What are the treatment options for scalp psoriasis?

Treatment Options for Scalp Psoriasis

For scalp psoriasis, medium to high-potency topical corticosteroids are the first-line treatment, with clobetasol propionate being particularly effective when used in a shampoo formulation for initial treatment, followed by twice-weekly maintenance therapy. 1

First-Line Treatments

Topical Corticosteroids

• Medium to high-potency (class 2-4) topical corticosteroids are recommended for initial treatment of scalp psoriasis 1
• Ultra-high potency (class 1) corticosteroids like clobetasol propionate are particularly effective for thick, chronic plaques 1
• Application regimen: Apply twice daily for 2-4 weeks, followed by weekend-only application for maintenance therapy 1
• Clobetasol propionate shampoo 0.05% has demonstrated superior efficacy compared to other formulations:
  • 68% of patients achieved clear or almost clear status after just 2 weeks of treatment 2
  • Provides convenient short-contact therapy that minimizes systemic exposure 3
  • Twice-weekly maintenance application can extend remission to a median of 141 days compared to 30.5 days with vehicle 4

Vitamin D Analogues

• Calcipotriene foam has shown effectiveness for scalp psoriasis after 8 weeks of treatment 5
• Combination therapy: Morning application of corticosteroid and evening application of vitamin D analogue is an effective regimen 1
• Note: Vitamin D analogues are less effective than corticosteroids for scalp psoriasis, with calcipotriene solution being less effective and causing more burning sensation than clobetasol propionate shampoo 6

Treatment Algorithm

1. Initial Treatment (First 2-4 weeks):

   • Start with clobetasol propionate 0.05% shampoo applied once daily 3
   • For severe cases, consider twice-daily application 7
   • Leave on for 15 minutes before rinsing

2. Maintenance Phase (After achieving control):

   • Reduce to twice-weekly application of clobetasol propionate shampoo 4
   • This regimen has been shown to prevent relapse in 40.3% of patients over 6 months 4

3. For Inadequate Response:

   • Consider combination therapy with vitamin D analogues 5, 1
   • Calcipotriene plus betamethasone dipropionate gel for 4-12 weeks has shown efficacy 5

4. For Moderate-to-Severe Scalp Psoriasis Resistant to Topicals:

   • Consider biologic therapy such as ustekinumab, which is recommended for scalp psoriasis (strength of recommendation C) 5

Important Considerations

Safety Concerns

• Monitor for side effects: Prolonged use of high-potency corticosteroids can cause skin atrophy, striae, and telangiectasias 1
• Systemic absorption: Inflammation and occlusive dressings can increase percutaneous absorption of topical corticosteroids 8
• HPA axis suppression: While possible with extensive use, studies have shown that clobetasol propionate shampoo used as directed does not lead to significant HPA axis suppression 4

Practical Tips

• Liberal moisturization is essential as adjunctive treatment 1
• Avoid irritants such as harsh soaps and detergents 1
• For long-term management, the alternate regimen of daily treatment for flares followed by twice-weekly maintenance has proven both effective and safe 4

Special Populations

• For facial and intertriginous areas, use low potency (class 6-7) corticosteroids or topical calcineurin inhibitors instead 1
• In children, use the lowest effective potency for the shortest duration 1
• Elderly patients are at higher risk of skin atrophy and should be monitored closely 1

The evidence strongly supports that clobetasol propionate shampoo 0.05% provides an optimal balance of efficacy, safety, and patient satisfaction for scalp psoriasis, with the ability to maintain long-term control when used in an appropriate maintenance regimen.