Psoriasis capitis L40.8

Author: Prof. Dr. med. Peter Altmeyer

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Last updated on: 29.10.2020

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Synonym(s)

Head Psoriasis; psoriasis capillitii; Psoriasis of the scalp; scalp psoriasis; Scalp Psoriasis

Definition
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Very common (possibly the most common manifestation of psoriasis- good epidemiological data are missing!), localized or in combination with other body foci, a form of psoriasis of the head that manifests itself up to 80% on the hairy scalp (psoriasis capillitii).

Etiopathogenesis
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Pathogenetically, there is no clear picture of psoriasis capitis. Histologically, the classical phenomena of psoriasis can be proven, whereby the hair apparatus is obviously not involved. Possibly, high hair density as well as pruritus and scratching effects act as mechanically irritating factors. In addition, a special germ colonisation (e.g. Malazessia furfur) could be an activating factor (Sticherling M 2017).

Indication for natural remedies
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Formulation for a 5% coal tar solution that can be used as a substitute for a standard tar shampoo.

  • Rp.
  • Coal tar spirit 5,0 g
  • Sodium lauryl ether sulphate 27% 60.0 g
  • Sodium chloride 6,0 g
  • Purified water ad 100,0 g

Formulation for a 5% coal tar solution for the treatment of psoriasis capillitii

Alternatively, preparations with sulphonated oil from sulphur-rich slate can be used. As ready-to-use preparations, the Medical Shampoo® from Dermasence or Bionatar® from Faroderm is available.

Localization
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Hairy head, especially in the area of the temporal bones. Characteristically and diagnostically important (differentiation from seborrhoeic scalp eczema) is the crossing of the forehead hair line by the psoriatic lesions. This also affects the lateral hairline.

Clinical features
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Quite predominantly the hairy parts of the scalp, (usually) sharply defined, highly scaly, often itchy, clearly hardened plaques. The maximum variant is pityriasis amiantacea, which is characterized by keratotic excretions of the hair shafts (almost always with accompanying hair loss).

Colour: Bright red or with a more or less distinct white, adherent, dry or greasy scaly coating, depending on the pre-treatment.

It is not uncommon to find less spectacular, less indurated seborrhoidal plaques which do not cause any other complaints apart from annoying desquamation and possibly slight itching.

At the forehead hairline and the lateral hairline, the psoriatic changes often spread to the hairless skin(pathognomic sign of psoriasis of the hairy scalp - distinction to seborrhoeic eczema of the scalp).

Hair loss is not a typical accompanying phenomenon of psoriasis capitis. However, severe and extensive psoriatic scalp infestation can lead to relevant hair loss up to alopecic areas (see below alopecia, scarring). The cause of this is not clear.

Little attention is paid to pustular psoriasis forms of capillitii. They are partly subsumed under the clinical picture of folliculitis decalvans.

Differential diagnosis
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Complication(s)
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In case of strong (asbestos-like), pronounced dandruff formation, the hair may break off or irreversible hair loss may occur.

External therapy
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Initial: First of all scaling therapy, e.g. treatment with 2-5% salicylic acid containing gels (e.g. squamasol gel, Stieproxal shampoo) or a well washable salicylic acid containing oil (see below salicylic acid).

Alternative: Put on a head cap for several hours (e.g. Lygal Head Ointment N)

Alternative: application of a solution of dicaprylylcarbonate and dimethicone. This mixture of a fatty acid ester and a silicone oil flows under the scales and infiltrates the cellular cohesion (Loyon®, Cetiol®)

Mild infestation:

  • Treatment with 2-5% salicylic acid containing gel (e.g. squamasol gel) or shampoo (Stieproxal), which is spread on the capillitium 2-3 times/week. Leave for 20-30 minutes and then rinse with clear water.
  • Aftercare of the affected scalp with Liquor carbonis detergent (LCD) containing O/W emulsion ( R154 ). Alternate 2 times/week with tar-containing scalp pack and wash (e.g. Tarmed Shampoo Remark available again). Always make sure that this therapy does not irritate the scalp too much (itching!).
  • Alternative: Topical application of vitamin A derivatives or D derivatives: Tazarotene (Zorac® 0.05-0.1%) 1mal/day or local vitamin D3 analogues. In this case solutions, e.g. Psorcutan® solution 2 times/day or emulsions, e.g. Curatoderm® emulsion, 1 time / day, are preferable. Indication for adults and children > 12 years with hairy scalp.

Medium infestation:

  • Treat scalp with salicylic acid-containing ointments (e.g. Lygal head ointment) 2-3 times/week overnight. Cover the head with a TG tube bandage (Cave: contamination of the pillow is possible). In the morning wash out with liquid syndet (e.g. Seba-med® liquid).
  • Alternative: For patients with"dithranol-experience" a dithranol-containing preparation can be applied 1-2 times/week for 7-8 hours or as a short-term therapy for 2-3 hours. (e.g. R074 ) can be applied. Cave! Discoloration of light hair colour may occur!
  • Alternatively. A good alternative is the combination of calcipotriol and betamethasone dipropionate in a gel base (Xamiol Gel®; Daivobet Gel®). At the beginning of the treatment, 1 x daily application is recommended.

Heavy infestation:

  • First treat the capillitium with medium-strength glucocorticoid in a gel or oil base such as 0.1% dexamethasone gel ( R063 ) or 0.05% clobetasol-17-propionate head oil ( R054A; Rp 219 from NFA) or 0.1% triamcinolone acetonide oil for several hours (e.g. also overnight) under occlusive foil. Gel and oil can be rinsed out with clear water.
  • Alternatively, use a steroid shampoo (Clobex Shampoo) or salicylic acid oil 2/5% or 10% in combination with triamcinolone acetonide 0.1%. Afterwards therapy with Tazarotene or Calcipotriol solution. In the case of intelligent patients, an outpatient trial with a 0.25-2.0% washable dithranol ointment can also be carried out (the signature with the information on the dithranol side effects is important). Start with a 0.25% ointment (initially, possibly lower dosage), increase every 2 weeks to double the concentration!

In case of very severe affection with weeping psoriasis:

  • Initial gel containing betamethasone (e.g. Diprosis® Gel) over several days with foil occlusion.
  • In the meantime, wash hair with tar shampoo (e.g. Tarmed® back on the market). As an alternative to a tar shampoo, the "Medical Shampoo®" with Ichthyol from Dermasence can be used.
  • Alternatively, use a steroid shampoo (Clobex Shampoo) alternating daily with a tar shampoo. (Subsequently, under standardized stationary conditions, transition to a washable dithranol ointment, see above)

Basically, it is always recommended to "grease" the scalp temporarily with an O/W emulsion (e.g. after washing out the dexamethasone gel, apply a few ml of a lotion - e.g. Abitima Lotion, Excipial U Hydrolotio, Sebamed Lotion- on the previously moistened scalp; blow-dry hair).

Radiation therapy
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In addition to the external treatment, the use of local UVB rays has proven to be effective. In the area of the hairy head, the so-called UV combs are suitable (e.g. Hönle company, Saalmann).

Internal therapy
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In case of resistance to therapy, a systemic therapy with fumaric acid ester (Fumaderm) or acitretin (Neotigason) should definitely be considered. In making this decision one may have to choose between the local therapeutic "sysiphos effect" and the unintentional systemic "overtreatment". Satisfactory clinical findings in chronically active psoriasis capitis (capillitii), especially in dense and long hair, can only be achieved by local therapy with a considerable and constant, sometimes impossible, "therapeutic effort".

In this therapeutic dilemma, after considering all aspects, a suitable systemic therapy (see psoriasis vulgaris) should be considered as an alternative. Similar considerations will be made for intertriginous psoriasis, nail poriasis or pityriasis amiantacea.

Fumaric acid esters are a therapeutic option. Good effects were achieved in a double-blind randomized study with secukinumab (Bagel J et al. 2017).

Progression/forecast
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Often a course lasting years, usually recurrent.

Note(s)
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Psoriasis capitis, together with ingtertriginous psoriasis and psoriasis of the nail, is classified in the group "difficult to treat". The dilemma between the "psychosocial limitation" (57% of cases) due to the visibility of the skin changes and the accompanying itching (26% of cases) and the therapeutic options often occurs (Sticherling M . 2016)

Literature
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  1. Bagel J et al (2017) The effect of secukinumab on moderate to severe scalp psoriasis: Results of a24-week
    , randomized, double-blind, placebo-controlled phase 3b study. J Am Acad Dermatol 77:667-674.

  2. Eichenfield LF et al (2014) Safety and efficacy of calcipotriene plus betamethasone dipropionate topical suspension in the treatment of extensive scalp psoriasis in adolescents ages 12 to 17 years. Pediatric Dermatol 32:28-35

  3. Elewski BE (2005) Clinical diagnosis of common scalp disorders. J Investig Dermatol Symp Proc 10: 190-193
  4. Hengge UR (2014) Topical, Non-Medicated LOYON(®) in Facilitating the Removal of Scaling in Infants and Children with Cradle Cap: a Proof-of-Concept Pilot Study. Dermatol Ther (Heidelberg) 4:221-232

  5. Radtke MA et al (2010) Calcipotriol plus betamethasone dipropionate gel in the treatment of scalp psoriasis. Dermatologist 61: 770-775
  6. Wilsmann-Theis D et al (2014) Psoriasis and eczema on the scalp. dermatologist 65:1043-11049

  7. Kim TW et al (2014) Clinical characteristics of pruritus in patients with scalp psoriasis and their relation with intraepidermal nerve fiber density. Ann Dermatol 26:727-732

  8. Sticherling M (2017) Psoriasis capitis and seborrheic eczema of the scalp. Dermatologist 68: 457-468

Disclaimer

Please ask your physician for a reliable diagnosis. This website is only meant as a reference.

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Last updated on: 29.10.2020