Exasperated, frustrated, “at their wits end” — these are just some of the adjectives used to describe patients with seborrheic dermatitis and scalp psoriasis. Often confused, these two disorders are the most common scalp conditions seen by dermatologists. Although their treatment regimens often overlap, successful management relies on getting to the root of the problem — literally, in the case of topical regimens, which involve matching regimens with the patient’s lifestyle and budget and not being afraid to “hit the inflammation hard.”
Their Causes
It is estimated that 25% of the general population has seborrheic dermatitis, and between 2% to 3% of Americans have psoriasis. Although the etiology of seborrheic dermatitis is not entirely understood, most experts share the belief of Bruce Strober, M.D., Ph.D., Co-Director of the Psoriasis and Psoriatic Arthritis Center at New York University Medical Center, who says, “The disease may be triggered by environmental factors, but there is a strong immune predisposition.” For example, the disease is far more prevalent in patients with HIV, neurologic disorders, elderly patients, and infants.
Studies have also shown a causative role of the yeast-like fungus Pityrosporum (Malassezia sp.) in the development of seborrheic dermatitis, notes Joel Schlessinger, M.D., a dermatologist in private practice in Omaha, NE, and President Emeritus of the American Society of Cosmetic Dermatology & Aesthetic Surgery.
Psoriasis shares some similarities with seborrheic dermatitis, including a genetic predisposition; 30% of affected patients have a first-degree relative with the disease. Although no specific pathogen has been identified, well-known risk factors — including viral and bacterial infection with Streptococcus — are thought to “trigger” the disease in predisposed patients. “Psoriasis is clearly immunodisregulatory,” notes Dr. Strober. “The infection can initiate psoriasis in the predisposed patient, and new infections can either perpetuate or exacerbate the disease.”
Physical Exam
Despite their prevalence, it can be difficult to differentiate the two disorders. “A lot of psoriasis patients are misdiagnosed as seborrheic dermatitis patients; it can be hard to easily discriminate between these two conditions in a lot of patients,” says Dr. Strober.
However, according to Amy McMichael, M.D., Associate Professor of Dermatology, Department of Dermatology, Wake Forest University School of Medicine, Winston-Salem, NC, the differential diagnosis is usually not difficult with a careful physical examination that extends “below the neck.”
“The main way to distinguish the two disorders is by the severity and location of the plaques,” she maintains. In the case of scalp psoriasis, the patient usually presents with well-defined erythematous plaques that are clearly distinct from the normal scalp. The scale is usually very adherent and thick. Patients with scalp psoriasis may have disease that is limited to their head, or have plaques on their elbows, knees and other classic locations for psoriasis.
Dr. Schlessinger also recommends a careful body check on any patient suspected of having scalp psoriasis. “Patients may come in complaining only about the scalp, but when you conduct a careful body examination, you find psoriasis in other locations,” he explains.
With seborrheic dermatitis, by contrast, the patients may present with a red scalp, but the border between diseased scalp and normal scalp is not distinct, notes Dr. McMichael. The location for seborrheic dermatitis is usually limited to the face and scalp, and can be quite severe. In addition, she says, the type of scale is different with seborrheic dermatitis: “You usually have a finer, looser scale.”
Treatment Strategies: Psoriasis
“When patients come to the dermatologist, they usually have tried one or two over-the-counter (OTC) dandruff medications without any relief,” says Dr. McMichael. Therefore, it is the dermatologist’s job to “hit the psoriasis hard, get the inflammation down and then teach patients how to ramp up or down their medications to maintain their remission.”
Dr. McMichael usually starts with a very strong, topical corticosteroid. The formulation — shampoo, gel, oil, lotion or foam — is based on the patient’s hair type and lifestyle. “It is very important to ask patients about their hair-care regimen, lifestyle, and budget when picking an agent. If the patient can’t afford the medication, for example, they are not going to use it.”
In addition to the topical corticosteroids, Dr. McMichael prescribes a ketoconazole-containing shampoo (usually 2%), or an OTC tar- or zinc-containing shampoo ot even a corticosteroid shampoo. “I switch the shampoos around; that way you get the benefit of having several different ways to treat the scalp.”
The goal of therapy, notes Dr. McMichael, is to get patients off steroids. This will help to avoid some of the side effects of long-term therapy, “like the risk of developing tachyphylaxis and thinning of the skin around the treatment areas,” she says.
Dr. Strober agrees: “If you can get control after 1 to 2 weeks with a class-one corticosteroid, then you could taper to a less rigorous approach — shampoo-based antifungal or mid-potency corticosteroid.” To maintain patients who have been able to taper off their corticosteroid, Dr. Michael likes to use Dovonex (calcipotriene) scalp solution.
Thick Plaques
For patients with very thick plaques, however, Dr. McMichael turns to another proven remedy. “I really like to use fluocinolone oil (Derma-Smoothe/FS scalp oil). This is a mid-level steroid that really helps lift scales off and allows the medication to penetrate to the scalp. But because the agent is messy and difficult to rinse out, I only suggest patients use it once or twice a week,” she says.
In rare cases, Dr. McMichael will resort to interlesional corticosteroid injections, but only in patients with very thick — almost callous-like — lesions. “Although they take down the inflammation very quickly, they are painful and they can give patients a false sense of security,” she notes.
Dr. Strober also uses interlesional injections in certain patients, an approach he says “is highly effective and gives lasting benefit for at least 4 to 6 weeks.”
Systemic Agents
All three experts agree that in the most severe cases, physicians should try systemic agents, which can include older agents such as methotrexate and cyclosporine, and the newer biologic agents. In Dr. McMichael’s practice, she starts with methotrexate. “I can’t think of a time where I used a biologic medication in patients with psoriasis limited to their scalp,” she says.
In these difficult-to-treat patients, Dr. Strober does not hesitate to use a biologic agent. “I view patients with bad scalp psoriasis similarly to any patient with moderate-to-severe disease, regardless of the body distribution,” he says. But before prescribing these medications, the usual checks and balances must be in place. “If the patient responds to the medication, they are extraordinarily pleased,” he adds. “The worst things is to keep hitting them over the head with another topical regimen that does not work; that creates an exasperated, frustrated patient.”
While Dr. Schlessinger does use biologics for severe scalp psoriasis, he is not a fan of methotrexate or cyclosporine in any patients and “always find other options that are preferential over those treatments.”
Seborrheic Dermatitis
The treatment of seborrheic dermatitis tends to be similar to that for scalp psoriasis, note the experts. In Dr. McMichael’s practice, “I tend to treat with the same medications, just at lower frequency and lower strength than that used for psoriasis patients. But for seborrheic dermatitis, we rely heavily on products that contain ketoconazole and zinc, because of their antifungal effect,” says Dr. McMichael. When prescribing a corticosteroid, Dr. McMichael starts with a more mild agent, like Derma-Smoothe F/S, once or twice a week, and then quickly gets the patient off the agent.
Dr. Schlessinger advocates the use of both oral ketoconazole (400 mg once weekly for 6 to 8 weeks) and a topical foam formulation (Extina) to treat the underlying pityrosporum infection. In addition, newer formulations of corticosteroids, like clobetasol (Olux) and betamethasone (Luxiq), he says,“have markedly changed the treatment of scalp psoriasis and seborrheic dermatitis. “Before these were available, there were few palatable options for these conditions, but now the treatments are quite ‘patient friendly.’ Older treatments such as Derma-Smoothe F/S and other tar-based shampoos are clearly a challenge for patients and often result in poor results due to compliance issues.”
For Dr. Strober, initial therapy is also with a topical ketoconazole-containing agent. If that is not effective, he then uses a topical corticosteroid, with lower potency on the face, higher potency on the scalp. Another very attractive option, says Dr. Strober, is the use of topical immunomodulatory drugs, like tacrolimus (Protopic ointment) and pimecrolimus (Elidel cream). “These agents have been found to be safe and effective for seborrheic dermatitis on the face. The down side is that they burn and sting, especially Protopic. If there is not a reimbursement issue, I often prescribe these drugs as first-line therapy,” he states.
Exciting Time To Practice
According to Dr. Schlessinger, “This is an exciting time to be treating both seborrheic dermatitis and scalp psoriasis. Never before have we had so many options at our fingertips.” This makes choosing an appropriate treatment for your patients a lot easier, “hopefully making for improved compliance and life-altering changes,” Dr. Schlessinger concludes.
Exasperated, frustrated, “at their wits end” — these are just some of the adjectives used to describe patients with seborrheic dermatitis and scalp psoriasis. Often confused, these two disorders are the most common scalp conditions seen by dermatologists. Although their treatment regimens often overlap, successful management relies on getting to the root of the problem — literally, in the case of topical regimens, which involve matching regimens with the patient’s lifestyle and budget and not being afraid to “hit the inflammation hard.”
Their Causes
It is estimated that 25% of the general population has seborrheic dermatitis, and between 2% to 3% of Americans have psoriasis. Although the etiology of seborrheic dermatitis is not entirely understood, most experts share the belief of Bruce Strober, M.D., Ph.D., Co-Director of the Psoriasis and Psoriatic Arthritis Center at New York University Medical Center, who says, “The disease may be triggered by environmental factors, but there is a strong immune predisposition.” For example, the disease is far more prevalent in patients with HIV, neurologic disorders, elderly patients, and infants.
Studies have also shown a causative role of the yeast-like fungus Pityrosporum (Malassezia sp.) in the development of seborrheic dermatitis, notes Joel Schlessinger, M.D., a dermatologist in private practice in Omaha, NE, and President Emeritus of the American Society of Cosmetic Dermatology & Aesthetic Surgery.
Psoriasis shares some similarities with seborrheic dermatitis, including a genetic predisposition; 30% of affected patients have a first-degree relative with the disease. Although no specific pathogen has been identified, well-known risk factors — including viral and bacterial infection with Streptococcus — are thought to “trigger” the disease in predisposed patients. “Psoriasis is clearly immunodisregulatory,” notes Dr. Strober. “The infection can initiate psoriasis in the predisposed patient, and new infections can either perpetuate or exacerbate the disease.”
Physical Exam
Despite their prevalence, it can be difficult to differentiate the two disorders. “A lot of psoriasis patients are misdiagnosed as seborrheic dermatitis patients; it can be hard to easily discriminate between these two conditions in a lot of patients,” says Dr. Strober.
However, according to Amy McMichael, M.D., Associate Professor of Dermatology, Department of Dermatology, Wake Forest University School of Medicine, Winston-Salem, NC, the differential diagnosis is usually not difficult with a careful physical examination that extends “below the neck.”
“The main way to distinguish the two disorders is by the severity and location of the plaques,” she maintains. In the case of scalp psoriasis, the patient usually presents with well-defined erythematous plaques that are clearly distinct from the normal scalp. The scale is usually very adherent and thick. Patients with scalp psoriasis may have disease that is limited to their head, or have plaques on their elbows, knees and other classic locations for psoriasis.
Dr. Schlessinger also recommends a careful body check on any patient suspected of having scalp psoriasis. “Patients may come in complaining only about the scalp, but when you conduct a careful body examination, you find psoriasis in other locations,” he explains.
With seborrheic dermatitis, by contrast, the patients may present with a red scalp, but the border between diseased scalp and normal scalp is not distinct, notes Dr. McMichael. The location for seborrheic dermatitis is usually limited to the face and scalp, and can be quite severe. In addition, she says, the type of scale is different with seborrheic dermatitis: “You usually have a finer, looser scale.”
Treatment Strategies: Psoriasis
“When patients come to the dermatologist, they usually have tried one or two over-the-counter (OTC) dandruff medications without any relief,” says Dr. McMichael. Therefore, it is the dermatologist’s job to “hit the psoriasis hard, get the inflammation down and then teach patients how to ramp up or down their medications to maintain their remission.”
Dr. McMichael usually starts with a very strong, topical corticosteroid. The formulation — shampoo, gel, oil, lotion or foam — is based on the patient’s hair type and lifestyle. “It is very important to ask patients about their hair-care regimen, lifestyle, and budget when picking an agent. If the patient can’t afford the medication, for example, they are not going to use it.”
In addition to the topical corticosteroids, Dr. McMichael prescribes a ketoconazole-containing shampoo (usually 2%), or an OTC tar- or zinc-containing shampoo ot even a corticosteroid shampoo. “I switch the shampoos around; that way you get the benefit of having several different ways to treat the scalp.”
The goal of therapy, notes Dr. McMichael, is to get patients off steroids. This will help to avoid some of the side effects of long-term therapy, “like the risk of developing tachyphylaxis and thinning of the skin around the treatment areas,” she says.
Dr. Strober agrees: “If you can get control after 1 to 2 weeks with a class-one corticosteroid, then you could taper to a less rigorous approach — shampoo-based antifungal or mid-potency corticosteroid.” To maintain patients who have been able to taper off their corticosteroid, Dr. Michael likes to use Dovonex (calcipotriene) scalp solution.
Thick Plaques
For patients with very thick plaques, however, Dr. McMichael turns to another proven remedy. “I really like to use fluocinolone oil (Derma-Smoothe/FS scalp oil). This is a mid-level steroid that really helps lift scales off and allows the medication to penetrate to the scalp. But because the agent is messy and difficult to rinse out, I only suggest patients use it once or twice a week,” she says.
In rare cases, Dr. McMichael will resort to interlesional corticosteroid injections, but only in patients with very thick — almost callous-like — lesions. “Although they take down the inflammation very quickly, they are painful and they can give patients a false sense of security,” she notes.
Dr. Strober also uses interlesional injections in certain patients, an approach he says “is highly effective and gives lasting benefit for at least 4 to 6 weeks.”
Systemic Agents
All three experts agree that in the most severe cases, physicians should try systemic agents, which can include older agents such as methotrexate and cyclosporine, and the newer biologic agents. In Dr. McMichael’s practice, she starts with methotrexate. “I can’t think of a time where I used a biologic medication in patients with psoriasis limited to their scalp,” she says.
In these difficult-to-treat patients, Dr. Strober does not hesitate to use a biologic agent. “I view patients with bad scalp psoriasis similarly to any patient with moderate-to-severe disease, regardless of the body distribution,” he says. But before prescribing these medications, the usual checks and balances must be in place. “If the patient responds to the medication, they are extraordinarily pleased,” he adds. “The worst things is to keep hitting them over the head with another topical regimen that does not work; that creates an exasperated, frustrated patient.”
While Dr. Schlessinger does use biologics for severe scalp psoriasis, he is not a fan of methotrexate or cyclosporine in any patients and “always find other options that are preferential over those treatments.”
Seborrheic Dermatitis
The treatment of seborrheic dermatitis tends to be similar to that for scalp psoriasis, note the experts. In Dr. McMichael’s practice, “I tend to treat with the same medications, just at lower frequency and lower strength than that used for psoriasis patients. But for seborrheic dermatitis, we rely heavily on products that contain ketoconazole and zinc, because of their antifungal effect,” says Dr. McMichael. When prescribing a corticosteroid, Dr. McMichael starts with a more mild agent, like Derma-Smoothe F/S, once or twice a week, and then quickly gets the patient off the agent.
Dr. Schlessinger advocates the use of both oral ketoconazole (400 mg once weekly for 6 to 8 weeks) and a topical foam formulation (Extina) to treat the underlying pityrosporum infection. In addition, newer formulations of corticosteroids, like clobetasol (Olux) and betamethasone (Luxiq), he says,“have markedly changed the treatment of scalp psoriasis and seborrheic dermatitis. “Before these were available, there were few palatable options for these conditions, but now the treatments are quite ‘patient friendly.’ Older treatments such as Derma-Smoothe F/S and other tar-based shampoos are clearly a challenge for patients and often result in poor results due to compliance issues.”
For Dr. Strober, initial therapy is also with a topical ketoconazole-containing agent. If that is not effective, he then uses a topical corticosteroid, with lower potency on the face, higher potency on the scalp. Another very attractive option, says Dr. Strober, is the use of topical immunomodulatory drugs, like tacrolimus (Protopic ointment) and pimecrolimus (Elidel cream). “These agents have been found to be safe and effective for seborrheic dermatitis on the face. The down side is that they burn and sting, especially Protopic. If there is not a reimbursement issue, I often prescribe these drugs as first-line therapy,” he states.
Exciting Time To Practice
According to Dr. Schlessinger, “This is an exciting time to be treating both seborrheic dermatitis and scalp psoriasis. Never before have we had so many options at our fingertips.” This makes choosing an appropriate treatment for your patients a lot easier, “hopefully making for improved compliance and life-altering changes,” Dr. Schlessinger concludes.
Exasperated, frustrated, “at their wits end” — these are just some of the adjectives used to describe patients with seborrheic dermatitis and scalp psoriasis. Often confused, these two disorders are the most common scalp conditions seen by dermatologists. Although their treatment regimens often overlap, successful management relies on getting to the root of the problem — literally, in the case of topical regimens, which involve matching regimens with the patient’s lifestyle and budget and not being afraid to “hit the inflammation hard.”
Their Causes
It is estimated that 25% of the general population has seborrheic dermatitis, and between 2% to 3% of Americans have psoriasis. Although the etiology of seborrheic dermatitis is not entirely understood, most experts share the belief of Bruce Strober, M.D., Ph.D., Co-Director of the Psoriasis and Psoriatic Arthritis Center at New York University Medical Center, who says, “The disease may be triggered by environmental factors, but there is a strong immune predisposition.” For example, the disease is far more prevalent in patients with HIV, neurologic disorders, elderly patients, and infants.
Studies have also shown a causative role of the yeast-like fungus Pityrosporum (Malassezia sp.) in the development of seborrheic dermatitis, notes Joel Schlessinger, M.D., a dermatologist in private practice in Omaha, NE, and President Emeritus of the American Society of Cosmetic Dermatology & Aesthetic Surgery.
Psoriasis shares some similarities with seborrheic dermatitis, including a genetic predisposition; 30% of affected patients have a first-degree relative with the disease. Although no specific pathogen has been identified, well-known risk factors — including viral and bacterial infection with Streptococcus — are thought to “trigger” the disease in predisposed patients. “Psoriasis is clearly immunodisregulatory,” notes Dr. Strober. “The infection can initiate psoriasis in the predisposed patient, and new infections can either perpetuate or exacerbate the disease.”
Physical Exam
Despite their prevalence, it can be difficult to differentiate the two disorders. “A lot of psoriasis patients are misdiagnosed as seborrheic dermatitis patients; it can be hard to easily discriminate between these two conditions in a lot of patients,” says Dr. Strober.
However, according to Amy McMichael, M.D., Associate Professor of Dermatology, Department of Dermatology, Wake Forest University School of Medicine, Winston-Salem, NC, the differential diagnosis is usually not difficult with a careful physical examination that extends “below the neck.”
“The main way to distinguish the two disorders is by the severity and location of the plaques,” she maintains. In the case of scalp psoriasis, the patient usually presents with well-defined erythematous plaques that are clearly distinct from the normal scalp. The scale is usually very adherent and thick. Patients with scalp psoriasis may have disease that is limited to their head, or have plaques on their elbows, knees and other classic locations for psoriasis.
Dr. Schlessinger also recommends a careful body check on any patient suspected of having scalp psoriasis. “Patients may come in complaining only about the scalp, but when you conduct a careful body examination, you find psoriasis in other locations,” he explains.
With seborrheic dermatitis, by contrast, the patients may present with a red scalp, but the border between diseased scalp and normal scalp is not distinct, notes Dr. McMichael. The location for seborrheic dermatitis is usually limited to the face and scalp, and can be quite severe. In addition, she says, the type of scale is different with seborrheic dermatitis: “You usually have a finer, looser scale.”
Treatment Strategies: Psoriasis
“When patients come to the dermatologist, they usually have tried one or two over-the-counter (OTC) dandruff medications without any relief,” says Dr. McMichael. Therefore, it is the dermatologist’s job to “hit the psoriasis hard, get the inflammation down and then teach patients how to ramp up or down their medications to maintain their remission.”
Dr. McMichael usually starts with a very strong, topical corticosteroid. The formulation — shampoo, gel, oil, lotion or foam — is based on the patient’s hair type and lifestyle. “It is very important to ask patients about their hair-care regimen, lifestyle, and budget when picking an agent. If the patient can’t afford the medication, for example, they are not going to use it.”
In addition to the topical corticosteroids, Dr. McMichael prescribes a ketoconazole-containing shampoo (usually 2%), or an OTC tar- or zinc-containing shampoo ot even a corticosteroid shampoo. “I switch the shampoos around; that way you get the benefit of having several different ways to treat the scalp.”
The goal of therapy, notes Dr. McMichael, is to get patients off steroids. This will help to avoid some of the side effects of long-term therapy, “like the risk of developing tachyphylaxis and thinning of the skin around the treatment areas,” she says.
Dr. Strober agrees: “If you can get control after 1 to 2 weeks with a class-one corticosteroid, then you could taper to a less rigorous approach — shampoo-based antifungal or mid-potency corticosteroid.” To maintain patients who have been able to taper off their corticosteroid, Dr. Michael likes to use Dovonex (calcipotriene) scalp solution.
Thick Plaques
For patients with very thick plaques, however, Dr. McMichael turns to another proven remedy. “I really like to use fluocinolone oil (Derma-Smoothe/FS scalp oil). This is a mid-level steroid that really helps lift scales off and allows the medication to penetrate to the scalp. But because the agent is messy and difficult to rinse out, I only suggest patients use it once or twice a week,” she says.
In rare cases, Dr. McMichael will resort to interlesional corticosteroid injections, but only in patients with very thick — almost callous-like — lesions. “Although they take down the inflammation very quickly, they are painful and they can give patients a false sense of security,” she notes.
Dr. Strober also uses interlesional injections in certain patients, an approach he says “is highly effective and gives lasting benefit for at least 4 to 6 weeks.”
Systemic Agents
All three experts agree that in the most severe cases, physicians should try systemic agents, which can include older agents such as methotrexate and cyclosporine, and the newer biologic agents. In Dr. McMichael’s practice, she starts with methotrexate. “I can’t think of a time where I used a biologic medication in patients with psoriasis limited to their scalp,” she says.
In these difficult-to-treat patients, Dr. Strober does not hesitate to use a biologic agent. “I view patients with bad scalp psoriasis similarly to any patient with moderate-to-severe disease, regardless of the body distribution,” he says. But before prescribing these medications, the usual checks and balances must be in place. “If the patient responds to the medication, they are extraordinarily pleased,” he adds. “The worst things is to keep hitting them over the head with another topical regimen that does not work; that creates an exasperated, frustrated patient.”
While Dr. Schlessinger does use biologics for severe scalp psoriasis, he is not a fan of methotrexate or cyclosporine in any patients and “always find other options that are preferential over those treatments.”
Seborrheic Dermatitis
The treatment of seborrheic dermatitis tends to be similar to that for scalp psoriasis, note the experts. In Dr. McMichael’s practice, “I tend to treat with the same medications, just at lower frequency and lower strength than that used for psoriasis patients. But for seborrheic dermatitis, we rely heavily on products that contain ketoconazole and zinc, because of their antifungal effect,” says Dr. McMichael. When prescribing a corticosteroid, Dr. McMichael starts with a more mild agent, like Derma-Smoothe F/S, once or twice a week, and then quickly gets the patient off the agent.
Dr. Schlessinger advocates the use of both oral ketoconazole (400 mg once weekly for 6 to 8 weeks) and a topical foam formulation (Extina) to treat the underlying pityrosporum infection. In addition, newer formulations of corticosteroids, like clobetasol (Olux) and betamethasone (Luxiq), he says,“have markedly changed the treatment of scalp psoriasis and seborrheic dermatitis. “Before these were available, there were few palatable options for these conditions, but now the treatments are quite ‘patient friendly.’ Older treatments such as Derma-Smoothe F/S and other tar-based shampoos are clearly a challenge for patients and often result in poor results due to compliance issues.”
For Dr. Strober, initial therapy is also with a topical ketoconazole-containing agent. If that is not effective, he then uses a topical corticosteroid, with lower potency on the face, higher potency on the scalp. Another very attractive option, says Dr. Strober, is the use of topical immunomodulatory drugs, like tacrolimus (Protopic ointment) and pimecrolimus (Elidel cream). “These agents have been found to be safe and effective for seborrheic dermatitis on the face. The down side is that they burn and sting, especially Protopic. If there is not a reimbursement issue, I often prescribe these drugs as first-line therapy,” he states.
Exciting Time To Practice
According to Dr. Schlessinger, “This is an exciting time to be treating both seborrheic dermatitis and scalp psoriasis. Never before have we had so many options at our fingertips.” This makes choosing an appropriate treatment for your patients a lot easier, “hopefully making for improved compliance and life-altering changes,” Dr. Schlessinger concludes.
