Apr
Scalp psoriasis is a chronic inflammatory condition that affects millions of people worldwide. It is characterized by thick, red, scaly patches on the scalp that can cause itching, flaking, and discomfort. While there is no cure for scalp psoriasis, recent advancements in medical research have led to the development of new and effective treatments that can help manage symptoms and improve quality of life.
In this article, we will explore the latest treatment options for scalp psoriasis, including topical medications, systemic therapies, light therapy, and alternative remedies. We will also discuss lifestyle changes and self-care practices that can help reduce flare-ups and maintain healthy scalp and hair. By understanding the various treatment approaches and their potential benefits and risks, individuals with scalp psoriasis can work with their healthcare providers to develop personalized management plans that effectively target their specific needs and goals.
Understanding Scalp Psoriasis
What is Scalp Psoriasis?
Scalp psoriasis is a chronic autoimmune condition that causes the rapid buildup of skin cells on the scalp, resulting in thick, red, scaly patches. It is a form of plaque psoriasis, the most common type of psoriasis, which can affect any part of the body. Scalp psoriasis can range from mild, with slight itching and flaking, to severe, with extensive plaques and inflammation[1].
Symptoms and Diagnosis
The main symptoms of scalp psoriasis include:
- Red, raised patches on the scalp
- Silvery-white scales
- Itching, burning, or soreness
- Flaking or shedding of skin
- Dry, cracked skin that may bleed
Diagnosis of scalp psoriasis typically involves a visual examination by a dermatologist and a review of medical history. In some cases, a skin biopsy may be performed to rule out other conditions and confirm the diagnosis[2].
Causes and Risk Factors
The exact cause of scalp psoriasis is unknown, but it is believed to involve a combination of genetic and environmental factors. The immune system mistakenly attacks healthy skin cells, causing them to grow too quickly and accumulate on the surface of the skin.
Risk factors for developing scalp psoriasis include:
- Family history of psoriasis
- Stress
- Obesity
- Smoking
- Certain medications (e.g., beta-blockers, lithium)
Impact on Quality of Life
Scalp psoriasis can have a significant impact on an individual’s quality of life. The visible plaques and scales can cause embarrassment and self-consciousness, leading to social isolation and psychological distress. The itching and discomfort can also interfere with daily activities and sleep[3].
Topical Treatments for Scalp Psoriasis
Topical treatments are often the first line of defense against scalp psoriasis. These medications are applied directly to the affected areas and can help reduce inflammation, slow down skin cell growth, and alleviate symptoms such as itching and flaking.
Corticosteroids
Topical corticosteroids are the most commonly prescribed medications for scalp psoriasis. They work by suppressing the immune system and reducing inflammation. Potency varies from mild to very strong, and the choice of steroid depends on the severity of the condition. Examples include clobetasol propionate, betamethasone dipropionate, and triamcinolone acetonide[4].
Vitamin D Analogues
Vitamin D analogues, such as calcipotriol and calcitriol, slow down the growth of skin cells and have anti-inflammatory properties. They can be used alone or in combination with corticosteroids to enhance their effectiveness. Studies have shown that vitamin D analogues are safe and well-tolerated for long-term use[5].
Salicylic Acid
Salicylic acid is a keratolytic agent that helps soften and remove thick, scaly plaques. It is often combined with other topical medications, such as corticosteroids or coal tar, to improve their penetration and effectiveness. Salicylic acid is available in various formulations, including shampoos, lotions, and ointments.
Coal Tar
Coal tar has been used for centuries to treat various skin conditions, including psoriasis. It works by slowing down skin cell growth and reducing inflammation. Coal tar is available in shampoos, lotions, and ointments, and can be used in combination with other topical treatments[6].
| Medication | Mechanism of Action | Formulations | |
|---|---|---|---|
| Corticosteroids | Reduce inflammation and suppress immune system | Varies in potency from mild to very strong | Lotions, foams, shampoos, ointments |
| Vitamin D Analogues | Slow down skin cell growth and reduce inflammation | Safe for long-term use | Ointments, creams, lotions |
| Salicylic Acid | Softens and removes thick, scaly plaques | Often combined with other topical treatments | Shampoos, lotions, ointments |
| Coal Tar | Slows down skin cell growth and reduces inflammation | Used for centuries to treat various skin conditions | Shampoos, lotions, ointments |
Combination Therapies
Combining different topical treatments can enhance their effectiveness and provide better symptom relief. For example, a corticosteroid may be used in conjunction with a vitamin D analogue or salicylic acid. Your dermatologist can recommend the most suitable combination based on your individual needs and response to treatment.
Systemic Medications for Severe Cases
When topical treatments fail to control scalp psoriasis or the condition is severe, systemic medications may be necessary. These drugs work throughout the body to reduce inflammation and slow down the overproduction of skin cells. While they can be highly effective, they also carry a higher risk of side effects and require close monitoring by a healthcare provider.
Oral Medications
Oral systemic medications for scalp psoriasis include:
- Methotrexate: An immunosuppressant that slows down skin cell growth and reduces inflammation[7].
- Acitretin: A retinoid that normalizes skin cell differentiation and reduces inflammation.
- Cyclosporine: An immunosuppressant that inhibits T-cell activation and reduces inflammation.
- Apremilast: A phosphodiesterase-4 inhibitor that reduces inflammation by regulating the production of pro-inflammatory cytokines.
Biologic Therapies
Biologic therapies are a newer class of systemic medications that target specific components of the immune system involved in the pathogenesis of psoriasis. They are administered via injection or intravenous infusion and are typically reserved for moderate to severe cases that have not responded to other treatments. Examples include:
- Adalimumab, etanercept, and infliximab: Tumor necrosis factor (TNF) inhibitors that reduce inflammation by blocking the activity of TNF-alpha[8].
- Ustekinumab: An interleukin (IL)-12 and IL-23 inhibitor that reduces inflammation by blocking the activity of these cytokines.
- Secukinumab and ixekizumab: IL-17A inhibitors that reduce inflammation by blocking the activity of IL-17A.
Biologic therapies have shown significant efficacy in the treatment of scalp psoriasis, with many patients achieving clear or nearly clear skin. However, they also carry a risk of serious side effects, such as increased susceptibility to infections and potential for malignancies[9].
Light Therapy Options
Light therapy, also known as phototherapy, is a treatment option for scalp psoriasis that uses ultraviolet (UV) light to slow down skin cell growth and reduce inflammation. It can be an effective alternative or complementary treatment for patients who have not responded well to topical or systemic medications or those who prefer a non-pharmacological approach.
Narrowband UVB Phototherapy
Narrowband UVB (NB-UVB) phototherapy uses a specific wavelength of UV light (311-313 nm) that has been shown to be particularly effective in treating psoriasis. This treatment is administered in a dermatologist’s office or specialized phototherapy center, typically 2-3 times per week for several months. NB-UVB has a lower risk of side effects compared to older forms of UV therapy and can provide long-lasting remission of scalp psoriasis symptoms[10].
Excimer Laser
The excimer laser is a targeted form of phototherapy that delivers high-intensity UVB light to specific areas of the scalp affected by psoriasis. This allows for the treatment of localized plaques without exposing the surrounding healthy skin to UV radiation. Excimer laser treatments are usually performed 1-2 times per week for several weeks, depending on the severity of the condition and the patient’s response to therapy[11].
Psoralen and UVA (PUVA) Therapy
PUVA therapy combines the use of an oral or topical photosensitizing medication called psoralen with exposure to UVA light. The psoralen makes the skin more sensitive to the effects of UVA, enhancing the therapeutic response. PUVA therapy is generally reserved for more severe cases of scalp psoriasis that have not responded to other treatments, as it carries a higher risk of side effects, including skin aging and an increased risk of skin cancer[12].
In conclusion, light therapy options such as narrowband UVB, excimer laser, and PUVA therapy can be valuable tools in the management of scalp psoriasis, particularly for patients who have not responded well to other treatments or prefer a non-pharmacological approach. However, it is crucial to consider the potential risks and benefits of each option and to work closely with a dermatologist to determine the most appropriate course of treatment for individual needs and circumstances.
Natural and Alternative Remedies
In addition to conventional treatments, some patients with scalp psoriasis may seek natural and alternative remedies to manage their symptoms. While there is limited scientific evidence to support the effectiveness of these approaches, some individuals may find them helpful as complementary therapies or for managing mild cases of scalp psoriasis.
Herbal Remedies
Certain herbs and plant extracts have been traditionally used to treat skin conditions like psoriasis. These include:
- Aloe vera: Known for its anti-inflammatory and soothing properties, aloe vera gel may help reduce itching and redness associated with scalp psoriasis[13].
- Tea tree oil: This essential oil has antimicrobial and anti-inflammatory effects, which may help manage symptoms of scalp psoriasis. However, it should be used with caution as it can cause skin irritation in some people.
- Turmeric: Curcumin, the active compound in turmeric, has been shown to have anti-inflammatory properties that may be beneficial for psoriasis. However, more research is needed to confirm its effectiveness[14].
Dietary Modifications
Some studies suggest that certain dietary changes may help manage psoriasis symptoms, although more research is needed to confirm these findings. Potential dietary modifications include:
- Reducing alcohol consumption, as alcohol can trigger psoriasis flares and interfere with treatment.
- Increasing intake of anti-inflammatory foods, such as fruits, vegetables, whole grains, and fatty fish.
- Limiting consumption of red meat, dairy products, and processed foods, which may contribute to inflammation.
- Identifying and avoiding personal trigger foods, as some people may have specific dietary triggers that worsen their psoriasis symptoms.
Stress Management
Stress is a well-known trigger for psoriasis flares, and managing stress levels may help reduce the frequency and severity of symptoms. Some stress management techniques that may be beneficial for people with scalp psoriasis include[15]:
- Relaxation techniques, such as deep breathing, meditation, or progressive muscle relaxation.
- Regular exercise, which can help reduce stress and improve overall health.
- Counseling or therapy to address emotional stressors and develop coping strategies.
While natural and alternative remedies may be helpful for some people with scalp psoriasis, it is essential to remember that they should not replace conventional medical treatment without consulting a healthcare provider. A combination of conventional and complementary therapies, tailored to individual needs and preferences, may offer the best approach to managing scalp psoriasis symptoms.
Lifestyle Changes and Self-Care
In addition to medical treatments and alternative remedies, lifestyle changes and self-care practices can play a significant role in managing scalp psoriasis symptoms and improving overall quality of life. Implementing these strategies can help reduce flares, minimize discomfort, and promote healthier skin.
Gentle Hair Care
Adopting a gentle hair care routine can help minimize irritation and avoid exacerbating scalp psoriasis symptoms. Some tips for gentle hair care include:
- Using a mild, fragrance-free shampoo and conditioner specifically designed for sensitive or psoriatic skin.
- Avoiding harsh hair treatments, such as hair dyes, perms, or relaxers, which can irritate the scalp.
- Gently combing or brushing hair to avoid damaging the scalp and causing further irritation.
- Limiting the use of heat styling tools, such as hair dryers or straighteners, which can dry out the scalp and aggravate symptoms.
Sun Exposure
Moderate sun exposure can help improve scalp psoriasis symptoms, as UV light has been shown to slow down skin cell growth and reduce inflammation. However, it is essential to practice safe sun exposure to minimize the risk of skin damage and skin cancer. Some tips for safe sun exposure include[16]:
- Limiting sun exposure to short periods, typically 10-15 minutes per day.
- Avoiding peak sun hours (usually between 10 am and 4 pm) when UV rays are strongest.
- Protecting the skin with a broad-spectrum, high-SPF sunscreen when spending extended time outdoors.
- Wearing protective clothing, such as wide-brimmed hats and long-sleeved shirts, to minimize skin exposure.
Stress Reduction
As mentioned earlier, stress can be a significant trigger for psoriasis flares. Engaging in stress-reducing activities and practicing self-care can help manage symptoms and improve overall well-being. Some effective stress reduction techniques include[17]:
- Regular exercise, such as walking, yoga, or swimming, which can help reduce stress and improve mood.
- Mindfulness and relaxation practices, such as meditation, deep breathing exercises, or progressive muscle relaxation.
- Engaging in hobbies and activities that promote relaxation and enjoyment, such as reading, gardening, or listening to music.
- Seeking support from family, friends, or support groups to help manage stress and cope with the emotional impact of scalp psoriasis.
Maintaining a Healthy Lifestyle
Adopting a healthy lifestyle can help support overall skin health and potentially reduce the severity of scalp psoriasis symptoms. Some key aspects of a healthy lifestyle include:
- Eating a balanced, nutrient-rich diet with plenty of fruits, vegetables, whole grains, and lean proteins.
- Staying well-hydrated by drinking plenty of water throughout the day.
- Getting sufficient sleep each night to promote healing and reduce stress.
- Avoiding smoking and excessive alcohol consumption, which can worsen psoriasis symptoms and overall health.
By incorporating these lifestyle changes and self-care practices into their daily routine, individuals with scalp psoriasis can take an active role in managing their symptoms and improving their quality of life. However, it is important to remember that these strategies should be used in conjunction with medical treatment and under the guidance of a healthcare provider for optimal results.
Emerging Treatments and Research
As our understanding of the pathophysiology of psoriasis continues to grow, new and innovative treatments are being developed to target specific mechanisms involved in the disease process. These emerging therapies offer hope for individuals with scalp psoriasis who have not responded well to conventional treatments or who are seeking more targeted and effective options.
Biologic Therapies
Biologic therapies are a class of medications that target specific immune system pathways involved in the development of psoriasis.These medications are usually administered by injection or intravenous infusion and have shown promising results in the treatment of moderate to severe psoriasis, including scalp involvement. Some examples of biologic therapies currently being studied for scalp psoriasis include[18]:
- Interleukin (IL) inhibitors, such as ustekinumab (Stelara), secukinumab (Cosentyx), and ixekizumab (Taltz), which target specific inflammatory cytokines involved in psoriasis pathogenesis.
- Tumor necrosis factor (TNF) inhibitors, such as adalimumab (Humira) and etanercept (Enbrel), which block the action of TNF-alpha, a key inflammatory mediator.
- Janus kinase (JAK) inhibitors, such as tofacitinib (Xeljanz) and baricitinib (Olumiant), which interfere with intracellular signaling pathways involved in the inflammatory response.
Small Molecule Inhibitors
Small molecule inhibitors are a newer class of oral medications that target specific enzymes or receptors involved in the inflammatory cascade of psoriasis. These medications have the potential to provide more convenient and targeted treatment options for scalp psoriasis. Some examples of small molecule inhibitors currently under investigation include[19]:
- Phosphodiesterase 4 (PDE4) inhibitors, such as apremilast (Otezla), which reduce inflammation by increasing levels of cyclic adenosine monophosphate (cAMP) in cells.
- Tyrosine kinase 2 (TYK2) inhibitors, which block the activity of TYK2, an enzyme involved in the signaling of several inflammatory cytokines.
- Sphingosine 1-phosphate (S1P) receptor modulators, such as ponesimod, which interfere with the migration of lymphocytes and reduce inflammation.
Novel Topical Therapies
Researchers are also exploring new topical formulations and delivery systems to improve the efficacy and convenience of topical treatments for scalp psoriasis. Some examples include:
- Nanoparticle-based drug delivery systems, which can enhance the penetration and retention of active ingredients in the skin.
- Foam and spray formulations, which can improve the ease of application and distribution of medications on the scalp.
- Combination therapies, which incorporate multiple active ingredients with complementary mechanisms of action to enhance treatment outcomes.
As research continues to advance our understanding of the complex mechanisms underlying scalp psoriasis, it is hoped that these emerging treatments will provide more effective, targeted, and convenient options for individuals struggling with this challenging condition. However, it is important to note that many of these therapies are still in the experimental stages, and further studies are needed to establish their long-term safety and efficacy[20].
Managing Scalp Psoriasis Long-Term
Scalp psoriasis is a chronic condition that requires ongoing management to control symptoms and prevent flares. While there is no cure for psoriasis, a comprehensive approach that combines medical treatments, self-care practices, and lifestyle modifications can help individuals with scalp psoriasis maintain remission and improve their quality of life.
Adhering to Treatment Plans
One of the most important aspects of long-term scalp psoriasis management is adhering to the treatment plan prescribed by a healthcare provider. This may involve:
- Consistently using topical medications, such as corticosteroids, vitamin D analogs, or calcineurin inhibitors, as directed.
- Attending phototherapy sessions or taking systemic medications as scheduled.
- Regularly monitoring skin for signs of improvement or adverse reactions and reporting any concerns to a healthcare provider.
- Adjusting treatment plans as needed based on the effectiveness of current therapies and changes in disease severity.
Adhering to treatment plans can be challenging, especially for individuals with busy lifestyles or those who experience side effects from medications. Working closely with a healthcare provider and developing strategies to overcome barriers to adherence can help ensure long-term treatment success[21].
Maintaining a Healthy Lifestyle
In addition to following a treatment plan, adopting a healthy lifestyle can help support long-term scalp psoriasis management. This includes:
- Eating a balanced, anti-inflammatory diet rich in fruits, vegetables, whole grains, and omega-3 fatty acids.
- Engaging in regular physical activity, which can help reduce stress, improve mood, and promote overall skin health.
- Managing stress through relaxation techniques, such as deep breathing, meditation, or yoga.
- Avoiding triggers, such as smoking, excessive alcohol consumption, and harsh hair care products, that can exacerbate psoriasis symptoms.
Monitoring for Comorbidities
Individuals with psoriasis, including scalp psoriasis, are at an increased risk of developing other health conditions, such as[22]:
- Psoriatic arthritis, which causes joint pain, stiffness, and swelling.
- Cardiovascular disease, including heart attack and stroke.
- Metabolic syndrome, a cluster of conditions that includes obesity, high blood pressure, and insulin resistance.
- Mental health disorders, such as depression and anxiety.
Regular health screenings and monitoring for signs and symptoms of these comorbidities can help ensure early detection and intervention. Working with a multidisciplinary healthcare team, including dermatologists, rheumatologists, and primary care physicians, can help individuals with scalp psoriasis receive comprehensive care and manage their overall health[23].
Seeking Support
Living with a chronic condition like scalp psoriasis can be emotionally challenging. Seeking support from family, friends, or support groups can help individuals cope with the physical and emotional impact of the disease. Some resources for support and information include:
- National Psoriasis Foundation (NPF)
- Psoriasis and Psoriatic Arthritis Alliance (PAPAA)
- Online forums and social media groups dedicated to psoriasis and skin health
- Local support groups or events organized by healthcare providers or patient advocacy organizations
By taking a proactive and comprehensive approach to long-term scalp psoriasis management, individuals can effectively control their symptoms, reduce the frequency and severity of flares, and maintain a high quality of life despite the challenges of living with a chronic skin condition.
Frequently Asked Questions
While scalp psoriasis itself does not directly cause hair loss, the constant scratching, picking, and harsh treatments can lead to temporary hair loss. However, once the psoriasis is under control, the hair usually grows back.
No, scalp psoriasis is not contagious. It is an autoimmune condition that is not transmitted through contact with affected individuals or by sharing personal items like combs or hats.
Yes, stress is a common trigger for scalp psoriasis flares. Managing stress through relaxation techniques, exercise, and self-care practices can help reduce the frequency and severity of flares.
The frequency of shampooing depends on the severity of your scalp psoriasis and the specific products you use. Generally, mild cleansing with a gentle, moisturizing shampoo every 2-3 days is recommended. Always follow the advice of your healthcare provider.
Some natural remedies that may help alleviate scalp psoriasis symptoms include aloe vera, tea tree oil, and omega-3 fatty acids. However, it is essential to consult with a healthcare professional before trying any natural remedies, as they may interact with other medications or cause side effects.
It is generally recommended to avoid hair dyes and other chemical treatments if you have active scalp psoriasis, as they may irritate the skin and worsen symptoms. If you wish to dye your hair, consult with your dermatologist first and consider using gentle, natural, or ammonia-free hair dyes.
Scalp psoriasis is a chronic condition, meaning it may persist for a long time and require ongoing management. While there is no cure for psoriasis, consistent treatment and a healthy lifestyle can help control symptoms and achieve periods of remission.
While there is no specific diet for scalp psoriasis, some people find that certain foods trigger their symptoms. An anti-inflammatory diet rich in fruits, vegetables, whole grains, and omega-3 fatty acids may help reduce inflammation and support overall skin health. Keeping a food diary can help identify potential dietary triggers.
Reference list
- Borda LJ, Wikramanayake TC. Seborrheic dermatitis and dandruff: a comprehensive review. Journal of Clinical and Investigative Dermatology. 2015;3(2):10.13188/2373-1044.1000019.
- Gibbs S. Skin disease and socioeconomic conditions in rural Africa: Tanzania. International Journal of Dermatology. 1996;35(9):633-639.
- Parisi R, Symmons DP, Griffiths CE, Ashcroft DM. Global epidemiology of psoriasis: a systematic review of incidence and prevalence. Journal of Investigative Dermatology. 2013;133(2):377-385.
- National Psoriasis Foundation. About Psoriasis. https://www.psoriasis.org/about-psoriasis
- Icen M, Crowson CS, McEvoy MT, Dann FJ, Gabriel SE, Maradit Kremers H. Trends in incidence of adult-onset psoriasis over three decades: a population-based study. Journal of the American Academy of Dermatology. 2009;60(3):394-401.
- Raychaudhuri SK, Maverakis E, Raychaudhuri SP. Diagnosis and classification of psoriasis. Autoimmunity Reviews. 2014;13(4-5):490-495.
- Rendon A, Schäkel K. Psoriasis pathogenesis and treatment. International Journal of Molecular Sciences. 2019;20(6):1475.
- Kim WB, Jerome D, Yeung J. Diagnosis and management of psoriasis. Canadian Family Physician. 2017;63(4):278-285.
- Pragya A, Kaur CD. Scalp psoriasis: an overview of disease and its management. Journal of Clinical and Diagnostic Research. 2016;10(11):WE01-WE05.
- Blakely K, Gooderham M. Management of scalp psoriasis: current perspectives. Psoriasis (Auckland, N.Z.). 2016;6:33-40.
- Clarke P. Psoriasis. Australian Family Physician. 2011;40(7):468-473.
- Wozel G. Psoriasis treatment in difficult locations: scalp, nails, and intertriginous areas. Clinics in Dermatology. 2008;26(5):448-459.
- Chan CS, Van Voorhees AS, Lebwohl MG, et al. Treatment of severe scalp psoriasis: from the Medical Board of the National Psoriasis Foundation. Journal of the American Academy of Dermatology. 2009;60(6):962-971.
- Papp K, Berth-Jones J, Kragballe K, Wozel G, de la Brassinne M. Scalp psoriasis: a review of current topical treatment options. The Journal of the European Academy of Dermatology and Venereology. 2007;21(9):1151-1160.
- Bagel J, Duffin KC, Moore A, et al. The effect of secukinumab on moderate-to-severe scalp psoriasis: Results of a 24-week, randomized, double-blind, placebo-controlled phase 3b study. Journal of the American Academy of Dermatology. 2017;77(4):667-674.
- Thaci D, Unnebrink K, Sundaram M, Sood S, Yamaguchi Y. Adalimumab for the treatment of moderate to severe psoriasis: subanalysis of effects on scalp and nails in the BELIEVE study. Journal of the European Academy of Dermatology and Venereology. 2015;29(2):353-360.
- Kircik L, Fowler J, Weiss J, Meng X, Guana A, Nyirady J. Efficacy of secukinumab for moderate-to-severe head and neck psoriasis over 52 weeks: pooled analysis of four phase 3 studies. Dermatology and Therapy. 2016;6(4):627-638.
- Blauvelt A, Reich K, Tsai TF, et al. Secukinumab is superior to ustekinumab in clearing skin of subjects with moderate-to-severe plaque psoriasis up to 1 year: Results from the CLEAR study. Journal of the American Academy of Dermatology. 2017;76(1):60-69.
- McInnes IB, Behrens F, Mease PJ, et al. Secukinumab versus adalimumab for treatment of active psoriatic arthritis (EXCEED): a double-blind, parallel-group, randomised, active-controlled, phase 3b trial. Lancet. 2020;395(10235):1496-1505.
- Warren RB, Brnabic A, Saure D, et al. Matching-adjusted indirect comparison of efficacy in patients with moderate-to-severe plaque psoriasis treated with ixekizumab vs. secukinumab. British Journal of Dermatology. 2018;178(5):1064-1071.
- White SH, Manjer J, Becker W, Sander B, Nielsen J. Addressing adherence in the treatment of psoriasis: a call to action. Journal of the European Academy of Dermatology and Venereology. 2020;34(2):e66-e68.
- Takeshita J, Grewal S, Langan SM, et al. Psoriasis and comorbid diseases: Epidemiology. Journal of the American Academy of Dermatology. 2017;76(3):377-390.
- Elmets CA, Leonardi CL, Davis DMR, et al. Joint AAD-NPF guidelines of care for the management and treatment of psoriasis with awareness and attention to comorbidities. Journal of the American Academy of Dermatology. 2019;80(4):1073-1113.
