Durable, Anatomically Confined Clearance of Scalp Psoriasis and Associated Pruritus After Single Bilateral Greater Occipital Nerve Block.

Psoriasis is a chronic, immune-mediated inflammatory skin disease that frequently involves the scalp, presenting as well-demarcated, erythematous plaques with silvery scale, pruritus, and impaired quality of life. Emerging evidence supports the role of sensory nerves in psoriatic inflammation through neuroimmune signaling involving the calcitonin gene-related peptide (CGRP) and interleukin-23/interleukin-17 (IL-23/IL-17) axis. Here, we report a case of severe, recalcitrant, markedly pruritic scalp psoriasis in a patient who failed multiple topical therapies and had only temporary improvement with apremilast before denial by her insurance, requiring discontinuation. Given the proposed neuroimmune pathophysiology of psoriasis, the patient underwent bilateral greater occipital nerve block utilizing lidocaine. At 169 days post-procedure, she demonstrated complete resolution of itch and clearance of plaques restricted to the anatomical territory of the greater occipital nerves, despite persistent disease in the adjacent scalp, without concomitant topical or systemic therapy. This sustained, anatomically confined response suggests that local nerve blockade represents a simple, inexpensive, in-office adjunct therapy for recalcitrant scalp psoriasis.