Scalp psoriasis: What to know about this uncomfortable inflammatory skin condition

Scalp psoriasis is a common but often frustrating skin condition that can cause itching, flaking, and discomfort. It results from an overactive immune response that leads to rapid skin cell turnover. While scalp psoriasis can be persistent, various treatments — including prescription medications and over-the-counter options — can help manage symptoms and reduce flare-ups.

What is scalp psoriasis?

Scalp psoriasis is a type of psoriasis that affects the skin on the scalp. Psoriasis is a chronic inflammatory condition that causes skin cells to multiply too quickly, leading to the buildup of thick, scaly patches. It is characterized by periods of flare-ups and remission.

When psoriasis affects the scalp, it can be particularly troublesome due to the presence of hair, which can make it challenging to apply treatment.

Scalp psoriasis can occur in mild to severe forms. In mild cases, it may appear as fine scaling that looks similar to dandruff. In more severe cases, thick, red, inflamed plaques covered with silvery-white scales can develop, sometimes extending beyond the hairline onto the forehead, neck, or ears.

Signs and symptoms of scalp psoriasis

While the symptoms of psoriasis can vary from person to person, there are some common features:

• red patches of skin covered with silvery-white scales
• flaking, which can resemble dandruff but is often more extensive
• dryness that may lead to cracking and bleeding
• itching, which can range from mild to severe
• burning or soreness on the scalp
• hair loss, often temporary, due to excessive scratching or inflammation.

Scalp psoriasis or eczema?

Scalp psoriasis and eczema (also called atopic dermatitis) can look similar, but they are different conditions. Eczema, like psoriasis, is a long-term skin condition that causes inflammation and is linked to an overactive immune system.

Eczema causes an intensely itchy, dry, red rash with fine scales that blends into the surrounding skin. In contrast, scalp psoriasis appears as dry, silvery-white scales and well-defined red plaques.

Although eczema can occur later in life, it most commonly starts during childhood. Psoriasis often first appears between the ages of 20 and 30 or between 50 and 60 years old.

Scalp psoriasis or dandruff?

Dandruff (also called seborrheic dermatitis) is another common scalp condition that may be confused with psoriasis. However, dandruff is caused by an overgrowth of yeast and tends to cause greasy, yellowish scaling. It does not typically cause thick scaling like scalp psoriasis does.

Medical treatments for scalp psoriasis

While there is no known cure for psoriasis, many treatments are available to help control symptoms and prevent flare-ups.

"The scalp is a very sensitive area with many nerve endings, so inflammation and itch can be particularly bothersome," notes Dr. Rebecca Gaffney, board-certified dermatologist, director of the Bullous Disease and Connective Tissue Disease clinics at Brigham and Women's Hospital, and Instructor in dermatology at Harvard Medical School.

Applying treatments to the scalp presents unique challenges due to the presence of hair. Dr. Gaffney advises that while "it may be hard to directly apply medicine to this area and can leave the hair feeling messy, you can select whichever formulation works best based on your hair texture and preference. Options include foams, solutions, and oils."

Topical corticosteroids (such as betamethasone, clobetasol, and fluocinolone) areconsidered the first-line or standard treatment option for scalp psoriasis. These anti-inflammatory medications are applied directly to the scalp to help reduce redness and scaling. However, potential side effects such as skin thinning, acne-like breakouts, and stretch marks can occur with long-term use.

Other medical treatment options include:

• Non-steroidal topical treatments. These treatments, which are applied directly to the scalp, contain vitamin D analogs (calcipotriene, calcitriol) and vitamin A derivatives (tazarotene). Newer options include roflumilast (Daliresp), which works by blocking the release of immune system proteins called cytokines to reduce itch and inflammation, and tapinarof (Vtama), which regulates the skin's immune responses and supports building and maintaining the skin barrier.
• Light therapy. Many people with psoriasis notice a benefit from exposure to ultraviolet (UV) light. The most common and effective method uses ultraviolet B (UVB) light, which penetrates only the outermost layer of skin. UVB light can repress inflammation and slow down the cell division that causes the growth of scaly patches on the skin. Dermatologists recommend the use of controlled "narrow-band" UVB treatments over direct sun exposure. Some dermatologists also use UV lasers, sometimes called excimer lasers, to target patches of psoriasis while sparing surrounding skin.
• Biologic medications. Biologic medications alter the immune system response. Most are given by injection or intravenous infusion. Examples include risankizumab (Skyrizi), secukinumab (Cosentyx), and adalimumab (Humira), which target immune pathways involved in psoriasis.
• Immunomodulating medications. These systemic medications have a variety of effects on the immune system to control skin disease. They suppress the immune system at earlier or less targeted stages than biologic drugs. Examples include methotrexate and cyclosporine, along with newer options such as apremilast (Otezla) and deucravacitinib (Sotyktu).

You and your doctor can select the best treatment options for your psoriasis based on the severity of your symptoms, your personal preferences, and other individual factors. Make sure to discuss the potential risks and benefits of each option.

Over-the-counter treatments for scalp psoriasis

Several over-the-counter (OTC) treatments can help manage symptoms of mild scalp psoriasis. When choosing products, look for active ingredients known to help with itching, scaling, and dryness:

• Coal tar. A long-used ingredient in psoriasis treatments, coal tar can slow rapid skin cell growth and reduce redness and scaling. You can find shampoos, gels, and scalp oils containing coal tar in many retail pharmacies.
• Hydrocortisone. Another option is to apply hydrocortisone, a mild corticosteroid that helps relieve itching and inflammation, particularly for small patches of psoriasis.
• Scale softeners. You can also find cleansers and shampoos containing scale softeners like salicylic acid, lactic acid, and urea. They help remove thick scaling and improve the absorption of other treatments, but overuse can worsen irritation.
• Anti-itch products. Ingredients like calamine or menthol may provide temporary relief, though they can sometimes cause dryness.

Best shampoos for scalp psoriasis: Ingredients to look for

Scalp psoriasis can be particularly stubborn due to the difficulty of treating the skin under the hair. You may have to experiment to find a treatment that's comfortable so you can use it consistently. Shampoos offer a simple, mess-free option, either on their own or alongside other treatments. When choosing a shampoo for scalp psoriasis, look for ingredients such as:

• coal tar
• salicylic acid
• pyrithione zinc
• selenium sulfide
• aloe vera.

Managing and preventing flare-ups of scalp psoriasis

Ongoing treatment is necessary to keep the condition from getting worse. This means committing to long-term treatments, whether medical or over-the-counter.

Dr. Gaffney also emphasizes the importance of overall health in managing psoriasis: "Other medical conditions may be more common in people with psoriasis, so it is important to have regular checkups with a primary care physician. Additionally, smoking and obesity appear to increase the risk of developing psoriasis and tend to make it more severe and difficult to treat. So I encourage a healthy lifestyle."

Finally, while scalp psoriasis is a lifelong condition, certain lifestyle strategies can help prevent flare-ups. Steps you can take to help prevent worsening symptoms include:

• Manage stress. Stress is a known trigger for psoriasis. Techniques like stress management, cognitive behavioral therapy, and guided imagery can help improve psoriasis symptoms.
• Avoid harsh hair products. Hair dyes, alcohol-based sprays, and harsh shampoos can worsen symptoms, or may even cause allergic rashes in some people.
• Eat a balanced diet. Some people find that anti-inflammatory diets rich in omega-3 fatty acids (found in fish, nuts, and seeds) help reduce symptoms. Adding antioxidants like vitamins A, C, and E, as well as carotenoids, flavonoids, and selenium (found in fruits and vegetables), may also play an important role in controlling flare-ups.
• Avoid scratching. Scratching causes further irritation, which can lead to more flare-ups and potential hair loss.