From the Guidelines
The recommended initial topical treatment for scalp psoriasis is a potent or super-potent corticosteroid solution, foam, or shampoo, such as clobetasol propionate 0.05%, betamethasone dipropionate 0.05%, or fluocinonide 0.05%. These agents have been shown to be effective in reducing inflammation and suppressing T-cell activation, addressing the underlying pathophysiology of psoriasis 1. According to the joint AAD-NPF guidelines of care for the management and treatment of psoriasis with topical therapy and alternative medicine modalities for psoriasis severity measures, topical corticosteroids are classified into 7 categories based on their skin vasoconstrictive activity, ranging in strength from ultra-high (class 1) to low (class 6 and 7) 1.
For scalp psoriasis, areas with thick, chronic plaques often require treatment with class 1 (ultrahigh-potency) corticosteroids 1. The efficacy of topical corticosteroids has been demonstrated in numerous randomized controlled trials (RCTs), with efficacy rates varying from 58% to 92% for ultrahigh-potency (class 1) corticosteroids 1.
In addition to corticosteroids, vitamin D analogs like calcipotriene can be added as steroid-sparing agents, and have been shown to be effective in the treatment of mild to moderate psoriasis, including scalp psoriasis 1. However, simultaneous use of salicylic acid with calcipotriene should be avoided, as the acid pH of salicylic acid can inactivate calcipotriene and reduce its effectiveness 1.
Key points to consider when using topical corticosteroids for scalp psoriasis include:
- Applying the medication directly to the scalp, not just the hair
- Leaving the medication on for several hours or overnight before washing
- Tapering to intermittent use (2-3 times weekly) for maintenance after 2-4 weeks of initial treatment
- Monitoring for local side effects, such as skin atrophy, with prolonged use
- Considering the use of keratolytic agents, such as salicylic acid, to enhance penetration of the corticosteroid.
From the FDA Drug Label
INDICATIONS AND USAGE Calcipotriene ointment, 0.005%, is indicated for the treatment of plaque psoriasis in adults. The initial topical agent that can be used for plaque psoriasis (which may include scalp psoriasis) is calcipotriene ointment, 0.005% 2.
- Key points:
- Calcipotriene is indicated for plaque psoriasis in adults.
- The safety and effectiveness of topical calcipotriene for other dermatoses, including specific mention of scalp psoriasis, have not been established.
From the Research
Initial Topical Treatment for Scalp Psoriasis
The recommended initial topical treatment for scalp psoriasis includes:
- Topical corticosteroids, which remain the mainstay in the treatment of scalp psoriasis due to their rapid effects and patient-friendly formulations 3
- Vitamin D3 analogues, such as calcipotriol, which are a patient-friendly, tolerable, and effective alternative to corticosteroids, although their effects are optimal after 8 weeks 3
Treatment Options
Treatment options for scalp psoriasis include:
- Keratolytics for scaling
- Coal tar (liquor carbonis detergens)
- Dithranol
- Corticosteroids
- Vitamin D3 analogues
- Topical imidazole derivatives
Specific Topical Agents
Specific topical agents that can be used for scalp psoriasis include:
- Clobetasol propionate, a potent topical corticosteroid that is effective in the treatment of scalp psoriasis 4, 5
- Calcipotriol, a vitamin D3 analogue that is safe and effective for the treatment of psoriasis, including scalp psoriasis 6, 7
Treatment Regimens
Treatment regimens for scalp psoriasis may involve: