What are the treatment options for scalp psoriasis?

Treatment Options for Scalp Psoriasis

Topical corticosteroids combined with vitamin D analogues are the most effective first-line treatment for scalp psoriasis, with vehicle formulations specifically designed for scalp application (solutions, foams, shampoos) providing optimal efficacy and adherence. 1

First-Line Treatment Options

Topical Corticosteroids

• Topical corticosteroids are recommended as first-line treatment for scalp psoriasis, with potency classes varying based on severity 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 preferred 1
• Efficacy rates vary widely among different potency classes, ranging from 41% to 92% 1
• Vehicle formulations specifically designed for scalp application (solutions, foams, shampoos) improve adherence and efficacy compared to creams or ointments 1
• Clobetasol propionate 0.05% foam has demonstrated significant effectiveness for scalp psoriasis, with twice-daily applications showing better results than once-daily use 2, 3

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
• Calcipotriene foam and calcipotriene plus betamethasone dipropionate gel for 4-12 weeks are recommended for mild to moderate scalp psoriasis (Strength of recommendation A) 4, 1

Combination Therapy

Corticosteroid + Vitamin D Analogue Combinations

• Combination of calcipotriene with potent corticosteroids is more effective than either agent alone for treating psoriasis 4, 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 4, 1
• No serious adverse events, including striae or hypothalamic-pituitary-adrenal axis suppression, were observed over the 52-week treatment period with this combination 4, 1

Regimen Options

• Application of vitamin D analogues twice daily on weekdays in conjunction with high-potency topical corticosteroids twice daily on weekends can be considered for maintenance treatment (Strength of recommendation B) 4
• Morning high-potency topical corticosteroid and evening topical vitamin D analogue is an effective treatment regimen (Strength of recommendation B) 4
• For long-term management, gradually reduce frequency of corticosteroid application, and consider combination with vitamin D3 derivatives or coal tar-containing shampoo 1, 5

Important Considerations and Precautions

Adverse Effects

• Most common local adverse effects of corticosteroids include burning and stinging sensation 6
• Less frequent adverse events include itching, tightness of the scalp, dermatitis, tenderness, headache, hair loss, and eye irritation 6
• Potential adverse effects with prolonged use include skin atrophy, striae, folliculitis, telangiectasia, and purpura 1, 6
• Systemic absorption of topical corticosteroids has produced reversible HPA axis suppression, manifestations of Cushing's syndrome, hyperglycemia, and glucosuria in some patients 6

Application Considerations

• UVA radiation can decrease the concentration of calcipotriene on the skin, so it should be applied after phototherapy to avoid inactivation 4, 1
• Simultaneous use of salicylic acid with calcipotriene should be avoided because the acid pH will inactivate calcipotriene and reduce its effectiveness 4
• Occlusive dressings substantially increase the percutaneous absorption of topical corticosteroids 6
• Poor adherence to treatment regimens is common, often due to inconvenience, time constraints, and frustration with messy formulations 1

Treatment Algorithm

1. Initial Assessment: Evaluate the severity of scalp psoriasis 1

2. For Mild to Moderate Scalp Psoriasis:

   • Start with class 3-7 corticosteroids in a vehicle formulation designed for the scalp (solution, foam, shampoo) 1
   • Consider calcipotriene foam or calcipotriene plus betamethasone dipropionate gel for 4-12 weeks 4, 1

3. For Moderate to Severe Scalp Psoriasis:

   • Begin with class 1-2 (high-potency) corticosteroids such as clobetasol propionate 0.05% foam or solution 1, 3
   • Apply twice daily for optimal results 2, 3

4. Maintenance Therapy:

   • After clinical improvement, gradually reduce frequency of corticosteroid application to prevent rebound 1
   • Consider alternating regimens: vitamin D analogues on weekdays and corticosteroids on weekends 4
   • Or morning corticosteroid and evening vitamin D analogue application 4
   • Medicated shampoos containing tar or antifungal agents can be used as adjunctive therapy 5, 7

5. For Resistant Cases:

   • Intralesional corticosteroids can be used for localized non-responding or very thick lesions 1
   • Consider systemic therapies if topical treatments fail to provide adequate control 5, 8

Duration of Treatment

• Topical corticosteroids: Initial therapy up to 4 weeks, with longer use (>12 weeks) under careful physician supervision 1
• Vitamin D analogues: Optimal results seen after 8 weeks of treatment 1, 5
• Combination therapy with calcipotriene and betamethasone dipropionate: Safe and effective for up to 52 weeks 4, 1