What are the treatment options for scalp psoriasis?

Treatment Options for Scalp Psoriasis

Topical corticosteroids are the first-line treatment for scalp psoriasis, with class 1 (ultra-high potency) formulations like clobetasol propionate being most effective for initial therapy of thick, chronic plaques. 1

First-Line Therapy: Topical Corticosteroids

Potency Selection

• Ultra-high potency (Class 1): For thick, chronic plaques

  • Clobetasol propionate 0.05% foam or solution - achieves 50% or better clearing in 81% of patients after 2 weeks 1
  • Recommended for initial treatment of moderate to severe cases

• High potency (Class 2-3):

  • Fluticasone propionate 0.005% ointment - 68-69% of patients achieve good to excellent results after 4 weeks 2

• Medium potency (Class 4):

  • Betamethasone valerate foam - improves symptoms in 72% of patients with moderate to severe scalp psoriasis after 4 weeks 2, 1

• Lower potency (Class 5-7):

  • Consider for maintenance, sensitive areas, or mild disease

Formulation Selection

• Solutions, foams, and shampoos are preferred for scalp application due to ease of use and cosmetic acceptability 3
• Clobetasol propionate shampoo 0.05% is particularly effective and convenient for scalp application 4, 5

Treatment Regimen

• Apply once or twice daily for initial treatment 1
  • Twice daily application of clobetasol propionate solution shows superior efficacy compared to once daily application (100% vs 65% good/excellent response) 6
• Continue for 2-4 weeks for initial treatment 1
• Limit continuous use of class 1 corticosteroids to 2-4 weeks to reduce risk of side effects 2, 1

Maintenance Therapy

• After clinical improvement, gradually reduce frequency of application 2, 1
• For long-term control, twice weekly application of clobetasol propionate shampoo can maintain remission:
  • 31.1% of patients remain relapse-free after 6 months with twice weekly maintenance 5
• Consider alternating with other agents to minimize steroid exposure

Alternative and Adjunctive Treatments

• Vitamin D analogues:

  • Calcipotriene foam or calcipotriene plus betamethasone dipropionate gel for 4-12 weeks 1
  • Can be used in combination with corticosteroids for enhanced efficacy

• Intralesional corticosteroids:

  • For thick, non-responding lesions
  • Triamcinolone acetonide (up to 20 mg/mL) every 3-4 weeks 1

• For moderate-to-severe psoriasis with inadequate response to topicals:

  • Systemic agents like apremilast, adalimumab, or etanercept should be considered 3

Safety Considerations and Monitoring

• Local adverse effects of topical corticosteroids include:

  • Skin atrophy, striae, folliculitis, telangiectasia, and purpura 1
  • More common at steroid-sensitive sites and with prolonged use

• Systemic absorption:

  • Clobetasol propionate solution has potential to depress plasma cortisol levels in some patients 7
  • Effects are typically transient and reversible upon completion of treatment 7

• Tachyphylaxis (decreased effectiveness with continued use) may occur with long-term use 2

• Rebound can occur with abrupt withdrawal; implement gradual tapering 1

Clinical Pearls

• Scalp involvement occurs in up to 80% of individuals with psoriasis and significantly impacts quality of life 3
• Medicated shampoos provide a more convenient alternative than creams or ointments for scalp application 4
• For frequent relapsers, twice weekly maintenance therapy can significantly delay time to relapse 5
• Long-term use (>12 weeks) should only be done under careful physician supervision 1
• Consider combination therapy for enhanced efficacy - corticosteroid shampoo alternating with antifungal shampoo has shown efficacy in seborrheic dermatitis and may be beneficial in some cases of scalp psoriasis 8