ABSTRACT Scalp itch is a frequent complaint in the dermatological setting It is common for the dermatologist to encounter patient with no evident cause of scalp pruritus, making it a distressing situation for both the clinician and the patient. The aim of this article is to purpose a systematic approach to scalp itch, which classifies scalp pruritus into two types; with or without dermatological lesions, and presence or absence of hair loss The acronym SCALLP and the five steps for scalp evaluation (listen, look, touch, magnify, and sample) are useful tools to keep in mind for an assertive approach in these patients introduction
Itch, by definition, is the presence of an
uncomfortable tingling or uneasy sensation, which is associated with a desire to scratch Just like skin pruritus, its etiology may be of dermatological or non dermatological origin The aim of this article is to review the clinical signs of the most common causes of scalp itch and other less common causes that must be considered in a systematic approach to scalp pruritus A partical method to classify scalp itch is to consider two types: (1) with dermatological lesions Patient Examination - Scalp itch with scalling/erythema For evaluating scalp itch, - Seborrheic Dermatitis we can follow the five steps - Psoriasis proposed by Shapiro and - Contact dermatitis Otberg for evaluation of - Red Scalp Syndrome hair loss: listen, look, - Tinea capitis - Dermatomyositis touch, magnify, and sample, - Sensitive Scalp/Atopic dermatitis while focusing on scalp itch - Urticaria lesions - Infestations - Other skin lesions (2) Without skin lesions - Neuropathic itch - Psychogenic Pruritus Seborrheic dermatitis Contact dermatitis Anxiety Lichen planopilaris Lice Psoriasis
SCALLP acronym in order to easily recall the most common
causes of scalp itch Scalp Itch with Skin Lesions Scalp Itch with Scaling/Erythema Seborrheic Dermatitis (16% of the adult Scalp itch associated with population) interfollicular and perifollicular Is one of the most common causes of scalp scales and/ or erythema can be due itch. to the following causes: seborrheic Other common symptoms included dermatitis; scalp psoriasis, contact sensations of prickling, tightness, pain and dermatitis; early lichen planopilaris (LPP);Tinea capitis;dermatomyositis burning and xerosis secondary to atopic dermatitis or aging skin. Contact Dermatitis Clinically, it may present with itch, erythema, and scaling. Other common scalp allergens Psoriasis ( 67-97%) implicated in scalp contact dermatitis include Possible mechanisms that explain fragnances and preservatives that are typical pruritus in scalp psoriasis are ingredients of shampoos, conditioners and hair hyperinnervation, neurogenic styling products. It also important to ask about inflammation, neuropeptide misbalance, the type of brush associated with nickel, abnormal functioning of the peripheral rubber, or plastic may be the cause of the opioid system, cytokine release and vascular abnormalities problem Tinea Capitis Dermatomyositis ( has been linked to May cause severe pruritus, pruritus in up to 94% of diagnosed erythema, and scaling; alopecia patients) may or may not be present. A Other scalp manifestations that may be prominent inflammatory reaction is present are erythema, atrophy, scales, typical for kerion lesion and and diffuse non-scarring alopecia presence of servical node enlargement suggest diagnosis. Wood’s light may help to identify infection by Microsporum audoinii Scalp Itch with Alopecic Patches and M. canis by the presence of Distinguishing between non-scaring and green fluorescence. scarring alopecias is an important aspects of clinical evaluation. Non-scarring alopecias associated with scalp itch include alopecia Sensitive Scalp / Atopic Dermatitis areata (complain of mild itching or burning) and In this condition , the scalp is adrogenetic alopecia (often complain of scalp prone to experiencing pruritus, and itch and frequently have concomitant paresthesias including prickling, seborrheic dermatitis). The most common types burning, and tingling when of scarring alopecia associated with itch are exposed to physical, psychological LPP, frontal fibrosing alopecia, discoid lupus or hormonal factors. An linked to a erythematosus, and central cicatrical specific immune or allergic centrifugal alopecia. mechanism. Urticarial Lesions Usually doesn’t present with the classic findings of erythema and edema, because of the scalp’s skin structure. Rather, patients complain of irritation, pruritus, Infestations stinging, or burning of the scalp. Some patients with scalp itch may Contact urticarial occurs with present with infestations, with the interactions with an most common being lice and irritating/allergic substance. scabies. Scabies usually spares the scalp in Other Skin Lesions adults, but may be present in this Other more specific lesions that location in children and may be diagnosed clinically or with immunocompromised patient. a biopsy are: seborrheic keratosis, keloid scars, burns, eosinophilic, polymorphic, and pruritic eruption associated wiyh radiotherapy (EPPER) and rarely skin tumors. Keloid scars and burn lesions cause peripheral neuropathic itch. Scalp itch without Skin lesions
Neuropathic Itch Psychogenic Pruritus
Is caused by an abnormality in The most difficult part of the the afferent pathway of the assessment of pruritus of the nervous system. It can be central scalp is when a dermatologist doesn’t find any dermatological, or peripheral. Neurological systemic, or neurological cause causes of pruritus should be of such complaint. The patient suspected if a patient has with psychogenic pruritus sensory symptoms like normally presents with a paresthesia, hypoesthesia, and healthy scalp or with secondary hyperalgesia in the same area lesions such as scratch marks and there is no dermatological or and excoriations, without a systemic cause primary lesion CONCLUSION
Itch is a common complaint in the dermatological
setting. A dermatologist must use an algorithmic approach to investigate the possible cause of scalp pruritus. Also, it’s important to think first about the most common causes and then rule out other, less common etiologies. The acronym SCALLP and the five steps for scalp evaluation are useful tools to keep in mind for an assertive approach in these patients