Psoriasis capitis L40.8

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).

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.

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.

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.
• Aftercare of the affected scalp with Liquor carbonis detergent (LCD) containing O/W emulsion ( R154 ). Alternate twice a week with a scalp pack and wash containing tar (e.g. Tarmed shampoo - currently no longer available). Always make sure that the scalp is not irritated too much by this therapy (itching!).
• Alternative: Topical application of vitamin A derivatives or D derivatives: Tazarotene (Zorac® 0.05-0.1%) once a 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:

• First treat the capillitium with a 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 occlusively for several hours (e.g. also overnight) under a film. Gel and oil can be rinsed out with clear water.
• Alternatively, use a shampoo containing steroids (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 well-informed 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 betamethasone-containing gel (e.g. Diprosis® Gel) for 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) alternating daily 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 certainly be considered in cases of resistance to therapy. When making this decision, it may be necessary to choose between the local therapeutic "sysiphosis effect" and the undesirable 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. Good effects were achieved in a double-blind randomized study with secukinumab (Bagel J et al. 2017).

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).

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