Scalp psoriasis

Scalp psoriasis, resulting from excessive scaling occurring together with
inflammation, affects at least half of all psoriasis patients (Figure 5). Because
scales on the scalp, face and clothing can be very obvious, this ailment can be
very rough on a patient’s emotional and psychological well-being. Some patients
even try to scrape their severe scaling off. Don’t be one of them! Scraping
damages the scalp skin and worsens psoriasis.
There is good news and bad news regarding scalp psoriasis. The good news is
that with so many treatment options available, most patients can be helped. The
bad news is that the scalp is one of the most difficult areas to treat, and many
patients do not easily tolerate the treatment agents. Thus, frequent alterations in
their medication plans are needed. It is a constant challenge to clear scalp psoriasis
effectively, maintain improvements and modify treatments based on patients’
reactions to the toxicity of medications.
There are a few conditions that mimic the symptoms of scalp psoriasis, but
they are actually different diseases. Seborrhoeic dermatitis or seborrhoeic
eczema of the scalp is probably the most common condition that looks like scalp
psoriasis. If your dermatologist has prescribed dithranol (anthralin) be sure that
someone in the clinic (usually it’s a nurse) gives you detailed instructions, so
that you can avoid unnecessary staining and irritation. Most importantly,
remember to shampoo backwards, away from the face, to prevent the dithranol
from dripping onto your forehead and from there into your eyes.
Imidazole lotions or creams are effective for some patients and once they have
achieved maximum improvement, patients can usually reduce their applications
from daily to occasional use and still effectively control their psoriasis.
Cortisone-containing scalp preparations are frequently helpful (Figure 5d).
Injecting cortisone directly into the lesions of scalp psoriasis can lead to long
periods of improvement for some patients with tough but localized cases. PUVA
(psoralen-ultraviolet-A) therapy may help— particularly with thin-haired patients
—and sunlight therapy is sometimes effective as well.
Vitamin D scalp lotion (Dovonex) or tazarotene gel (a new type of vitamin A)
can be applied to the scalp at night—if they irritate then use a cortisone scalp
lotion or foam (Olux and Luxiq foams in the USA) every other night.
I believe that shampoos are vitally important in controlling scalp psoriasis,
even though there have been few scientific studies on them. Therapeutic
shampoos, usually available without a doctor’s prescription, usually contain coal
tars, wood tars, salicylic acid, sulphur, selenium and zinc parathione or they may
combine several of these agents in one shampoo. I give samples of several
shampoos to my patients and allow them to select one that proves most
beneficial and least irritating. I have found that some patients with blonde or
dyed hair resist using tar shampoos because they sometimes stain the hair. As
these shampoos can be expensive, one of my patients offered the following tip to
reduce the cost.
‘I apply tar soap (Polytar) as the first coat. I then apply the tar shampoo
such as T-Sal, T-gel or Pentrax, which are highly concentrated and require
smaller quantities. A bar of tar soap lasts a very long time. Any shampoo or
conditioner can then be used after the tar shampoo has been rinsed out.’
Examples of shampoos which can be bought without prescription include:
Alphosyl, Capasal, Ceanel, Clinitar, Ionil T, Nizosal, Polytar (UK); Ionil T,
Nizoral, Selsun, T Gel (USA)
Newer, less messy scalp treatments
A prescription shampoo called Nizoral contains ketoconazole to reduce yeasts
present on scalp skin, which in turn may improve scalp psoriasis in some
patients.
Tazarotene gel (known as Tazorac in the USA and Canada and Zorac in
Europe) applied to the scalp nightly or on alternate nights is very helpful in
improving psoriasis. Some patients also benefit from Dovonex scalp lotion (see
previous page).

Psychotherapy support

As you discuss the stresses in your life with your psychotherapist or your support
group members, you may learn first-hand what dermatologists have known for a
while— often several weeks elapse between the time of the stress and the
worsening of the psoriasis. You may have thought that there was no connection
between life’s little dramas and the state of your skin. But, when you come to see
the cycle’s pattern, it will be easier for you to break the cycle. For example, if
you discover that having a fight with your parent, child, spouse or work
supervisor always results in a bad psoriatic outbreak, you may have an extra
incentive to find a more amicable way to settle your differences. If nothing else,
recognizing exactly how and when stress affects your psoriasis will help you to
find the relaxation techniques that help minimize the flare-ups if you employ
them soon enough after the stress trigger.
Some of the techniques that may work for you include self-hypnosis,
meditation and yoga. Major metropolitan centres have classes in all of these
disciplines, and some psoriasis centres have support groups that can train you in
these stress reduction techniques as well.
If these stress reduction strategies are not sufficient, you may want to consult a
psychiatrist. Unlike psychologists, psychiatrists are licensed to prescribe drugs,
and there are many new drug therapies available that are designed to reduce
stress and depression. However, let me stress that these drugs must be used
under the continued guidance of a psychiatrist, because there are sometimes side-
effects to be weighed against the benefits of the drug. Some of the medicines now
available include fluoxetine (Prozac) and its relatives, which are antianxiety,
antipanic and antidepressant drugs, and buspirone (Buspar), also an
antidepressant. Your doctor or psychiatrist can tell you more about specific drugs
and their respective pros and cons.
In the years I have been treating psoriasis, I have found that the patients who
have been most successful in dealing with psoriasis, and by successful I mean in
their attitudes as well as in their physical condition, share several characteristics.
First, they have made peace with their psoriasis. This doesn’t mean that they
have given up on seeking treatments that work for them. On the contrary, it
means that they have said to themselves, ‘I have psoriasis. I will not be ashamed
of it or limited by it, either socially or professionally. Since I cannot change it, I
will accept it and continue to treat it as best I can’.
This leads us to the second main characteristic: the most successful patients
are persistent in their treatments. It can become quite discouraging for patients to
live through so many new psoriatic eruptions, especially after relishing the
freedom of being clear for a few weeks or months. Unfortunately, this is often
the nature of psoriasis. The patients who cope best are those who know to expect
that new outbreaks may occur and are willing to try new treatments, creams,
shampoos and whatever else may be required.
As you continue to read this book and to live with psoriasis, remember that
you may not be able to control your skin, but you can control your attitude
towards it. Accepting psoriasis as a fact of life will free up your emotional
energy for more productive endeavours and should alleviate some of the stress
associated with psoriasis.

Learning to live with psoriasis —coping mechanisms and programmes

Our understanding of psoriasis is increasing but as yet we have no cure for this
once baffling disease. However, until a cure is found, there are many treatments,
strategies and attitudes that can make life easier and less painful for psoriasis
patients.
If you have suffered from psoriasis for a while, you probably know that stress
can aggravate the condition. Avoiding stress is difficult for anyone living at the
start of the 21st century but to make matters worse, psoriasis itself can heighten
stress, creating a vicious cycle of flare-ups and increased tension. Also, once the
cycle has built up momentum, it can affect your self-esteem and can even cause
problems at work and in your social life. People who have dependence on drugs
or who have alcohol addiction can be driven to use more, again worsening the
psoriasis.
Luckily, there are several ways to avoid or minimize the stresses that life and
psoriasis bring with them, and more stress-minimizers are being developed every
day.
Stress reduction and psoriasis
There are several ways to ease the stresses psoriasis brings with it:
• Make your friends and colleagues aware of your condition, and let
them know how they can help you through the tough times. If you
don’t ask for support, no one will know that you need it. Enlisting
friends’ support is helpful not only on a practical level, but also
because it will make you feel less alone in your disease.
• If you find that your psoriasis worsens at certain times of the year,
avoid making big time commitments for those periods. Try to reduce
the number of deadlines you face and don’t plan large gatherings or
social events at home. It is essential that you have sufficient time to
unwind and relax during psoriasis outbreaks.
• Don’t rely on drugs or alcohol to lift you out of the depression that
sometimes accompanies psoriasis. For one thing, while these
substances might improve your mood temporarily, they may lead to
even greater depression the morning after. Also, alcohol can be
dangerous when taken in combination with some of the drugs used
to treat severe psoriasis.
• Start the day with pleasant thoughts and images. Imagine that your
skin is going to improve and think about the positive aspects of your
life. Picture yourself in a peaceful and tranquil setting, or listen to a
tape of crashing waves or rain-forest noises. Relaxation tapes are
available at many music stores.
If you find that your psoriasis is stressing you out even with all of these exercises
or that everyday stresses are making it worse, your first step should be to visit
your dermatologist. Dermatologists can be supportive and helpful when dealing
with psoriasis, and dermatologists have a lot to be positive about today. Many
new treatments are available to control psoriasis and with correct use of these
treatments, your psoriasis can improve maximally or clear for prolonged periods
of time. Learning about these treatments may help you not only tackle the
physical symptoms of your condition, but may also give you an emotional boost.
Just knowing that help is on the way can be very helpful in itself!
Discussing your psoriasis and its effects with a dermatologist who understands
them can go a long way to relieving anxiety, but more importantly, your
dermatologist can recommend the stress-relief techniques that will work best in
getting your psoriasis under control. He or she may refer you to a
psychotherapist for talk therapy, stress reduction programmes and biofeedback.
In addition to reducing the stress that can aggravate psoriasis, psychotherapy
may help you to change your responses to the psoriasis itself. Working with a
good psychotherapist, you will be able to learn new behaviour patterns that can
enable you to cope more effectively with your emotional concerns and to control
the effect psoriasis has on your social interactions, rather than letting the disease
control you.

Different types of psoriasis 2

Localized pustular psoriasis
An unusual form of the disease, pustular psoriasis is often found on the palms of
the hands or the soles of the feet. It can be very uncomfortable when you are
working with your hands or walking. Instead of thickened scaling patches, patients
often see brownish or whitish dots surrounded by inflamed red skin. Some patients
with pustular psoriasis also have plaques and patches of regular psoriasis.
Standard psoriasis treatments must be modified to treat pustular psoriasis. For
example, topical cortisones on the hands and feet usually have to be covered
withplastic gloves or plastic wrap to enable sufficient medication to penetrate the
thickened skin of the palms and soles.
Generalized pustular psoriasis
This is a very severe form of psoriasis in which the skin is covered with non-
infected pustules, which are collections of white blood cells appearing in the skin.
Patients feel very ill and frequently have fever. General pustular psoriasis of this
type may be caused by a number of things, including infections, medications
such as lithium, or the use of systemic cortisones. It may also occur as a reaction
to severe sunburn. Figure 4 shows generalized pustular psoriasis and its response
to treatment.
Generalized pustular psoriasis requires urgent dermatological care.
Fortunately, though, this form of the disease is rare.
Eczema-type psoriasis
This is most commonly found on the hands or feet. It is frequently itchy and very
inflamed with painful cracks or fissures. It may be more common in families
with a history of eczema. Treatment is gentle and consists of non-irritating
ointments, e.g. moisturizers, pimecrolimus cream (Elidel), tacrolimus (Protopic)
ointment and mild cortisones. It is possible that this type of psoriasis has different
genes than plaque psoriasis.
DIFFERENT TYPES OF PSORIASIS
Common, plaque type
Guttate
Flexural
Erythrodermic (rare)
Pustular (rare)
Eczema-type psoriasis (often hands and feet)

Different types of psoriasis

Psoriasis reveals itself in many ways. The following are the most common
varieties.
Common plaque (patch) psoriasis
Common psoriasis, also known as psoriasis vulgaris, is by far the most common
type of psoriasis, accounting for 80–90% of all psoriasis patients. It appears as
raised red scaling patches. The scales, which are often silvery and thickened,
appear most frequently on the elbows, knees, scalp and lower back. Figure 2
shows a typical elbow patch. However, all parts of the skin may occasionally be
subject to psoriasis.
Guttate psoriasis
This type of psoriasis often starts in childhood or teenage years, with the sudden
onset of small, raindrop-like patches of scaling skin (‘guttate’), much thinner
than plaque psoriasis. Often a sore throat caused by streptococcal infection will
prompt the appearance of guttate psoriasis. (See Case Study 2 of Lillian as an
example.)
Guttate psoriasis
(see Figure 3) often covers large parts of the body, but it
responds rapidly to ultraviolet therapy and some other forms of treatment. It can
also clear up, leaving the patient free of further outbreaks of guttate psoriasis. In
such cases, localized patches or plaques of psoriasis may develop later in life.
Skin-fold, ‘flexural’ and genital psoriasis
This type of psoriasis occurs in the skin-folds or flexures and can cause great
discomfort when one part of the skin rubs against another. This discomfort can
be so severe as to become disabling for the patient. It can occur in genital areas,
which can lead to discomfort and difficulties with sexual relations. It is more
common and troublesome in overweight patients.
Erythrodermic or exfoliative psoriasis
When psoriasis completely covers the body, it is known as erythrodermic,
exfoliative psoriasis or generalized psoriasis. Because such a large area of skin is
involved, patients may feel extreme discomfort. Patients may also encounter
problems controlling their body temperature, particularly in very hot or very cold
climates. Older people, particularly those with heart disease and heart failure, can
also develop problems from accelerated heart rate due to increased blood supply
flowing through the severely inflamed skin. This may lead to heart failure.

What causes psoriasis skin to look as it does?

Beyond understanding how psoriasis is inherited, researchers have several
theories as to how psoriasis actually develops in people with a geneticpredisposition to it. Recent research suggests several different possible sites
(locations) for the ‘psoriasis’ gene—and there may well be several genes. One
theory is that a lack of control of the outer skin cells leads to the greatly
increased production of cells that characterize psoriasis. This, in turn, may lead
to an abnormality of the blood vessels and the inflammation characteristic of
psoriasis.
Other researchers feel that psoriasis patients have an abnormality in the skin
that leads to inflammation. This inflammation leads to a build-up of white blood
cells from the blood. This build-up of white blood cells then triggers the
thickened skin of psoriasis.
Still another possibility is that the epidermal skin cells fail to mature into the
flat, thickened ‘cornified’ layer they’re supposed to. As a result, the epidermis
tries to produce more cells than usual, leading to the thickened epidermis; this
then leads to inflammation.
A recent theory has suggested that there may be an abnormal immune reaction
in skin with psoriasis. The precise abnormality is not known—it may be a lack of
control of certain cells in the skin that regulate the immune system. This has been
suggested because of the promising results doctors obtained with the immune-
regulating drug cyclosporin. Now researchers have developed new targeted and
safer immune-regulating drugs, e.g. etanercept, infliximab and alefacept, which
block some of these immune changes in the skin. (I will discuss these in more
detail in Chapters 9 and 10.)
Many patients find that symptoms vary over time. There are various reasons
for this. First, infections may prompt or worsen psoriasis. For example, guttate
psoriasis sometimes flares up in patients who are sensitive to bacterial
(streptococcal) sore throats. Some people may get severe psoriasis on the skin-
fold and scalp as a result of a yeast infection in the skin. Stress has also been
named as a major culprit in psoriasis flare-ups. Fortunately, counselling and
relaxation techniques can go a long way towards minimizing the stress trigger
and can be very helpful in keeping psoriasis under control.
Let me stress that most people with psoriasis do NOT have immune
deficiency, nor are they at increased risk of contracting AIDS. If there is an
abnormal immune function in the skin, it is likely to affect only the skin. People
with psoriasis do not display any evidence of general changes in their body’s
immunoregulatory systems.

Correct diagnosis of psoriasis

Proper diagnosis of your psoriasis helps to assure proper treatment. Many
doctors who are not dermatologists see very few patients with psoriasis. Your
family doctor may have difficulty in pinpointing the diagnosis, which could lead
to inappropriate treatment. That’s why it is important to consult a dermatologist
at the early stages of psoriasis.
The role of the dermatologist
Trained dermatologists can usually diagnose psoriasis simply by looking at the
skin and other key areas like the nails and scalp. However, dermatologists mayhave a harder time diagnosing unusual instances of psoriasis or cases that have
been incompletely treated by another doctor. Under these circumstances, the
doctor may have to wait for you to develop more typical features of psoriasis
before confirming the diagnosis.
In some cases, your dermatologist may suggest a skin biopsy to aid in the
diagnosis. This is a very simple and relatively painless procedure. In a skin
biopsy, the doctor takes very small samples of the skin, which has been numbed
by a local anaesthetic. These samples can then be examined under the
microscope and can reveal certain characteristics of psoriasis that will help the
dermatologist to diagnose your psoriasis and devise a treatment plan that will
work for you.
If your physician only treats mild cases of the disease, he or she may refer you
to a psoriasis specialist or psoriasis centre where more advanced facilities are
available.
Dermatologists can be supportive and positive when dealing with psoriasis. It
is important for the psoriasis patient to realize that:
• Many treatments are available to control their disease.
• Their disease can improve maximally or clear up for prolonged
periods of time with the correct use of different treatments.
• The impact of the disease on their daily lives can be reduced
significantly.
• Support groups, psychotherapy and counselling can lead to a major
improvement in feelings of self-esteem and ability to cope with
psoriasis.
• Improved treatments continue to be developed.
The purpose of this book is to assist the psoriasis patient in dealing with their
disease and to provide them with positive information about major
improvements in the treatment of the disease, which may result in many patients’
lives being considerably improved over the next decade, as these new treatments
become available.
There is no getting around the fact that psoriasis can be a difficult disease to
live with. In moderate to severe cases, patients experience pain and severe
discomfort. Their self-images can plummet. They understandably become tired of
messy and sometimes smelly creams.

What is psoriasis?

No one fully understands what causes psoriasis yet, but doctors have several
theories. We have known for a long time that psoriasis seems to run in families.
This is not to say that if you have the disease your children definitely will, or that
if your parents didn’t you won’t either. Rather, there is a marked increase in
psoriasis among people whose parents, grandparents or siblings have the disease.
If one spouse has psoriasis, a couple’s children have a one-in-four chance of
developing psoriasis too. If both parents have psoriasis, there is a 50:50 chance
that their children will inherit the disease. If one fraternal twin has psoriasis,
there is a 70% chance that the other will, and there is a 90% chance that if one
identical twin has the disease, so will the other.
Although we have nailed down the numbers, dermatologists and genetics
experts still don’t know exactly how psoriasis is passed from one generation to
the next, but we are getting closer to an answer. Recent study of blood samples
has suggested to researchers that there are several genes that transmit psoriasis.
The exact locations of the genes remain unknown (there are millions of genes on
each of the 26 chromosomes), but scientists are currently trying to identify them
precisely. They may be able to alter the way they affect people who are born
with them and also possibly lead to new treatments. A greater understanding of
the psoriasis genes may also help to select the ideal treatment for some patients.