What is the first line therapy for psoriasis on the scalp?

First-Line Therapy for Scalp Psoriasis

Topical corticosteroids are the first-line therapy for psoriasis on the scalp, with high-potency formulations being most effective for initial treatment. 1

Treatment Algorithm

Initial Treatment

1. High-potency topical corticosteroids

   • Class 1-2 (potent to super-potent) corticosteroids
   • Available in various vehicles (solutions, foams, sprays) for scalp application
   • Apply twice daily for 2-4 weeks 1
   • Clobetasol propionate 0.05% spray/foam has shown 85% success rate after 4 weeks 2

2. Vehicle selection considerations

   • Solutions, foams, and sprays are preferred for scalp application due to ease of use
   • Foams have minimal residue and increased ease of application 3
   • Patient preference for vehicle is important for adherence

For Persistent Cases or Maintenance

• After initial improvement, reduce to weekend-only application 1
• Consider combination therapy with vitamin D analogs:
  • Morning application of corticosteroid and evening application of vitamin D analog 1
  • Calcipotriene 0.005% is FDA-approved for plaque psoriasis in adults 4

Evidence Strength and Considerations

Topical corticosteroids remain the mainstay treatment for scalp psoriasis, with efficacy rates of 68-92% for potent formulations 1. They provide rapid relief of symptoms, with effects typically seen within 2-3 weeks 5.

Studies comparing different corticosteroids have shown that higher potency formulations like clobetasol propionate are superior to lower potency options for scalp psoriasis 6. In one study, clobetasol propionate 0.05% spray achieved success (clear or almost clear) in 85% of patients after 4 weeks 2.

Important Cautions and Monitoring

• Limit use: High-potency corticosteroids should be limited to 50g/week due to risk of adrenal suppression 3
• Duration: No safety data support continuous use beyond 4 weeks 5
• Monitoring: Watch for local adverse effects such as skin atrophy
• Special populations:
  • For children: Use the lowest effective potency for the shortest duration 1
  • For facial involvement: Consider tacrolimus 0.1% ointment instead of corticosteroids 7

Alternative First-Line Options

For patients concerned about steroid side effects or for facial/intertriginous areas:

• Topical calcineurin inhibitors (tacrolimus 0.1% ointment) are recommended for facial and genital psoriasis 7
• Vitamin D analogs (calcipotriene) are effective but may take longer to show results (optimal at 8 weeks vs. 2-3 weeks for corticosteroids) 5

Practical Tips

• For significant scaling, start with a keratolytic shampoo before applying active treatment 5
• Intermittent use of topical corticosteroids alternating with vitamin D derivatives is suitable for long-term management 5
• Patient education and support are crucial for adherence in this chronic condition