What are the treatment options for psoriasis on the scalp?

Treatment Options for Scalp Psoriasis

The most effective treatment for scalp psoriasis is a combination of topical corticosteroids and vitamin D analogues, with calcipotriene plus betamethasone dipropionate being more efficacious than either agent alone. 1

First-Line Treatment Options

Topical Corticosteroids

• Potency selection:
  • Medium to high-potency (class 2-4) corticosteroids are recommended for initial treatment of scalp psoriasis 2
  • Ultra-high potency (class 1) corticosteroids like clobetasol propionate 0.05% are effective for thick, resistant plaques 2
  • Apply twice daily for 2-4 weeks, followed by weekend-only application for maintenance 2

Vitamin D Analogues

• Calcipotriene (calcipotriol) foam or solution is effective for scalp psoriasis 1
• Note that efficacy is typically seen at 8 weeks rather than 4 weeks, which should be discussed with patients when planning treatment 1
• Calcipotriene foam has shown significant improvement compared to vehicle (40.9% vs 24.2%) in achieving clear or almost clear skin 1

Combination Therapy

• Calcipotriene plus betamethasone dipropionate is more effective than either agent alone 1, 2
• In a 52-week study, 69-74% of patients treated with calcipotriene 0.005% plus betamethasone 0.064% once or twice daily achieved clear or almost clear status compared to 27% with vehicle 1
• Can be applied simultaneously or serially for enhanced efficacy 2

Formulation Considerations

• For scalp psoriasis, use solutions, lotions, foams, sprays, or shampoos which are more suitable for hair-bearing areas 3, 4
• Foam preparations offer cosmetic and pharmacodynamic advantages over creams and ointments 5
• Shampoos containing coal tar (liquor carbonis detergens) can be used as adjunctive therapy 6

Treatment Algorithm

1. Initial approach:

   • Start with a keratolytic agent (such as salicylic acid) if significant scaling is present 6, 4
   • Follow with topical corticosteroid solution/foam for 2-4 weeks 1, 2

2. Maintenance therapy:

   • For frequent relapsers, twice weekly maintenance therapy may decrease time to first relapse 3
   • Consider alternating corticosteroids with vitamin D analogues to minimize side effects 6

3. For resistant cases:

   • Consider intralesional steroids, phototherapy, or excimer laser 3
   • For patients with moderate-to-severe psoriasis who fail topical therapy, systemic agents like apremilast, adalimumab, or etanercept may be necessary 3

Important Considerations and Cautions

• Corticosteroid side effects: Burning/stinging sensation (reported in 29 of 294 patients), scalp pustules, tingling, and folliculitis are the most common local adverse events with clobetasol propionate 7
• Duration of use: Limit high-potency corticosteroid use to 2-4 weeks to avoid adverse effects 2, 7
• Systemic absorption: Prolonged use of potent topical corticosteroids can cause HPA axis suppression, particularly with extensive application 2, 7
• Vitamin D analogues: UVA radiation can decrease the concentration of calcipotriene on the skin; if using with phototherapy, apply after the treatment 1
• Quality of life impact: Scalp psoriasis affects up to 80% of individuals with psoriasis, with 80% of those experiencing negative impact on quality of life 3

Practical Tips

• For optimal results with clobetasol propionate solution, twice daily application is more effective than once daily (100% vs 65% good/excellent response after 2 weeks) 8
• Liberal moisturization is essential as adjunctive treatment 2
• Avoid irritants such as harsh soaps and detergents 2
• Patient compliance exceeds 90% with foam preparations due to their cosmetic acceptability 5