Treatment of Scalp Psoriasis
Topical corticosteroids are the first-line treatment for scalp psoriasis, with high-potency formulations (class 1-2) recommended for moderate to severe disease and applied 1-2 times daily for up to 4 weeks initially. 1
First-Line Treatment: Topical Corticosteroids
Potency Selection Based on Severity
- For mild to moderate scalp psoriasis: Use class 3-7 corticosteroids 1
- For moderate to severe scalp psoriasis: Use class 1-2 (high-potency) corticosteroids such as clobetasol propionate 1, 2
- High-potency corticosteroids demonstrate efficacy rates of 74-83% for severe scalp psoriasis, compared to 36-45% with vehicle 1
Vehicle Formulation Matters
- Solutions, foams, and shampoos are superior to creams or ointments for scalp application because they improve adherence and efficacy 1
- Clobetasol propionate 0.05% shampoo applied once daily is FDA-approved and safe for long-term management 2, 3, 4
- Betamethasone valerate foam (class IV) shows 72% improvement compared to 47% with placebo 1
Dosing and Duration
- Apply 1-2 times daily for up to 4 weeks for initial therapy 1
- Longer use (>12 weeks) can be considered under careful physician supervision 1
- After clinical improvement, gradually reduce frequency to prevent rebound 1
Safety Considerations
- Most common adverse effects are burning and stinging sensations 1
- Monitor for skin atrophy, striae, folliculitis, telangiectasia, and purpura with extended high-potency use 1
- Clobetasol propionate may transiently depress plasma cortisol levels, but HPA axis suppression is reversible after completing a 2-week course 2
Second-Line and Combination Therapy
Vitamin D Analogues
- Calcipotriene foam achieves clear or almost clear status in 40.9% of patients after 8 weeks 1
- Vitamin D analogues show efficacy at 8 weeks but not at 4 weeks, making them slower-acting than corticosteroids 1
- Apply calcipotriene after phototherapy (if used) because UVA radiation decreases its concentration on the skin 1
Combination Therapy (Most Effective)
- Calcipotriene 0.005% plus betamethasone dipropionate 0.064% is more effective than either agent alone 1
- In a 52-week study, 69-74% of patients achieved clear or almost clear status with once or twice daily application 1
- No serious adverse events, including striae or HPA axis suppression, occurred over 52 weeks with this combination 1
- This combination is safe and effective for mild to moderate scalp psoriasis when used for 4-12 weeks 1
Treatment Algorithm
Step 1: Initial Assessment
- Evaluate severity of scalp psoriasis to guide potency selection 1
Step 2: Address Scaling First
- Use keratolytic agents to remove scale before applying active treatments 5
Step 3: Choose Based on Clinical Features
- If inflammation predominates: Start with high-potency topical corticosteroids (class 1-2) in foam, solution, or shampoo formulation 1, 5
- If scaling predominates: Consider vitamin D3 analogues 5
Step 4: Long-Term Management
- Transition to intermittent high-potency corticosteroids alternating with vitamin D3 derivatives 1, 5
- Consider adding coal tar-containing shampoo for maintenance 1, 5
- For localized non-responding or very thick lesions, use intralesional triamcinolone acetonide up to 20 mg/mL every 3-4 weeks 1
Important Caveats
Pregnancy Considerations
- Most topical psoriasis medications are pregnancy category C 1
- Tazarotene is category X and contraindicated in pregnancy 1