Case of the Month

Before Treatment

After Treatment

Oil spot sign

Nail pitting

A 42-year-old woman presents with a progressively “dry scalp” for the past 3 years. She said that the itching is so bad it can keep her awake at night and actually interferes with her job because she spends so much time scratching her head. Additionally, she reports being tremendously embarrassed to sit anywhere with dark seats. “When I get up, it looks like it has snowed all around me. My scalp problem is terribly embarrassing. I was visiting a girlfriend who had purchased a brand new black leather couch, and when I stood up to use the restroom, I was absolutely horrified. I remember frantically trying to wipe all the flakes away before she came back from pouring a glass of wine in the kitchen”. She reports the scalp flaking and itching are making her life miserable. She has a small scaling plaque on her right elbow about the size of a dime. Her skin is otherwise unremarkable. She has pitting on several of her fingernails, and one fingernail had a large golden-brown spot under it. She reported no joint pain and was otherwise healthy except for being “a few pounds overweight.”

What's your diagnosis?

Diagnosis: Scalp Psoriasis

The nail pitting is highly suggestive of psoriasis, and the golden brown spot is known as an "Oil Drops Sign" and is pathognomonic for psoriasis.

For this patient I had her put a compounded oil (sesame oil with 0.05% Triamcinolone) on for 3 hours every other night (for 2 weeks) and wash it out before bed. In some patients I have them keep the oil on overnight under a shower cap, but she hated the shower cap overnight because it made 'crinkly' noise and fell off and got her pillowcase oily. For such patients I use this ‘2-3-hours before bed’ protocol, instead.

I concomitantly had her use a compounded scalp lotion with palm oil, isopropyl myristate and 0.05% clobetasol, 15 drops, twice daily to the scalp for 10 days.

After the first two weeks, I have her use the 3-hour scalp oil program, (sesame oil with 0.05% Triamcinolone), just once weekly as a steroid pulse maintenance program. If the scalp psoriasis starts to flare up at any point (although this weekly scalp oil program significantly reduces flare-ups), I have her use the scalp solution, immediately at any sign of a flare-up, twice daily for 5 days in a row to clear it back up.

Here she is after 12 days on the program. She was not on any other medications. She was absolutely thrilled with the results and kindly left positive reviews on several social media sites.

Additional information: Instead of the compounded products I used above, for an alternative treatment program with readily available prescription products, the scalp oil can be replaced with DERMA-SMOOTHE-FS (Fluocinolone) Oil, and the scalp solution can be replaced with Diprolene (betamethasone dipropionate) lotion. I have no financial interests in either of these products.