CASE 3: Scalp Psoriasis

A 30-year-old man presents with scaling and erythema of the scalp that extends past the anterior hairline. The patient has a family history of psoriasis. For the past 5 years, he has experienced wintertime flares of the disease that affect his scalp and the extensor surfaces of the extremities. (Case and photograph courtesy of Drs Marti Jill Rothe and Jane M. Grant-Kels.)What would your management plan include?
A REVIEW OF THE OPTIONSA family history of psoriasis significantly increases the risk of the disease. Often a chronic manifestation of the disorder, scalp psoriasis usually presents with thick, scaly plaques in the scalp and, occasionally, pink plaques along the hairline. Local therapy for scalp psoriasis-generally, a combination of topical therapies- ameliorates the signs and symptoms but often fails to completely clear the disorder. To lift and debride scale, recommend that patients apply baby, olive, or mineral oil to the scalp overnight or for 20 to 30 minutes before washing the hair with an antidandruff shampoo. For maximum efficacy, suggest that your patients periodically alternate the use of antidandruff shampoos that contain active ingredients, such as tar, zinc pyrithione, ketoconazole(, salicylic acid(, or selenium. Topical corticosteroid lotions, solutions, or gels may be applied to the wet head after the shampoo is used. Derma-smoothe/FS, which contains the medium-strength corticosteroid fluocinolone( acetonide in a peanut-oil base, is usually applied overnight under a shower cap. Some patients prefer Olux, which contains the ultrapotent corticosteroid clobetasol(propionate, or Luxiq, with the medium-potency corticosteroid betamethasone(valerate; these foam preparations are used after shampooing the hair. Generally, ultrapotent topical corticosteroids should not be used for longer than 2 consecutive weeks; advise patients to alternate between applications of ultrapotent and mediumstrength corticosteroids every 2 weeks. Topical calcipotriene lotion, tazarotene(gel, anthralin, tar, and salicylic acid preparations may also be prescribed for scalp psoriasis. Although some patients can tolerate hairline applications of calcipotriene, the agent often causes an irritant contact dermatitis when applied to the face. Topical tacrolimus and pimecrolimus(can markedly clear facial psoriasis; reassure patients that the stinging and burning, which usually accompany the first several applications, generally resolve with continued use of these agents. Tacrolimus( and pimecrolimus can be helpful; however, they are not yet available in lotion or gel formulations for easy application to hair-bearing areas.CASE 3:
APPROACH AND OUTCOMEOvernight applications of olive oil to the scalp and postshampoo applications of betamethasone propionate solution brought about some improvement. After 2 weeks, the corticosteroid was discontinued and pimecrolimus was prescribed for use on the central scalp and hairline; clinical improvement continued.