What are the treatment options for scalp psoriasis?

Scalp Psoriasis Treatment Options

Topical corticosteroids are the first-line treatment for scalp psoriasis, with clobetasol propionate 0.05% (superpotent) being most effective for moderate to severe cases, applied twice daily for 2-4 weeks. 1, 2

Treatment Algorithm Based on Severity

Step 1: Initial Assessment and Keratolytic Treatment

• Begin with keratolytic agents to remove scaling before applying active treatments
• Use salicylic acid 5-10% to break down scales 3, 4

Step 2: First-line Treatment by Severity

Mild Cases (Minimal Scaling)

• Low-potency corticosteroid (hydrocortisone 1-2.5%) twice daily for 2-4 weeks 1
• Add daily emollient and sunscreen
• Consider coal tar shampoos (2-10% coal tar solution) for maintenance 4, 5

Moderate to Severe Cases (Noticeable Scaling/Inflammation)

• Medium to high-potency corticosteroids:
  • For moderate: Betamethasone (medium-potency) twice daily for 2-4 weeks 1
  • For severe: Clobetasol propionate 0.05% (superpotent) twice daily for 2-4 weeks 1, 2, 6
• After improvement, reduce to weekend-only application 1
• Vehicle selection is important for adherence:
  • Shampoo formulations for easier application and better cosmetic acceptance 5, 7
  • Lotions, foams, or sprays for areas with hair 7

Step 3: Alternative or Combination Therapy

• For steroid-sparing or maintenance:
  • Vitamin D3 analogues (calcipotriol 0.005%) twice daily for 8 weeks 1, 3, 4
  • Combination of corticosteroids with vitamin D3 analogues increases efficacy 1, 3
• For facial involvement or steroid side effect concerns:
  • Tacrolimus 0.1% ointment 1
• For cases with fungal overgrowth:
  • Consider antifungal shampoos or imidazole derivatives 4, 5

Step 4: Treatment for Resistant Cases

• For inadequate response after 2-4 weeks:
  • Consider systemic therapy (methotrexate, cyclosporine, biologics) 1, 4
  • Avoid systemic corticosteroids as they may precipitate erythrodermic or pustular psoriasis upon withdrawal 1

Important Considerations and Pitfalls

Corticosteroid Safety

• Monitor for skin atrophy, especially in elderly patients 1
• No data support safety during prolonged use (>4 weeks) 3, 4
• For pediatric patients, use lowest effective potency for shortest duration 1
• Clobetasol propionate can be absorbed through skin and potentially affect plasma cortisol levels 2

Treatment Adherence

• Vehicle selection significantly impacts treatment adherence and outcomes 7
• Medicated shampoos provide more convenient alternatives to creams/ointments 5
• Patient preference for vehicle may be more important than small differences in drug delivery 7

Maintenance Strategy

• Long-term management is necessary as scalp psoriasis is chronic 3, 4
• Consider rotation therapy: intermittent corticosteroids alternating with vitamin D3 derivatives 3
• Coal tar shampoos are effective for long-term maintenance 5

The evidence strongly supports topical corticosteroids as the most effective and rapid-acting treatment for scalp psoriasis, with vitamin D3 analogues as effective alternatives or combination therapy options. Vehicle selection should be based on patient preference to enhance adherence, with newer formulations like shampoos, foams, and sprays offering similar efficacy with improved convenience compared to traditional ointments.