the cuticle area, which I will refer to as the nail fold. When any of those components are affected by psoriasis, it's actually the same psoriasis that affects the skin and the scalp.

Most of the changes in the nail will depend on what portion of the nail is affected. The fingertips, the fingers and toes, and in very difficult situations, the palms and soles frequently are involved simultaneously. And psoriasis of the palms and soles can be very, very problematic for the patient because the skin becomes markedly thickened, and you get these painful cracks.

When it's the skin on the top part of the hands or the fingers or the toes, there it more closely resembles skin psoriasis. You will get scaling, and you will get some redness. And sometimes you get what is called fissuring where there are little cracks in the nail, and these can be very painful, particularly in the wintertime.

The good news is fortunately nail psoriasis very seldom causes permanent scarring or deformity of the nail.

Who Gets Nail Psoriasis and Links to Psoriatic Arthritis

Dr. Scher:

Nail psoriasis can be gotten by anyone who has psoriasis or anyone who has the susceptibility or family history of psoriasis. I would say that there is a very high percentage of patients who have cutaneous, or skin, psoriasis who will get nail psoriasis. And interestingly enough, we should mention in regards to nail psoriasis that there is a very high correlation with psoriatic arthritis, which is arthritis that affects certain joints of the body. The occurrence of nail involvement in patients who have psoriatic arthritis is extremely high, as high as 90 percent.

One of the more common types of psoriatic arthritis is what is referred to as distal joint arthritis. And that means that it affects the joints that are very close to the nail. The nail sits right on top of the bone just underneath it, so if there is a significant amount of arthritis in that joint with the inflammation that we see in psoriatic arthritis, the nail growth center is very likely to become inflamed too. This results in a very high percentage of nail changes.

Since a fungal infection can resemble nail psoriasis, many of these cases are not diagnosed as psoriasis, but they are diagnosed as a fungal infection. And so it brings up an extremely important point. It's really important to prove that the diagnosis is correct. And since nail fungus is one of the significant differentials [disorders that must be considered], the physician should perform a KOH (potassium hydroxide) test, which is a where you put a sample on a slide and look to see if there is fungus there. Another very popular test among physicians is the nail clipping, where a piece of the nail plate itself is clipped off and put in a bottle and submitted to the laboratory just as you would submit a biopsy.

The reason it is so important to do this is because, not only can you confuse these two conditions, but also we see a fair number of patients who have both conditions at the same time, and treating one without treating the other will not give the kind of results that you would get if you treat both conditions at the same time.

How Is Nail Psoriasis Treated?

Dr. Scher:

One of the problems that we have with topical treatment for psoriasis is that most of the topical treatments that will work on the skin, such as steroids, don't get through the nail, or they get through the nail in small amounts, so the effectiveness of the topical treatment is somewhat limited.

The treatment of choice for nail psoriasis is what is called intralesional cortisone, where cortisone or a corticosteroid is actually injected around the nail. After a period of four to six weeks, you begin to see the new and healthy nail coming in, and then you can reduce the frequency of those injections from monthly to every six weeks, every two months, and then sometimes just on an as- needed basis. And the patients do accept this treatment because they see the results. So I think that that would be my first line of defense.

For those patients who don't respond to that form of treatment, we do have some other choices. The systemic agents, as were mentioned for the scalp, can also be used for nails in more severe cases. We have the option of phototherapy, which is ultraviolet light therapy, which works reasonably well. So we do have some choices, but it can be very difficult.

I like to start with the mildest form that will work and then up the ante according to the response to therapy. I think many dermatologists tend to gets discouraged, as do their patients, in treating nail psoriasis, and I think if both form a partnership and persist and are really conscientious with their treatment, they can get very satisfactory results.

For hard-to-treat nail psoriasis, we go to the chemotherapeutic agents such as methotrexate and the biologics.

Manicures and Nail Polish Help Hide Nail Psoriasis

Dr. Scher:

It's probably a lot easier for women to hide nail psoriasis than for men because the dark colored nail polishes really do a reasonably decent job of camouflaging nail psoriasis until you can begin to get improvement. I have had some patients who have used the acrylic sculptured nails. In general, this is discouraged because there are cases where that can actually make the psoriasis worse, so I would not recommend that. But certainly the nail polishes, I think, help very well. Unfortunately we don't have a similar application for men.

Solar nails (a type of acrylic nail that can be refilled rather than replaced) really use acrylics as well, and acrylics are relatively safe. The only problem is that some people are allergic to the acrylic material. Some of my patients put the acrylic nails on and just keep them on indefinitely, and that can sometimes set up a good environment for secondary fungal infection. I don't think that I would recommend using the acrylics if there is nail psoriasis present, however.

And the other problem with the acrylic nails is that over an extended period of time, they can make the nails even thinner, so I don't feel that that would be the way to go.

If you go to a nail salon, they should just make it very clear that you have a nail problem, and that nail psoriasis is not contagious and you cannot give it to anyone. I would recommend that the very aggressive nail procedures be avoided, such as pushing the cuticles back with metal or wooden instruments, or overcleaning underneath the nail. Those procedures should be strictly avoided in nail psoriasis patients because we know that trauma and injury can definitely make psoriasis worse. However, the polishing and the beautifying of the nail in that way are perfectly fine.

More Information on Scalp and Nail Psoriasis

  • 10 Key Questions About Psoriasis
  • Ask the Doctor About Psoriasis
  • Life with Psoriasis Blog by Christa Joyce
  • Life with Psoriasis Blog by Gina Tupaczewski

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