Hair loss from psoriasis

Dermatology Center for Skin Health Blog

In our latest blog, Psoriasis Treatments: What Can Cause it and Can you Prevent It, we talked about the multiple forms of psoriasis including plaque, guttate, inverse, pustular and erythrodermic atopic dermatitis and how they can affect the elbows, knees, scalp and genitals.

We are frequently asked about the connection between psoriasis and hair loss, especially by patients suffering from scalp psoriasis.

SCALP PSORIASIS

Scalp psoriasis is most commonly found when an individual has plaque psoriasis. According to the American Academy of Dermatology (AAD), 50 percent of people who have plaque psoriasis will have a flare-up on the scalp.

This type can extend further than the scalp, appearing on the forehead, back of the neck and behind the ears.

SYMPTOMS OF SCALP PSORIASIS

Scalp psoriasis can cover the entire scalp. Symptoms of scalp psoriasis are less noticeable for patients who have thick hair.

Symptoms, which can be intermittent, include:

  • Reddish patches: These patches are sometimes barely noticeable, especially if a patient’s hair is thicker or the patches are not too severe.
  • Dandruff flaking: Psoriasis can mimic dandruff; however, there is a key difference. In addition to being dry and flaky, psoriasis will cause the scalp to appear silver in color.
  • Dry scalp, itching and bleeding: You may feel itchy because of the dryness scalp psoriasis can cause. Scratching will cause bleeding, and worsen the psoriasis patches by resulting in larger, thicker growth.

TREATMENTS FOR SCALP PSORIASIS | OVER THE COUNTER PRODUCTS & MEDICATIONS

There are many over the counter and medicated shampoos that can help relieve scalp psoriasis discomfort.

It’s important to remember that over the counter treatment options are not a one-size fits all solution. While these treatment options can relieve the itch, patients who have moderate to severe cases may need a prescription treatment.

Over the Counter

There are two main ingredients you should look for in over the counter treatment options.

  • Salicylic acid can soften and remove scales that have formed. You can find this ingredient in creams, gels, lotions, shampoos and soaps.
  • Wood or coal tar will slow skin cell growth and reduce inflammation, itching and scaling. You can find these ingredients in shampoos.

It’s important to remember that salicylic acid, wood and coal tar contain different amounts of concentrations.

If you have mild psoriasis, a high concentration may cause more skin irritation.

For any other over-the-counter treatments, you want to make sure that you’re using fragrance free products, applying the treatment before and after showering and using soaps that moisturize the skin.

For patients who prefer baths, you can use oil or epsom salts in the water. These can help remove scales. Soak in the bath for 15 minutes and apply moisturizer immediately after.

Medically Prescribed

If you are seeing a dermatologist, they will develop a treatment plan specifically designed for you. Treatment could include medicine you apply directly to the scalp, shampoos, a scale softener, injections, light treatments or biologic drug prescriptions.

HOW TO MANAGE SCALP PSORIASIS

Scalp psoriasis may result in the urge to scratch your scalp. Don’t do this. Picking or scratching at your scalp can actually cause your psoriasis to flare up, bleed and result in hair loss.

  • When removing scales, do this with care. Part of treating scalp psoriasis means the scales will have to be removed.
  • Don’t stress. Stress can result in a flare up of your psoriasis. We understand this treatment can be frustrating, but try to reduce stress as much as possible.
  • Pay attention to your hair care. When brushing your hair, be gentle. Limit the use of hot tools on your hair or wearing a tight hairstyle. Pulling on your hair can cause hair loss. Coloring and styling your hair may also cause your psoriasis to flare.

HOW TO STOP HAIR LOSS

Scalp psoriasis is not the sole cause of hair loss.

Symptoms of scalp psoriasis and behaviors, like stressing and scratching, can cause hair loss.

  1. Gently brush your hair.
  2. Remove scales gently.
  3. Have good nail care. Cutting your nails down can help prevent you from scratching.
  4. Get treatment.
  5. If you believe the treatment is too harsh or isn’t working, let your dermatologist know.

DERMATOLOGY CENTER FOR SKIN HEALTH | TREATING SCALP PSORIASIS & HAIR LOSS

Psoriasis can be a serious health issue that should not be ignored. If you have questions about psoriasis, our certified-dermatologists can answer those for you and help you find a treatment.

Scalp psoriasis: 10 ways to reduce hair loss

When psoriasis develops on the scalp, hair loss sometimes follows. While hair tends to regrow once the scalp psoriasis clears, there are things you can do right now to prevent further hair loss.

  1. Gently comb and brush away the scale. To treat scalp psoriasis, you must loosen and remove scale. To prevent hair loss, you should do this gently.

    Brush gently

    Forcefully removing scale often loosens your hair along with the scale.

  2. Avoid picking off scale. Picking can aggravate your skin, causing psoriasis to flare.

  3. Get the treatment on your scalp. For treatment to be effective, you need to apply the medicine or medicated shampoo to your scalp.

  4. Keep your fingernails short, and file your fingernails so that the tips are smooth. Scalp psoriasis can be itchy, making it difficult to avoid scratching your scalp. Short, smooth nails can prevent you from scratching so hard that you loosen your hair or cause your scalp to bleed.

  5. If you use a medicated shampoo, try alternating shampoos. To avoid overly drying your scalp and hair, try using a medicated shampoo one day and a non-medicated, gentle shampoo the next time you wash your hair. Dry hair is more likely to break, which can lead to hair loss.

  6. Use a conditioner after every shampoo. This can help your scalp feel less dry. Using a non-medicated conditioner can also help reduce the scent of a medicated shampoo.

  7. Let your hair air dry. When you have scalp psoriasis, your scalp is extremely dry. Blow drying can dry your scalp even more.

  8. Test your hair care products. Hair color, straightening products, and hair sprays can boost self-esteem, but they can also dry your hair and irritate your scalp. Before using a hair-care product, dab a small amount on your scalp and let it stay there a while. If your scalp feels irritated in a few hours, swap that product for something gentler. Be sure to test every product.

    Dry hair

    Dry hair breaks more easily, which can lead to hair loss.

  9. Tell your dermatologist if the treatment for your scalp seems too harsh. Skin on the scalp is thick, so treatment for scalp psoriasis is often stronger than treatment applied to other areas. If your treatment seems too strong, tell your dermatologist. Your dermatologist may switch treatments or change how you use the current one.

    Medicated shampoo

    After you get good clearing, using a medicated shampoo may prevent scalp psoriasis from returning.

  10. Tell your dermatologist if nothing seems to stop your hair loss. People lose hair for many reasons. Your hair loss could be caused by something other than your scalp psoriasis. A dermatologist can look for the cause of your hair loss.

If you have difficulty clearing your scalp psoriasis, be sure to make an appointment to see a board-certified dermatologist. It’s rare to have scalp psoriasis for long when you follow a dermatologist’s treatment plan.

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Scalp Psoriasis With Increased Hair Density

Case Report

A 19-year-old man first presented to our outpatient dermatology clinic for evaluation of a rash on the elbows and knees of 2 to 3 months’ duration. The lesions were asymptomatic. A review of symptoms including joint pain was largely negative. His medical history was remarkable for terminal ileitis, Crohn disease, anal fissure, rhabdomyolysis, and viral gastroenteritis. Physical examination revealed a well-nourished man with red, scaly, indurated papules and plaques involving approximately 0.5% of the body surface area. A diagnosis of plaque psoriasis was made, and he was treated with topical corticosteroids for 2 weeks and as needed thereafter.

The patient remained stable for 5 years before presenting again to the dermatology clinic for psoriasis that had now spread to the scalp. Clinical examination revealed a very thin, faintly erythematous, scaly patch associated with increased hair density of the right frontal and parietal scalp (Figure). The patient denied any trauma or injury to the area or application of hair dye. We prescribed clobetasol solution 0.05% twice daily to the affected area of the scalp for 2 weeks, which resulted in minimal resolution of the psoriatic scalp lesion.

Psoriatic patch on the top of the scalp with increased hair density.

Comment

The scalp is a site of predilection in psoriasis, as approximately 80% of psoriasis patients report involvement of the scalp.1 Scalp involvement can dramatically affect a patient’s quality of life and often poses considerable therapeutic challenges for dermatologists.1 Alopecia in the setting of scalp psoriasis is common but is not well understood.2 First described by Shuster3 in 1972, psoriatic alopecia is associated with diminished hair density, follicular miniaturization, sebaceous gland atrophy, and an increased number of dystrophic bulbs in psoriatic plaques.4 It clinically presents as pink scaly plaques consistent with psoriasis with overlying alopecia. There are few instances of psoriatic alopecia reported as cicatricial hair loss and generalized telogen effluvium.2 It is known that a higher proportion of telogen and catagen hairs exist in patients with psoriatic alopecia.5 Additionally, psoriasis patients have more dystrophic hairs in affected and unaffected skin despite no differences in skin when compared to unaffected patients. Many patients achieve hair regrowth following treatment of psoriasis.2

We described a patient with scalp psoriasis who had increased and preserved hair density. Our case suggests that while most patients with scalp psoriasis experience psoriatic alopecia of the lesional skin, some may unconventionally experience increased hair density, which is contradictory to propositions that the friction associated with the application of topical treatments results in breakage of telogen hairs.2 Additionally, the presence of increased hair density in scalp psoriasis can further complicate antipsoriatic treatment by making the scalp inaccessible and topical therapies even more difficult to apply.

4 Things To Know About Scalp Psoriasis, According To Dermatologists

Fun fact: Your skin is the largest organ in your body (that’s according to literally everywhere, like the American Academy of Dermatology)—and, as a chronic skin condition, psoriasis can happen anywhere on that organ. But when it shows up on your scalp, it’s specifically called scalp psoriasis.

A quick refresher: Psoriasis is a skin disease that causes itchy or sore patches of thick, red skin with silvery scales, according to the U.S. National Library of Medicine (NLM)—but it’s not a communicable disease, meaning you can’t catch it. Instead, psoriasis stems from an issue with your immune system. Your skin goes through something called cell turnover, where skin cells grow and rise to the surface of your skin. In most people, this happens over the course of a month, per the NLM—but in those with psoriasis, it can happen over the course of a few days, leading to those thick, scaly patches.

But when psoriasis occurs on the scalp, it’s a little bit different. The skin on the scalp is a little bit thicker than the rest of your skin, and hair that grows on the scalp can also get in the way, per the AAD. Here are four more things you need to know about scalp psoriasis—and what to do if you have it.

1. Scalp psoriasis is actually pretty common among those with psoriasis.

Overall, more than eight million Americans have psoriasis, according to the National Psoriasis Foundation (NPF)—and nearly 80 percent of patients with psoriasis will also have scalp psoriasis.

Conversely, some patients will only have scalp psoriasis, says Jessica Kaffenberger, MD, a dermatologist and psoriasis expert at The Ohio State University Wexner Medical Center. It can manifest as mild (fine scaling) or severe (thick crusted plaques), according to the NPF. Scalp psoriasis can also extend onto the forehead, the back of the neck, and around the ears.

RELATED: What is Inverse Psoriasis—and What’s the Best Way to Treat It?

2. Scalp psoriasis can look a lot like dandruff.

While dandruff is accompanied by flaking and dryness, scalp psoriasis looks silvery and has well-defined red, raised plaques, not just flaking and dryness. “The scales from psoriasis can flake off much like dandruff,” says Richard Torbeck, MD, a dermatologist at Advanced Dermatology in New York City. “Additionally, itching from psoriasis is quite similar to itching from dandruff. However, each condition needs to be treated very differently,” he adds.

3. Scalp psoriasis can lead to hair loss.

Unfortunately, hair loss is common with scalp psoriasis, per the NPF—but it’s more about damage to the hair shaft and follicles from excessive itching, rubbing, and combing; or from the ingredients in products, than it is about the psoriasis itself.

The good news: Hair loss from psoriasis is almost always temporary, and, with appropriate treatment, normal hair growth will return once psoriasis is managed.

RELATED: 6 Things That Can Cause a Psoriasis Flare-Up

4. There are a few different treatments for scalp psoriasis.

When you meet with your healthcare provider to discuss how to treat your scalp psoriasis, expect to be offered several options, including topical treatments, phototherapy and systemic medication, depending on how extensive your scalp psoriasis is, whether you have it elsewhere on the body and how much it affects your daily life.

As far as topical treatments go—that means medication that can be directly applied to the skin—corticosteroids that can be applied as a foam, shampoo, cream, gel or lotion are often prescribed. “This usually brings your scalp psoriasis under control within two to four weeks,” says Erum Ilyas, MD, a dermatologist in Philadelphia. “Once you take that, your scalp psoriasis can be maintained with topical calcipotriene (a synthetic, topical form of vitamin D) and shampoos that contain coal tar and salicylic acid.”

Phototherapy is another option. “This is done with a UV comb that permits the light to get directly to the scalp,” Dr. Ilyas says. “Light therapy for psoriasis has been around for decades as it has been shown to help treat psoriasis by reducing certain inflammatory cells in the skin.” While this therapy can be effective, the downside is that you may be required to undergo two to three treatments a week at your doctor’s office over the course of several weeks, Dr. Ilyas says.

Of course, these topical sorts of treatments are best used alongside systemic medications, says Dr. Kaffenberger. They work by altering the immune system to control psoriasis from the inside out—and they’re especially helpful if your psoriasis is widespread and not just limited to your scalp.

In the end, experts recommend speaking with your healthcare provider about the treatment options that are best for you. One tip: If you have this immune disease, don’t underestimate the way stress can contribute to flare-ups. “I always remind patients that there tends to be a strong stress correlation to flares,” Dr. Ilyas says. “It’s important to know this to help control symptoms, too.”

RELATED: This May Be Why Women Are Far More Likely to Get Autoimmune Diseases

Symptoms–Hair Loss

Psoriasis is a chronic autoimmune condition that causes raised, inflamed, and scaly patches called plaques to appear on the skin. Plaques can occur anywhere on the body, but the scalp is a common location–around half of people with psoriasis have symptoms on the scalp1.

Can psoriasis cause hair loss?

Many people with scalp psoriasis may worry that they will lose their hair. Some people who have psoriasis will experience hair loss, but it is usually only temporary2. Hair loss is not very common in people who have mild or moderate psoriasis. People who have more severe psoriasis may have small areas of hair loss, but psoriasis rarely causes permanent hair loss3.

What are the possible causes of hair loss?

Hair loss that is caused by psoriasis is called psoriatic alopecia. Psoriatic hair loss can affect the hair on the head as well as body hair. Hair loss occurs most often on areas of the scalp where there are plaques. A smaller number of people experience more general hair shedding all over the scalp1.

When hair loss happens on the scalp, it is usually caused by removing the silvery scale covering the top layer of the plaque. Scratching the plaque, by combing the hair, for example, can pull off parts of the scale. In some cases, patches of hair may come out along with the scale. When the plaque on that area of skin heals, hair usually grows back completely and there is no scarring2.

Certain types of psoriasis treatments may also have the side effect of hair loss for some patients3. These include acitretin, which is a Vitamin A analogue, and certain kinds of biologic therapies. Patients who need to apply topical treatments to the scalp on a regular basis might also experience hair loss due to the friction of rubbing in the medication4.

What are treatment options for hair loss?

An effective way to treat hair loss is to prevent it, by treating the psoriasis plaques that can cause hair to fall out. Products made from coal tar and salicylic acid can work well on scalp psoriasis that is milder. Other topical treatments for scalp psoriasis include anthralin, Tazorac (tazarotene), Taclonex (calcipotriene) and Dovonex (calcipotriene)3. More severe scalp psoriasis may need to be treated with phototherapy or stronger medications such as systemic or biologic treatments that affect the entire body to reduce psoriasis symptoms.

Itching on the scalp is very common for people with scalp psoriasis. It is important to treat the itch because itching leads to scratching, which can cause hair loss if scales on the plaques are removed. There are various medical shampoos available that can help reduce itching. They are usually rubbed into the scalp and left to sit for a while so that the treatment can penetrate the scalp through the hair. Over-the-counter antihistamines taken by mouth can also help to relieve itching.

Tips for living with hair loss caused by psoriasis

Although scalp psoriasis can be very itchy, it is best to minimize scratching as much as possible. In addition to causing hair loss, scratching can cause the scalp plaques to bleed. Being very gentle while shampooing (whether or not it is medicated shampoo) is also important because scrubbing and scratching can make the plaques worse1.

If you need to remove scale for psoriasis plaques on your scalp, it must be done very carefully and gently by first applying oil or ointment to soften the scale, then loosening it to remove it. Picking at the scale can make the plaque worse and also cause hair loss.

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