Scalp Psoriasis: Top Tips & Derm-Approved Treatments for Dry, Flaky Scalp! | Dr. Shereene Idriss

Welcome back little nerds to Pillow Talk Derm. I'm Dr. Shereen Idris, a board certified dermatologist and today we're going to cover practical tips as well as how to treat scalp psoriasis. Because it affects a lot of you guys out there and it's one of those things that is going to live with you throughout the course of your life. If you have not subscribed, subscribe below. We do this thing called Pillow Talk Derm every Saturday at 10am and let me know what you want to learn about next week. But don't forget to like this video. In this video we're going to talk about what scalp psoriasis is, what who gets it, why they get it, what causes it, practical tips you can do at home, followed by over the counter treatments. And then we're going to go into an office to understand the lay of the land so you don't get overwhelmed by your options. Because scalp psoriasis is one of those things that is often misunderstood. It is part of the psoriasis family. Psoriasis is one of those chronic autoimmune conditions that affects a lot of people out there. They don't even realize they have it. Additionally, it often comes with a stigma where people look at you and go, oh, is that contagious? And unfortunately that still happens. It is not contagious. And honestly, that stigma should die. Your body attacks its own immune system. And you know how our skin can regenerate every 28 days where it goes from the bottom layer up and then sloughs off. Very microscopically you do not see your dead skin cells shedding. The reality is with psoriasis, your skin cells do not want to leave your body and it doesn't really slough off. So it starts to build up. In addition to getting an accelerate, skin cells renews itself. So it's a double whammy where it's growing faster and it doesn't want to slough off and it just sticks on the surface of your skin and it appears as these red, raised, silvery, flaky, scaly plaques that can sometimes bleed, that can sometimes look worse than what they are. But imagine a bottom of a foot that's really dry with a mound of skin all over your skin on your body, but more importantly so on your scalp. And you'll feel little tiny quote unquote mountains. You'll feel little plaques. You'll want to scra them off. You look at your hands and you might see dead skin cells. You might seem like you have a lot of Dandruff on your scalp, but that's usually the overall picture. The important part to note is that in addition to what it looks like, it can often be very itchy, so you're going to want to scratch. It can often feel very sore. It may lead to the breakage of your skin, bleeding, infections and whatnot, and you might get some temporary hair loss. But it's important not to confuse it just with dandruff. Dandruff is a condition caused by a yeast that lives on our skin and even our scal. But the confusing part though is sometimes you can have two picture. This is my lip balm, by the way. You can have a two picture situation where you have sibo, seborrheic dermatitis, dandruff, psoriasis, where they live together and they coexist. So how do you know if you have psoriasis? Other signs may also happen. If you look at your nails, you might notice tiny pitting of your nails and that's usually a sign of psoriasis. And additionally, if you have joint pains, especially in the morning when you wake up, it may be a sign of psoriasis. Who gets it? Anyone can get psoriasis regardless of race or gender. It usually starts around the ages of 15 to 35 and 45 to 65% of people have scalp involvement. Some people do have genetic predispositions, but it can really affect anyone, anywhere of any race, of any height, of any gender, of any mental status. Although stress does make it worse. So what causes scalp psoriasis? Number one, an immune dysfunction that is the root cause of psoriasis. Your immune system mistakenly attacks your own skin health and therefore your skin cells will not want to let go of themselves and not fluff slough off. Number two, accelerated skin cell growth. Like we talked about, that double whammy where not only is it not falling off, but it's also growing slightly faster. Number three, I ment stress. Environmental triggers can cause psoriasis to come into effect. Anything that stresses your body, your mind, etc can cause your immune system to dysfunction and can result in something that is autoimmune, like psoriasis. It doesn't necessarily have to be psoriasis, but stress is a factor. Strep throat can cause psoriasis to get triggered. Yes, an infection like strep skin injuries, certain medications and extreme weather conditions can exacerbate it. Hormonal changes can make psoriasis worse like puberty and menopause. Hence 15 years old is when it kind of starts to Kick in menopause, it definitely can kick in as well. And guess what makes it better. This is one thing about pregnancy that your body will really enjoy. I don't know. For me pregnancy was a very tough experience. But pregnancy will make your psoriasis better because when you are pregnant you become immunosuppressed and your psoriasis will get better, but it will flare up once the baby comes out. Lifestyle factors, excessive alcohol consumption and smoking are no good as well as obesity can increase worsening of your psoriasis. So that is a big picture of what psoriasis does when it comes to your scalp. Anything above 10% involvement of your scalp is going to require a little bit more rigorous treatment. Anything less than 10% body surface area of your scalp is going to require less. You can kind of do at home. So you guys can do at home to help yourselves. Starting with the boring that hopefully you adhere to is limit alcohol, limit smoking. Those are two easiest things to do that will help minimize flare ups of your psoriasis. Anti inflammatory foods rich in omega 3 can also help like salmon etc or take fish oil. Additionally, vitamin D can also help minimize flare ups as well as avoiding excessive heat and scrubbing. We're going to get into this in a hot second but. But you don't want to be scrubbing so hard where you're causing your scalp to bleed and making it spread to other areas of your scalp. And you want to make sure that you are avoiding any sort of excess dryness. So in winter you want to keep your head warm, you want to wear a beanie, especially if it's cold out or if the air is dry. You want to do things to help yourself. So how do we treat scalp psoriasis then at home with over the counter things that are available to us, starting with over the counter medicated shampoos. This can really make a difference in your lifestyle, how you approach life, your quality of life and the appearance of your scalp psoriasis. Now it may sound a little bit silly, but the reality is if you're dealing with this every single day, it's going to take a mental toll and people might be looking at you and it might make you feel weird. So do everything you can to help yourself. Medicated shampoos include shampoos with coal. Coal tar color has been shown to reduce inflammation, has been shown to soften the scalp and has been shown to relieve itching and slow the cell growth cycle. It can be applied once a day at night, but it's probably going to make your Hair a little bit dry, so you want to find that right balance if you have long hair on how often you want to apply it to your scalp or shampoo with it. And sadly, Neutrogena Tea gel, which in my opinion was one of the most available options on the market, is no longer. I don't know why they discontinued it, but they did. But I'm going to link below Other coal tar shampoos. Other medicated shampoos that can also help reduce scale and inflammation are shampoos that address dandruff. Even though you don't know if you have a mixed picture, using a shampoo that addresses dandruff might help the overall picture. So why not incorporate it? So anything with zinc, I can never say this. Parathione or selenium sulfide or ketoconazole. So head and shoulders Celsius Blue Nizoral. Take your pick. Incorporate it into your hair care routine throughout the course of the week when you apply the shampoo, especially the anti dandruff shampoo that's available over the counter, that's formulated for washing your hair. Not necessarily just a medicated shampoo. I would apply it to my scalp, really focusing on the scalp, massage it in and maybe do a head wrap to keep it warm before I go into the shower, hoping to break up any sort of buildup or scale. This is also going to come in handy as a lifestyle tip. Before you take a shower, you can use any sort of oil, like a coconut oil or a mineral oil, apply it to your scalp, massage your scalp and do a warm head wrap to really try to soften those scales so that they break up. Gently being the key word. Because when you scratch your scalp, there's something known as Kebner's phenomena, which basically means that anywhere that you're scratching that's not affected might get triggered into being affected, so you might be making the overall picture worse. Hence why I hate head scrubs, especially for people with psoriasis, and why I tell people, do not pick at your flakes. Do not try to rip them off, because you're never going to rip it off perfectly exactly where it's at and you might get unaffected scalp triggered. So that is something I would tell you to be careful of. Other scale softeners that exist are salicylic acid over the counter as well as shampoos. So if you don't want to wash your hair necessarily every day, you can get salicylic acid in a dropper that can literally be applied. This is where maybe A dropper comes in handy to the scalp plaques themselves and massage it into the plaques, allowing it to sit. And I would even do this 30 minutes before I shower so that it really does get absorbed, or even after the shower if there's still a plaque, so that it really then penetrates better. Other softeners include urea or even lactic acid. Anything that you apply on your face, you can apply to your scalp. It may not be cosmetically elegant, but if you do it before the shower, you're going to wash it off and then you use the more cosmetically, cosmetically elegant option afterwards. A third option that you guys can do at home is applying a retinoid. Now, this is more of an unconventional one. We'll talk about vitamin A derivatives and scalp psoriasis, but applying a retinoid to some of these patches might help accelerate how it's turning over, not necessarily cell growth. So it's a fine balance there. You want to make sure that you're not triggering inflammation though, so you want to go low and slow. It's about consistency over intensity. And the fourth most available option to all of you guys over the counter, which is one of the mainstream ways we used to treat psoriasis solely, is using a steroid. So over the counter hydrocortisone can definitely help as well. Especially after the shower, when your scalp is moist and damp, applying it to those spots to allow it to calm down is going to help minimize the itch, is going to help minimize the irritation, and therefore is going to minimize any sort of inflammation and block you from wanting to do this to your scalp over the counter. Hydrocortisone, though, it's probably not going to be strong enough, it is the lightest type of steroid available to us to treat this, but something is better than nothing. And honestly, if you can help yourself and if these things make any sort of impact on your scalp, it's going to help your quality of life dramatically. Now, moving into in office, I think it's important that we note a couple of things. When do we go into office? We go into office when the over the counter care is not enough and it's continuously getting worse, or it's affecting our quality of life and our mental status. Number two, if 10% of your scalp surface area is covered in psoriasis, you go straight to the office and we'll talk about that in a second. When we get into oral and injectable medications, if you are experiencing joint pains, you go into the office again, we're going to talk about that. About oral and systemic medications. But if you don't have it under control and you need help, try to find yourselves a local board certified dermatologist who can help you through this ordeal. Because it's going to be a chronic thing you're living with throughout life and it's going to ebb and flow and the more empowered you are to take care of it, the better. So in office, we start usually, if it's usually minimal and not that extensive, with topical steroids, not hydrocortisone. Like I said, that's the lightest one. It has several classes when you're talking about steroids, and we have several different potencies within each range. And depending on the formulation, if it's a foam or if it's an ointment, some adhere better and therefore work more efficiently to your skin. And so we kind of have to figure out this song and dance between the dermatologist and the patient to understand which one works better. But like I said, it works by reducing inflammation, it reduces cellular proliferation, it constricts blood vessels, so it's not going to be as inflamed. And usually use it once a day. Ish. I would tell that because nobody wants to apply it on long hair in the morning, at night, and therefore we usually go stronger in terms of the steroid that we use. And we can use it for up to four weeks, but we must take breaks with any steroid. If you use it consistently forever, you're going to thin your skin out, you're going to get other problems. And the biggest risk is if it's a very strong steroid that's being used on a larger body surface area. And this is pretty big. Your whole scalp, your palm is 1%. So 1, 2, 3, 4, 5, 6. It's usually around 10% of your body surface area, 5 to 10%, depending on how big your head is. I have a big head. You want to make sure that you're not getting systemic absorption long term, but also it can affect the bone density long term if you're chronically doing it. So just things to be aware of. Number two, in terms of topical prescriptions, we have vitamin D analogs like Calcipatrat because of the trial, which is also known as Dovinex. And this is a great alternative to steroids because it doesn't come with those side effects. And so sometimes patients will use this on the weekend and use the steroids during the week. And this will help reduce inflammatory inflammation and normalize any sort of keratinization of your Scalp. It works really well when used with a steroid alone. It's not the best thing since sliced bread, but it's a great option to give your skin breaks. Now, like I said, when do you think about anything system systemic, oral or injectable? When we have joint pains and when we have more than 10% of our scalp affected. Because topical alone is not necessarily going to help. Why do we need to go on something, something systemic if it just affects our skin? Because psoriasis is a chronic inflammatory condition. It's not just affecting what you can see visibly, but it's also affecting internally and it can have this same risk as smoking alone on your heart health. And you want to make sure that you're not having inflammatory inflammation in your blood vessels and around your heart, which can lead to, unfortunately, heart attacks, etc. So we want to make sure that we are treating it because what we see on the surface of our skin is a reflection of what might be happening internally. Plus, if you have joint pains, that's a sign of psoriatic arthritis, which borders now on other issues that can also happen that can affect your joints. And so you want to make sure that you're treating those so that your joints don't worsen as you get older, they don't become completely hardened, they don't become useless to you as you get older, and they don't become a nuisance. So oral medications is where we were like 15 years ago, 20 years ago, and when I was in training, biologics, which is the injection, started to come out and become more commonly used. So oral medications that you usually see are, for example, sorry Attain, which is a type of vitamin A similar to Accutane, but usually used just for psoriasis. And it helps with psoriasis, but it can cause worsening of dryness and irritation. It's not great. You have to monitor your blood the same way you would with Accutane. Etc. Methotrexate is another strong medication that reduces inflammation and suppresses your immune system. It can be very effective for severe psoriasis, but you can't be on it forever because it can affect your liver. So you have to constantly check the overall dosage that you've gotten in your lifetime and you want to make sure that you are on top of it. If your psoriasis is so bad, might be worth starting with it and then switching. But if you've been on it for several years, talk to your doctor about making sure your total dose has not surpassed what you need. Cyclosporine is another immunosuppressant. It can have serious side effects on your kidneys, but it can also be a game changer in reducing inflammation quickly and symptoms very fast, especially if you have joint pains. And then Otezla is one of the newer ones on the market and has much fewer side effects effects than the rest. And it works by reducing the inflammation in your body. And it is often used for moderate psoriasis, which leads me to now systemic biologic therapies. And I go like this because they're usually injected injections. And this is a newer type of treatment that works by targeting your immune system, newer being in the last decade ish or so. And it helps by controlling specific proteins and molecules that are involved in your immune response. We're not going to get into the nitty gritty of it, but the three biggest ones are TNF inhibitors like Embreling, which you get once a week. Then you have IL12 and IL23 inhibitors like Stelara, which you get usually a cup once a week and then once a month. And then you do it on your maintenance dose once every three months, which is great because you don't really have to think about it. It's also great if you have irritable bowel disease like Crohn's, because that's also an autoimmune condition. And then we have IL17 inhibitors like Cosentyx, which is great at blocking your immune system in terms of causing inflammation and skin cell production. And it is probably the most effect. But this is once a month. So depending on your lifestyle, depending on your medical conditions and your history, you and your doctor will figure out which one is the best one for you. But this is especially helpful if you have moderate to severe scalp psoriasis or joint pains or other issues going on as well. In terms of autoimmune conditions, it can affect your entire immune system. So you do have to be a little bit more careful. But you don't have to be a bubble boy. You know that expression of people who are immunosuppressed living in a bubble. You don't have to live your life in that way. You can live your life regularly. Ish. But if somebody is sick, you might want to stay away or wear a mask just in case. And it can provide long lasting relief from flare ups even after treatment has stopped. And we've seen this, so it's very, very exciting. So those are pretty much in a nutshell, your treatment options from A to Z. I did not mention intralesional steroid injections. Almost like you would inject a pimple. If somebody has a big event and they need a steroid injection to a scalp psoriasis, you can, but I don't love doing that because it will trigger and it will get worse longer term. Plus if you only do that, you might decrease your bone density over time, like years. So you have to be careful. I hope this was helpful. I hope the practical tips were helpful. I hope the at home tips were helpful. But if you guys have any systemic symptoms, joint pains, more than 10% of your scalp affected, go into see a board certified dermatologist to help you through this problem because you're going to need more than over the counter treatments. I'm Dr. Shereen Idris. I hope this was helpful. Have a beautiful Saturday and if you guys have any questions, as always, leave them below.