What are the treatment options for scalp psoriasis?

Treatment Options for Scalp Psoriasis

Topical corticosteroids are the first-line treatment for scalp psoriasis, with vehicle formulations specifically designed for scalp application (solutions, foams, and shampoos) providing improved adherence and efficacy compared to creams or ointments. 1

First-Line Treatment: Topical Corticosteroids

• Topical corticosteroids are recommended as first-line treatment for scalp psoriasis by the American Academy of Dermatology, with efficacy rates ranging from 41% to 92% depending on potency class 1
• For mild to moderate scalp psoriasis, class 3-7 corticosteroids are recommended; for moderate to severe scalp psoriasis, class 1-2 (high-potency) corticosteroids are recommended 1
• Clobetasol propionate (0.05%), a high-potency corticosteroid, shows excellent efficacy in treating moderate to severe scalp psoriasis, with twice daily application providing better results than once daily application 2
• Vehicle formulations specifically designed for scalp application (solutions, foams, and shampoos) improve adherence and efficacy compared to creams or ointments 1
• Clobetasol propionate shampoo 0.05% has been shown to be effective, safe, and well-tolerated in treating moderate to severe scalp psoriasis with the advantage of being a short-contact formulation 3

Dosing and Duration

• Topical corticosteroids can be used 1-2 times daily, with initial treatment duration of up to 4 weeks recommended 1
• Longer use (>12 weeks) can be considered under careful physician supervision, with gradual reduction in frequency after clinical improvement to prevent rebound 1
• Intralesional corticosteroids can be used for localized non-responding or very thick lesions, with triamcinolone acetonide up to 20 mg/mL every 3-4 weeks 1

Potential Adverse Effects

• Most common local adverse effects include burning and stinging sensation 4
• Other potential adverse effects include skin atrophy, striae, folliculitis, telangiectasia, and purpura 1
• Systemic absorption of topical corticosteroids can produce reversible HPA axis suppression, manifestations of Cushing's syndrome, hyperglycemia, and glucosuria in some patients 4
• Clobetasol propionate may depress plasma cortisol levels in some patients, but these effects are typically transient and reversible upon completion of a 2-week treatment course 4

Second-Line and Combination Therapies

Vitamin D Analogues

• Calcipotriene foam is effective for scalp psoriasis, with 40.9% of patients achieving clear or almost clear status after 8 weeks 1
• Vitamin D analogues show efficacy at 8 weeks but not at 4 weeks, which should be considered when planning treatment duration 1
• UVA radiation can decrease the concentration of calcipotriene on the skin, so it should be applied after phototherapy to avoid inactivation 1

Combination Therapy

• Combination of calcipotriene with potent corticosteroids is more effective than either agent alone 1
• 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 1
• No serious adverse events, including striae or hypothalamic-pituitary-adrenal axis suppression, were observed over the 52-week treatment period with this combination 1

Other Treatment Options

• Coal tar shampoos are effective for long-term maintenance of remission in patients who respond to therapy 5
• Antifungal shampoos are effective for treating seborrheic dermatitis and other mycotic conditions that may coexist with scalp psoriasis 5

Treatment Algorithm for Scalp Psoriasis

1. Initial Assessment:

   • Evaluate severity of scalp psoriasis 1
   • Address scaling with keratolytic agents as a first step if significant scaling is present 6

2. Treatment Selection Based on Severity:

   • Mild to Moderate Scalp Psoriasis:

     • Start with class 3-7 corticosteroids in scalp-friendly vehicles (solutions, foams, shampoos) 1
     • Apply 1-2 times daily for up to 4 weeks 1

   • Moderate to Severe Scalp Psoriasis:

     • Start with class 1-2 (high-potency) corticosteroids such as clobetasol propionate 0.05% 1
     • Apply twice daily for better efficacy 2
     • Consider shampoo formulations for better adherence and convenience 3

3. Maintenance and Long-term Management:

   • Gradually reduce frequency of corticosteroid application after clinical improvement 1
   • Consider combination therapy with vitamin D analogues for maintenance 1
   • Alternate between corticosteroids and vitamin D derivatives, with or without coal tar-containing shampoo 6

Important Considerations and Pitfalls

• Poor adherence to treatment regimens is common, often due to inconvenience, time constraints, and frustration with messy formulations 1
• For women of childbearing potential, most topical psoriasis medications are pregnancy category C, and tazarotene is category X 1
• In rare instances, treatment (or withdrawal of treatment) of psoriasis with corticosteroids may exacerbate the disease or provoke the pustular form, requiring careful patient supervision 4
• Scalp psoriasis is a chronic disease requiring long-term management strategies; patient support and motivation are crucial for treatment success 6
• When scaling is the predominant feature, vitamin D analogues may be more appropriate; when inflammation is the main characteristic, anti-inflammatory drugs like corticosteroids are indicated 6