From the Guidelines
The most effective treatment for scalp psoriasis is a combination of calcipotriene and hydrocortisone, as evidenced by a recent study showing that calcipotriene foam was more effective than vehicle in achieving an Investigator’s Static Global Assessment score of 0 or 1 after 8 weeks 1.
Management of Scalp Psoriasis
The management of scalp psoriasis typically involves a combination of topical treatments, including:
- Medicated shampoos containing coal tar or salicylic acid, used 2-3 times weekly to reduce scaling and inflammation
- Topical corticosteroids, such as fluocinonide 0.05% solution or clobetasol 0.05% solution, applied directly to affected areas once or twice daily for 2-4 weeks
- Vitamin D analogs, such as calcipotriene 0.005% solution, used alone or in combination with steroids, applied once or twice daily
Treatment Recommendations
According to the joint AAD-NPF guidelines of care for the management and treatment of psoriasis, the use of class 1-7 topical corticosteroids for a minimum of up to 4 weeks is recommended as initial and maintenance treatment of scalp psoriasis 1.
Key Considerations
- The efficacy of vitamin D analogues, such as calcipotriene, may take 8 weeks to become apparent, and patients should be informed of this when planning treatment 1
- Combining separate vitamin D and corticosteroid preparations into specific easy-to-follow regimens can help reduce adverse effects and costs for patients
- Regular follow-up is important to monitor treatment efficacy and potential side effects, particularly with long-term steroid use, which can cause skin thinning and adrenal suppression
Additional Treatment Options
For resistant cases, intralesional steroid injections (triamcinolone 5-10 mg/ml) may be administered, and in severe or widespread psoriasis, systemic treatments like methotrexate, oral retinoids, or biologics may be necessary. Patients should be advised to avoid scratching, use gentle hair care products, and manage stress, as these factors can exacerbate symptoms.
From the FDA Drug Label
Following repeated nonocclusive application in the treatment of scalp psoriasis, there is some evidence that clobetasol propionate topical solution has the potential to depress plasma cortisol levels in some patients However, hypothalamic-pituitary-adrenal (HPA) axis effects produced by systemically absorbed clobetasol propionate have been shown to be transient and reversible upon completion of a 2-week course of treatment.
Management of scalp psoriasis with clobetasol propionate topical solution is possible, but it is essential to be aware of the potential for systemic absorption and HPA axis suppression. The treatment should be used for a limited period, such as a 2-week course, and patients should be monitored for any adverse effects.
- Key considerations:
- Transient and reversible HPA axis effects
- Potential for depression of plasma cortisol levels
- Limited treatment duration to minimize risks
- Patient supervision to monitor for adverse reactions 2
- Adverse reactions to consider:
- Local reactions, such as burning and/or stinging sensation, scalp pustules, and tingling
- Systemic reactions, such as reversible HPA axis suppression and Cushing's syndrome 2
From the Research
Treatment Options for Scalp Psoriasis
- Topical treatments are the mainstay of treatment for scalp psoriasis, with options including corticosteroids, vitamin D3 analogues, keratolytics, coal tar, and dithranol 3
- Topical corticosteroids are effective and rapid, but their long-term use is limited due to the risk of side effects 3, 4
- Vitamin D3 analogues are a patient-friendly and effective alternative to corticosteroids, although their effects may take longer to appear 3
- Other treatment options, such as phototherapy, systemic treatment with methotrexate, acitretin, and cyclosporin, and biologics, may be considered for patients with moderate-to-severe psoriasis or those who have failed topical therapy 5, 6, 7
Treatment Regimens
- Intermittently used topical corticosteroids alternating with vitamin D3 derivatives, either combined or not with liquor carbonis detergens containing shampoo, may be the most suitable treatment for most patients 3
- Twice weekly maintenance with topical corticosteroids may decrease the time to first relapse in frequent relapsers 6
- A combination of clobetasol propionate followed by calcipotriol may offer therapeutic advantages over continuous treatment with calcipotriol alone 4