Approach to the Treatment of Scalp Dysesthesias
The Treatment of the Scalp Dysethesias
Scalp Dysesthesias are a group of scalp disorders whereby patients feel a variety of scalp syptoms such as itching, burning, pain, tingling in the absence of any obvious scalp cause. The concept of scalp dysesthesia was first presented in the world medical literature by Hoss and Segal in 1998. Scalp dysesthesias are often misdiagnosed.
Scalp Dysesthesia: Towards Finding a Cause
The cause of scalp dysesthesias remain to be fully worked out. A variety of medical and dermatologic issues need to be completely ruled out. These include primary scalp disease of course (various types of, early scarring alopecia, contact dermatitis,etc). Generally speaking a true primary scalp dysesthesia does not have any physical findings on the scalp so there is no evidence of these diseases.
Depression and Anxiety in Scalp Dysesthesia.
In the original Hoss and Segal case series description of 11 patients - 7 had symptoms which were worsened by stress, 5 patients had at least 1 known psychiatric disorder (depressive type symptoms, anxiety, somatization). Interestingly, 9 patients had symptom improvement with low-dose antidepressant treatment.
Cervical Spine Disease in Scalp Dysesthesias
In 2013, Thornberry and colleagues from the University of Pittsburg examined the medical records or 15 women with scalp dysesthesia. 14 of these women had cervical spine disease. This included problems in the C5-C6 region of the cervical spine, anterolisthesis, osteophytic spurring, lordosis, kyphosis, and nerve root impingement. Treatment with gabapentin (topical or oral) had been recommended. 4 of the 7 patients that they had long term data on noted improvement in symptoms when taking gabapetin.
”Secondary Causes” of Scalp Dysesthesias
Primary scalp dysesthesias typically do not have a clear underlying cause. One must always perform a thorough and diligent evaluation to ensure there are no underlying causes that could be contributing. We call these '“secondary” causes. Such secondary causes are not commonly found but include:
allergic contact dermatitis
autoimmune scalp disease
autoimmune systemic disease
neurological disease
cervical spine disease
cerebrovascular disease
brain tumors
internal illness
infections
medication/drug side effects
endocrine issues
nutritional deficiencies
psychiatric
Questions to Ask Patients with Scalp Dyesthesisas
Questions to Ask - See Attached Documents
Scalp Dysesthesia: Towards Finding a Treatment
My approach to treating scalp dysesthesias has been discussed in other articles but will be stated briefly here again.
1. The first step begins with careful dermatoscopic/trichoscopic examination by a dermatologist ensuring that there is no primary scalp disease that could explain the symptoms. In some cases, this will require the use of a scalp biopsy to exclude an inflammatory scalp disorder.
Blood tests should be ordered for CBC, ESR, CRP, B12, ANA, TSH, creatinine, AST, ALT. Where appropriate, consideration is given to RPR, SPEP.
2. In the case of a non contributory biopsy or normal scalp examination, a trial of topical corticosteroids and/or topical antidandruff type shampoos may be considered to evaluate the effect of these treatments on the symptoms. Most primary scalp dysesthesias are not helped by these agents.
3. Evaluation of neurological and psychiatric and rheumatological history should be undertaking by a general practitioner such as the primary care physician or internist. At this point, I do consider it important that a physician screen for neurological, rheumatological and psychiatric disease. It is important to evaluate a variety of factors such as headaches, eye symptoms, symptoms radiating into the hands, joint pain, (especially hands), neck symptoms, depression symptoms, anxiety symptoms, history of previous neck injury.
It is important for all patients with scalp dysesthesias to have a complete examination. Sleep studies should be ordered in the event disrupted sleep is a component.
4. Referral to specialists in neurologic, rheumatology, psychiatry may be considered in some cases.
5. An X ray of the cervical spine or MRI or the cervical spine (or brain) may be considered in some cases. Generally speaking I may order a cervical spin x ray in some cases. However, leave this to the specialists to consider the utility of an MRI. These are often low yield and a finding on MRI does not necessary mean this contributes to the scalp dysesthesia.
6. Depending on the above findings, we may consider initiation of scalp exercises or a trial of pharmacological agents such as gabapentin, Lyrica, amitriptyline, antidepressants to address the scalp dysesthesia. Over the counter options like N-acetyl cysteine are currently being studied in our office. These require at least 2 months of use to get a sense if they truly impact the scalp dysesthesia.
7. Low level laser therapy. Many patients with scalp dysesthesias find 655 nm red light therapy helpful.
8. Bland, Fragrance Free shampoos. I advise all patients to use hypoallergenic shampoos.
9. Good sleep. Every effort must be undertaken to improve sleep. This is very important. A cool, dark room and good sleep hygiene all need to be reviewed.
10. Exercise. 30 minutes daily of moderate exercise is very important. We don’t understand all the reasons why that is, but it’s very important. 30 minutes of moderate exercise is extremely important.
11. Breathing exercises. It’s increasingly clear in my practice that breathing exercises are revolutionizing how scalp dysesthesias are managed. I’ve included a link to a series of helpful videos to consider.
12. Referral to a physiotherapist (or registered massage therapist) may be considered. With the publication of this 2013 Thornberry study, there has been increasing interest in whether physiotherapy related exercises for the neck, scalp muscles and cervical spine could provide benefit to relieving some of the symptoms of the scalp dysesthesias. The optimal exercises remain to be determined although a series of simple exercises may help and are outlined in the videos below. We recommend that each patient review these exercises with their own physician or physical therapist before starting to ensure that they are done properly and that there are no particular reasons to avoid doing them in the first place. In some cases, proper massage of the neck muscles and shoulders and spine can be very helpful.
This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.