Scalp psoriasis

Scalp. Plaques, sharply marginated, with thick adherent scales (Fig. 3-8). Scattered discrete or diffuse
involvement of entire scalp. Often very pruritic. Note: psoriasis of the scalp does not lead to hair loss,
even after years of thick plaque-type involvement. Scalp psoriasis may be part of generalized psoriasis or
coexist with isolated plaques, or the scalp may be only site involved

PATHOGENESIS

T he most obvious abnormalities in psoriasis are (1) an alteration of the cell kinetics of keratinocytes with
a shortening of the cell cycle from 311 to 36 h, resulting in 28 times the normal production of epidermal
cells, and (2) CD8+ T cells, which are the overwhelming T cell population in lesions. The epidermis and
dermis react as an integrated system: the described changes in the germinative layer of the epidermis
and inflammatory changes in the dermis, which trigger the epidermal changes. Psoriasis is a T cell–driven
disease. There are many CD8 + T cells present in psoriatic lesions surrounding the upper dermal blood
vessels, and the cytokine spectrum is that of a TH1 response. Maintenance of psoriatic lesions is
considered an ongoing autoreactive immune response.

LABORATORY EXAMINATIONS

Dermatopathology

• M arked overall thickening of the epidermis (acanthosis) and thinning of epidermis over elongated
dermal papillae

• Increased mitosis of keratinocytes, fibroblasts, and endothelial cells

• Parakeratotic hyperkeratosis (nuclei retained in the stratum corneum)

• Inflammatory cells in the dermis (lymphocytes and monocytes) and in the epidermis (lymphocytes
and polymorphonuclear cells), forming microabscesses of Munro in the stratum corneum

SEBORRHEIC DERMATITIS
A very common chronic dermatosis characterized by redness and scaling and occurring in regions
where the sebaceous glands are most active, such as the face and scalp, the presternal area, and in the
body folds. Mild scalp SD causes flaking, i.e., dandruf.

Generalized SD, failure to thrive, and diarrhea in an infant should bring to mind Leiner disease with a
variety of immunodeficiency disorders.

Synonyms: “Cradle cap” (infants), pityriasis sicca (dandruff).

PATHOGENESIS

Malassezia furfur is said to play a role in the pathogenesis, and the response to topical ketoconazole and
selenium sulfide is some indication that this yeast may be pathogenic; also the frequency of SD in
immunosuppressed patients (HIV/AIDS, cardiac transplants). SD-like lesions are seen in nutritional
deficiencies such as zinc deficiency (as a result of IV alimentation) and experimental niacin deficiency
and in Parkinson disease (including drug-induced). SD develops in experimental pyridoxine deficiency in
humans.

Skin Lesions

Orange-red or gray-white skin, often with “greasy” or white dry scaling macules, papules of varying size
(5–20 mm), or patches, rather sharply marginated (Fig. 2-26). Sticky crusts and fissures are common in
the folds behind the external ear. On the scalp there is mostly marked scaling (“dandruff”), diffuse
involvement of scalp. Scattered, discrete on the face and trunk. Nummular, polycyclic, and even annular
on the trunk

DIAGNOSIS/DIFFERENTIAL DIAGNOSIS

Usually made on clinical criteria. Red Scaly Plaques Common Mild psoriasis vulgaris (sometimes may
be indistinguishable), impetigo (rule out by smears for bacteria), dermatophytosis (tinea capitis, tinea
facialis, tinea corporis), pityriasis versicolor, intertriginous candidiasis (KOH: rule out dermatophytes and
yeasts), subacute lupus erythematosus (rule out by biopsy), “seborrheic” papules in secondary syphilis
(darkfield: rule out Treponema pallidum ). Rare L angerhans cell histiocytosis (occurs in infants, often
associated with purpura), acrodermatitis enteropathica, zinc deficiency, pemphigus foliaceus,
glucagonoma syndrome.

LABORATORY STUDIES

Dermatopathology F ocal parakeratosis, with few neutrophils, moderate acanthosis, spongiosis

(intercellular edema), nonspecific inflammation of the dermis. A characteristic feature is neutrophils at
the tips of the dilated follicular openings, which appear as crusts/scales