Psoriasis capitisL40.8

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).

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).

Recipe for a 5% coal tar solution:

• 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 shale can be used. The ready-to-use preparations Medizinal ^Shampoo® from Dermasence or ^Bionatar® from Faroderm are available.

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.

Mostly affecting the hairy parts of the scalp, (usually) sharply demarcated, strongly scaling, frequently also itchy, clearly consolidated plaques. The maximum variant is pityriasis amiantacea, which is characterized by keratotic deposits on the hair shafts (almost always with accompanying hair loss).

Color: Vivid red or with a more or less distinct, white, adherent, dry or greasy scaly coating, depending on the pretreatment.

Not uncommon are less spectacular, little indurated only small lamellar (seborrhoid) scaling plaques, which do not cause any other discomfort except disturbing desquamation and gfls. slight itching.

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

Hair loss is not a typical accompanying phenomenon of psoriasis capitis. However, in severe and extensive psoriatic scalp infestation, there may be relevant hair loss, usually reversible but also extending to alopecic areas (see alopecia, scarring). The cause of this is not clear.

Pustular forms of psoriasis of the capillitii are little known. They are sometimes subsumed under the clinical picture of folliculitis decalvans.

Basically: Local therapy is challenging for patients. Many patients prefer shampoos, emulsions, tinctures, gels or foams. Creams and ointments are less user-friendly (Ramic L et al. 2023).

Initial: Init ially desquamative therapy, e.g. treatment with gels containing 2-5% salicylic acid(e.g. Squamasol gel, Stieproxal shampoo) or an oil containing salicylic acid that washes out well (see salicylic acid below).

Alternatively: apply a head cap for several hours (e.g. Lygal Head Ointment N)

Alternatively: application of a solution of dicaprylyl carbonate 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 a gel containing 2-5% salicylic acid (e.g. Squamasol gel) or shampoo (Stieproxal), which is applied to the capillitium 2-3 times/week. Leave on for 20-30 minutes and then rinse with clear water.
• Alternative: Topical application of vitamin A derivatives or D derivatives: Tazarotene (^Zorac® 0.05-0.1%) 1 time/day or local vitamin D3 analogs. Solutions, e.g. ^Psorcutan® solution 2 times/day or emulsions, e.g. ^Curatoderm® emulsion, 1 time/day, are to be preferred. Indication for adults and children > 12 years with infestation of the hairy scalp.

Medium infestation:

• Treat scalp with ointments containing salicylic acid (e.g. Lygal scalp ointment) 2-3 times/week overnight. Cover head with TG tubular bandage (caution: contamination of pillow possible). In the morning, rinse out with liquid syndet (e.g. ^Seba-med® liquid).
• Alternatively: For"dithranol-experienced" patients, a preparation containing dithranol can be applied 1-2 times/week over 7-8 hours or as short-term therapy over 2-3 hours (e.g. R074 ). Caution! Discoloration may occur with light hair color!
• Alternative. 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, once-daily applications are recommended.
• Alternative: Microemulsion with 1 mg/ml tacrolimus for the acute topical treatment of psoriasis capitis (^Sumilor®, Klinge Pharma, mnemonic for remembering the trade name: read tacrolimus backwards)

Severe infestation:

• Initially treat the capillitium with medium-strength glucocorticoid in gel or oil base such as 0.1% dexamethasone gel (Rp: Dexamethasone-Carmellose-Gel 0.1%) or 0.05% clobetasol-17-propionate head oil (Rp: Clobetasolpropionate-Creme Hydrophile 0.05% /NRF 11.76) or 0.1% triamcinolone acetonide oil occlusively for several hours (e.g. also overnight) under foil. Gel and oil can be rinsed out with clear water.
• Alternatively, use a steroid-containing shampoo (Clobex ^Shampoo®) or salicylic acid oil 2/5% or 10% in combination with triamcinolone acetonide 0.1%. Followed by therapy with tazarotene or calcipotriol solution. In experienced patients, a trial with a 0.25-2.0% washable dithranol ointment can also be carried out on an outpatient basis (it is important to note the dithranol side effects!). Start with a 0.25% ointment (lower dosage initially if necessary), increase to double the concentration every 2 weeks!

For very severe infestation with weeping psoriasis:

• Initially apply betamethasone-containing gel (e.g. ^Diprosis® Gel) hourly over several days under foil occlusion.
• In the meantime, wash out hair with tar shampoo (e.g. ^Tarmed® currently no longer available). As an alternative to a tar shampoo, "Medizinal ^Shampoo®" with ichthyol from Dermasence can be used.
• Alternatively: use a steroid-containing shampoo (Clobex ^{Shampoo®/ClobeGalenShampoo®} ), if necessary alternating with a tar shampoo. (Subsequently transition to a washable dithranol ointment under standardized stationary conditions, see above).

It is always advisable 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 - to the previously moistened scalp; blow-dry hair).

Systemic therapy with fumaric acid esters (Fumaderm, dimethyl fumarate) or acitretin (Neotigason) should definitely be considered in cases of resistance to therapy. When making this decision, one may have to choose between the local therapeutic "sysiphosic effect" and the undesired systemic "overtreatment". In the case of chronically active psoriasis capitis (capillitii), especially in the case of thick and long hair, a satisfactory clinical result can only be achieved locally through a considerable and constant, sometimes unaffordable, "therapeutic effort".

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

Fumaric acid esters are a therapeutic option.

Secukinumab: Good effects were achieved in a double-blind randomized study with secukinumab (Bagel J et al. 2017).

Deucravacitinib: In a 1084-patient, 52-week, double-blind phase 3 study in adult patients with moderate to severe scalp psoriasis, deucravacitinib (an oral selective allosteric tyrosine kinase 2 (TYK2) inhibitor) was significantly more effective than placebo or apremilast and was well tolerated (Blauvelt A et al. 2024).

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

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2. 24-week, randomized, double-blind, placebo-controlled phase 3b study. J Am Acad Dermatol 77:667-674.
3. Blauvelt A et al. (2024) Deucravacitinib, a selective, allosteric tyrosine kinase 2 inhibitor, in scalp psoriasis: A subset analysis of two phase 3 randomized trials in plaque psoriasis. J Am Acad Dermatol 90:775-782.
4. 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. Pediatr Dermatol 32:28-35.
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