What are the treatment options for scalp psoriasis with hair loss?

Treatment Options for Scalp Psoriasis with Hair Loss

For scalp psoriasis with hair loss, the recommended first-line treatment is a combination of calcipotriene/betamethasone dipropionate gel or foam applied once daily for 4-12 weeks, which provides superior efficacy compared to either agent alone. 1

First-Line Topical Therapies

Topical Corticosteroids

• Class 1-7 topical corticosteroids are recommended as initial and maintenance treatment for scalp psoriasis for a minimum of up to 4 weeks 1
• Clobetasol propionate (ultrahigh-potency class 1) shows efficacy rates of 58-92% in clinical trials and is particularly effective for resistant scalp plaques 1, 2
• Solutions, foams, and shampoo formulations are preferred for scalp application due to the presence of hair making creams and ointments difficult to use 1
• Caution: Long-term use (>4 weeks) requires careful physician supervision due to potential for local adverse effects including skin atrophy and hypothalamic-pituitary-adrenal axis suppression 1, 2

Vitamin D Analogues

• Calcipotriene foam and calcipotriene plus betamethasone dipropionate gel are recommended for 4-12 weeks for mild to moderate scalp psoriasis 1
• Calcipotriene (calcipotriol) inhibits keratinocyte proliferation and enhances keratinocyte differentiation, providing complementary action to corticosteroids 1
• Efficacy is typically noted at 8 weeks rather than the 2-3 weeks seen with topical corticosteroids 3

Combination Therapy (Preferred Approach)

• Combination of calcipotriene and betamethasone dipropionate is more effective than either agent alone 1
• 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 with 27% of patients treated with vehicle control (p<0.001) 1
• Combination products provide steroid-sparing effects, reducing risk of adverse effects from long-term corticosteroid use 1

Second-Line and Alternative Approaches

Rotational Therapy

• Alternating topical corticosteroids with vitamin D analogues is recommended as a steroid-sparing regimen 1
• Morning application of high-potency topical corticosteroids and evening application of topical vitamin D analogues is an effective regimen 1
• Weekday application of vitamin D analogues with weekend application of high-potency corticosteroids can be considered for maintenance treatment 1

Keratolytics and Coal Tar

• Salicylic acid 5-10% has pronounced keratolytic effects for thick, scaly plaques but should not be used simultaneously with calcipotriene as it inactivates it 3, 4
• Coal tar shampoos (2-10% coal tar solution) can be effective for scalp psoriasis and have potent anti-pruritic effects 4
• A newer foam formulation of coal tar is cosmetically acceptable and easier to apply 5

Calcineurin Inhibitors

• Topical tacrolimus and pimecrolimus can be used as steroid-sparing agents, particularly for prolonged use (≥4 weeks) 1
• These are especially helpful for thinner skin areas and can be considered for maintenance therapy 1

Approach for Resistant Cases

Intralesional Corticosteroids

• Can be used for localized nonresponding or very thick lesions on the scalp 1
• Triamcinolone acetonide in doses up to 20 mg/mL can be administered every 3-4 weeks 1

Phototherapy

• Targeted phototherapy can be considered for limited, resistant plaques 1
• Localized phototherapy is better than generalized phototherapy for hair-bearing areas 6
• NB-UVB is well-tolerated and cost-effective but has limitations in improving scalp psoriasis due to hair coverage 1

Systemic Therapy for Severe Cases

• For extensive scalp psoriasis resistant to topical therapies, systemic agents may be considered 6
• Biologics show excellent effects on scalp psoriasis but are typically reserved for extensive disease due to cost considerations 6

Practical Management Algorithm

1. Initial Assessment: Evaluate severity, presence of hair loss, and impact on quality of life
2. First-Line: Start with combination calcipotriene/betamethasone dipropionate gel or foam once daily 1
3. If Inadequate Response After 4 Weeks:
   • Consider higher potency topical corticosteroid formulation (solution, foam, or shampoo) 1
   • Add keratolytic agent if significant scaling is present 4
4. Maintenance Strategy: Implement rotational therapy alternating vitamin D analogues with corticosteroids 1
5. For Resistant Cases: Consider intralesional corticosteroids, targeted phototherapy, or referral for systemic therapy evaluation 1, 6

Special Considerations for Hair Loss

• Address scalp psoriasis promptly as prolonged inflammation can lead to temporary or permanent hair loss 7
• Avoid harsh physical removal of scales which can worsen hair loss 4
• Gentle medicated shampoos should be used rather than aggressive scrubbing 5
• Consider combination therapy approaches which may provide faster resolution of inflammation and potentially limit hair loss 1