What is the recommended corticosteroid (CS) treatment for scalp eczema?

Topical Corticosteroids for Scalp Eczema

For scalp eczema, use topical corticosteroids of any potency class (class 1-7) applied no more than twice daily for up to 4 weeks as first-line treatment, selecting the least potent preparation that effectively controls symptoms. 1

Selecting Corticosteroid Potency

• Start with moderate to high potency (class 2-5) topical corticosteroids for most adults and children with scalp eczema, as these provide effective anti-inflammatory control while minimizing risk of adverse effects 2, 1

• The scalp tolerates higher potency corticosteroids better than thin-skinned areas (face, neck, flexures) due to thicker stratum corneum and hair follicle density, making potent preparations appropriate for initial therapy 2, 1

• For mild scalp eczema, begin with mild to moderate potency corticosteroids (class 4-6), escalating only if inadequate response after 1-2 weeks 1, 3

• For severe or refractory scalp eczema, potent to very potent corticosteroids (class 1-3) are appropriate, with moderate-certainty evidence showing potent corticosteroids result in 70% treatment success versus 39% with mild potency 4, 3

Application Frequency and Duration

• Apply topical corticosteroids once daily rather than twice daily - moderate-certainty evidence shows no difference in effectiveness between once versus twice daily application of potent corticosteroids (OR 0.97,95% CI 0.68 to 1.38) 4

• Treat acute flares for 2-4 weeks initially, then reassess response 2, 1

• After achieving control, transition to weekend (proactive) therapy - applying corticosteroids twice weekly to previously affected areas reduces relapse risk from 58% to 25% (RR 0.43,95% CI 0.32 to 0.57) with moderate-certainty evidence 4

• Implement "steroid holidays" when using potent or very potent preparations to minimize risk of adverse effects, though optimal tapering schedules are not well-established 2, 1

Vehicle Selection for Scalp Application

• Choose solutions, lotions, gels, or foams for scalp application rather than ointments or creams, as these vehicles penetrate hair-bearing areas more effectively and are better tolerated by patients 2, 5

• Clobetasol foam (class 1) achieved 68% treatment success in mild-to-moderate psoriasis, demonstrating effectiveness of foam vehicles for scalp conditions 2

Essential Adjunctive Measures

• Apply emollients liberally and regularly, even when eczema appears controlled - emollients are the cornerstone of maintenance therapy and should be applied after bathing to provide a lipid film that retards water loss 1

• Use soap-free cleansers and avoid alcohol-containing products that strip natural skin lipids 1

• For pruritus interfering with sleep, consider short-term sedating antihistamines for their sedative properties, not anti-pruritic effects - non-sedating antihistamines have no value in atopic eczema 1

Managing Secondary Infection

• Continue topical corticosteroids when bacterial infection is present, provided appropriate systemic antibiotics (flucloxacillin for Staphylococcus aureus) are given concurrently 1

• Watch for increased crusting, weeping, or pustules indicating secondary bacterial infection requiring systemic antibiotics 1

• If grouped vesicles, punched-out erosions, or sudden deterioration with fever occur, suspect eczema herpeticum - this is a medical emergency requiring immediate oral or IV acyclovir 1

Alternative Topical Agents for Steroid-Sparing

• Consider topical calcineurin inhibitors (tacrolimus 0.1% or pimecrolimus 1%) for maintenance therapy after initial corticosteroid control, particularly useful as steroid-sparing agents though they cause more application-site reactions (OR 2.2 for tacrolimus 0.1%) 2, 3

• Topical coal tar preparations may be considered when eczema involves the scalp, though generally not recommended as first-line 2, 5

Monitoring for Adverse Effects

• Short-term use (median 3 weeks) of any potency corticosteroid shows no evidence of increased skin thinning (low-certainty evidence from 25 trials with only 36 events among 3691 participants) 3

• Application-site reactions are least likely with corticosteroids compared to calcineurin inhibitors or PDE-4 inhibitors, with very potent, potent, moderate, and mild TCS ranked as least likely to cause site reactions 3

• Gradual reduction in frequency after clinical improvement is recommended to prevent rebound flares, though exact tapering protocols lack strong evidence 2, 1

When to Escalate or Refer

• Failure to respond to moderate potency topical corticosteroids after 4 weeks warrants referral or consideration of systemic therapy 1

• Suspected eczema herpeticum requires immediate medical attention and should not be managed with topical therapy alone 1