What lotion is recommended for treating scalp psoriasis?

Topical Treatments for Scalp Psoriasis

For scalp psoriasis, a combination of calcipotriene solution and a topical corticosteroid is the most effective treatment option, with calcipotriene solution alone showing marked improvement in 60% of patients compared to 17% with placebo. 1

First-Line Treatment Options

Vitamin D Analogues

• Calcipotriene solution is highly effective for scalp psoriasis
  • 60% of patients show marked improvement or clearance compared to 17% with vehicle 1
  • Takes optimal effect after approximately 8 weeks of use
  • Available as a solution formulation specifically designed for scalp application

Topical Corticosteroids

• Class I-IV corticosteroids have strong evidence (Level A recommendation) for scalp psoriasis 1
• Rapid acting (maximal efficacy within 3-4 weeks)
• Available in various scalp-friendly formulations:
  • Solutions
  • Foams
  • Shampoos
  • Gels

Combination Therapy (Preferred Approach)

• Combination of calcipotriene and betamethasone dipropionate has the strongest evidence (Level A) 1
  • In a 4-week trial, 48% of patients achieved absent or mild psoriasis with combination therapy versus 16.5% with calcipotriene alone 1
  • Long-term (52-week) study showed 70-80% of patients achieving clear or almost clear status 1
• Foam and gel formulations of this combination are specifically recommended for scalp psoriasis (Level A recommendation) 1

Adjunctive Treatments

Keratolytic Agents

• Salicylic acid 6% lotion can be used to remove scales before applying other medications 2, 3
  • In one study, salicylic acid 6% emollient foam as monotherapy reduced Psoriasis Scalp Severity Index from 15.3 to 3.0 after four weeks 3
  • Apply thoroughly to affected areas, preferably after hydrating the skin for at least 5 minutes 2
  • Can be combined with corticosteroids (Level B evidence) 1

Shampoos

• Coal tar shampoos (2-10%) can be effective for scalp psoriasis 4
• Keratolytic shampoos containing salicylic acid 2% with urea and glycerin can reduce PSSI by up to 69% after 30 days 5

Treatment Algorithm

1. Initial Assessment:

   • Evaluate severity of scaling, erythema, and thickness
   • Check for presence of infection or irritation

2. For Thick, Scaly Plaques:

   • Start with a keratolytic agent (salicylic acid 6% lotion) to remove scales
   • Apply after hydrating the scalp for 5 minutes 2
   • Use for 1-2 weeks until scales are reduced

3. Primary Treatment:

   • Apply combination calcipotriene/betamethasone dipropionate gel or foam once daily 1
   • If combination product unavailable, alternate between:
     • Morning: topical corticosteroid solution/foam
     • Evening: calcipotriene solution 1

4. Maintenance Therapy:

   • Once improvement occurs, reduce frequency to 2-3 times weekly
   • Consider weekend use of corticosteroids and weekday use of vitamin D analogues 1

Important Considerations and Pitfalls

• Avoid combining salicylic acid with calcipotriene in the same application - the acidic pH inactivates calcipotriene 1
• Limit potent corticosteroid use to 3-4 weeks to prevent adverse effects; consider rotating with vitamin D analogues for long-term management 6
• Vehicle selection is crucial for scalp application and patient adherence:
  • Solutions, foams, and gels are preferred over creams and ointments for hair-bearing areas 1
• Calcipotriene should not be applied before phototherapy as it can block UVB and be inactivated by UVA 1
• Patient adherence is a major challenge in scalp psoriasis treatment - selecting cosmetically acceptable formulations improves compliance 6, 4

For resistant cases not responding to topical therapy, consider systemic treatments such as methotrexate, cyclosporine, or biologics, particularly if psoriasis is extensive or significantly impacts quality of life 1, 4.