What are the treatment options for psoriasis (psoriasis) of the scalp?

Treatment Options for Scalp Psoriasis

Topical corticosteroids are the first-line treatment for scalp psoriasis, with specialized formulations like solutions, foams, and shampoos providing the most effective and patient-friendly delivery methods. 1

First-Line Treatment: Topical Corticosteroids

• Topical corticosteroids are recommended as initial therapy for scalp psoriasis with efficacy rates ranging from 41% to 92% depending on potency class 1
• For mild to moderate scalp psoriasis, use class 3-7 corticosteroids; for moderate to severe cases, use class 1-2 (high-potency) corticosteroids 1
• Treatment duration should be up to 4 weeks initially, with longer use (>12 weeks) requiring careful physician supervision 1
• Vehicle formulations specifically designed for scalp application (solutions, foams, shampoos) improve adherence and efficacy compared to creams or ointments which can be messy in hair-bearing areas 2
• Clobetasol propionate solution is highly effective but may cause local adverse effects including burning/stinging sensation (reported in 29 of 294 patients), scalp pustules, and folliculitis 3

Vitamin D Analogues

• Calcipotriene (calcipotriol) foam is effective for scalp psoriasis, with 40.9% of patients achieving clear or almost clear status after 8 weeks compared to 24.2% with vehicle 2
• Vitamin D analogues show efficacy at 8 weeks but not at 4 weeks, which should be considered when planning treatment duration 2
• Calcipotriene foam and calcipotriene plus betamethasone dipropionate gel for 4-12 weeks are safe and effective for mild to moderate scalp psoriasis 2
• UVA radiation can decrease the concentration of calcipotriene on the skin, so it should be applied after phototherapy to avoid inactivation 2

Combination Therapy

• Combination of calcipotriene with potent corticosteroids is more effective than either agent alone for treating psoriasis 2
• A 52-week study showed 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% with vehicle control 2
• No serious adverse events, including striae or hypothalamic-pituitary-adrenal axis suppression, were observed over the 52-week treatment period with this combination 2
• For long-term management, gradually reduce frequency of corticosteroid application and consider combination with vitamin D3 derivatives or coal tar-containing shampoo 1, 4

Treatment Algorithm

1. Initial Assessment: Evaluate severity of scalp psoriasis (mild, moderate, severe) 2
2. First-line therapy:
   • For mild-moderate: Class 3-7 topical corticosteroid in a solution, foam, or shampoo formulation 1
   • For moderate-severe: Class 1-2 topical corticosteroid (like clobetasol propionate solution) 1, 3
3. Treatment duration: Use daily for up to 4 weeks 1
4. Maintenance therapy:
   • Gradually reduce frequency to prevent rebound 1
   • Consider alternating with vitamin D analogues 2, 4
5. For resistant cases:
   • Combination therapy with calcipotriene plus betamethasone 2
   • Consider intralesional corticosteroids for localized thick lesions 1
   • For severe recalcitrant cases, systemic therapies may be required 5, 6

Important Considerations and Pitfalls

• Scalp psoriasis is notoriously difficult to treat due to the presence of hair making application challenging 2
• Poor adherence to treatment regimens is common (up to 40% of patients), often due to inconvenience, time constraints, and frustration with messy formulations 2
• Hypothalamic-pituitary-adrenal (HPA) axis suppression is possible with prolonged use of potent topical corticosteroids but is typically transient and reversible upon completion of a 2-week course of treatment 3
• Local adverse effects of topical corticosteroids include burning, stinging, folliculitis, skin atrophy, and telangiectasia 3
• For women of childbearing potential, most topical psoriasis medications are pregnancy category C, and tazarotene is category X 2