What shampoo is recommended for a patient with scalp psoriasis?

Recommended Shampoo for Scalp Psoriasis

Clobetasol propionate 0.05% shampoo is the recommended first-line treatment for moderate to severe scalp psoriasis, applied once daily for up to 4 weeks as a short-contact therapy. 1, 2

Primary Treatment Recommendation

For moderate to severe scalp psoriasis, use clobetasol propionate 0.05% shampoo (class I ultrapotent corticosteroid) applied once daily for up to 4 weeks maximum. 1, 2 This formulation demonstrates superior efficacy compared to calcipotriol solution, with significantly better reduction in total severity scores and global severity scores, while being better tolerated. 3

Application Protocol

• Apply the shampoo to dry scalp, lather, leave on for approximately 15 minutes, then rinse thoroughly—this short-contact approach minimizes systemic absorption while maintaining efficacy. 4
• Once daily application is sufficient for ultrapotent steroids like clobetasol propionate. 1
• Maximum duration is 4 weeks of continuous daily use; exceeding this significantly increases risk of cutaneous side effects (atrophy, telangiectasia, striae) and systemic absorption. 1, 2
• Do not exceed 50g per week of clobetasol propionate 0.05% in any formulation. 1

After Initial 4-Week Course

• Taper gradually: reduce to once daily, then alternate days, then twice weekly to prevent rebound. 1, 2
• For maintenance, consider transitioning to calcipotriene/betamethasone dipropionate combination therapy (see below). 2

Alternative First-Line Option for Mild to Moderate Disease

Calcipotriene 0.005% plus betamethasone dipropionate 0.064% suspension is equally effective as first-line therapy and can be used for longer duration (up to 52 weeks). 2 This combination achieved 69-74% clear or almost clear status in long-term studies with no serious adverse events, including no HPA axis suppression or striae. 2

Pediatric Considerations

• For children ages 12 years and older with scalp psoriasis, calcipotriene/betamethasone dipropionate suspension applied once daily for up to 8 weeks is recommended (Strength of recommendation: B). 5
• Maximum dosage for adolescents is 80g/week for the combination scalp formulation to prevent hypercalcemia. 5

Treatment Algorithm by Severity

Mild to Moderate Scalp Psoriasis

• Start with class III-VII corticosteroid shampoos or calcipotriene/betamethasone combination suspension. 2
• Vehicle formulations (solutions, foams, shampoos) improve adherence compared to creams or ointments. 2

Moderate to Severe Scalp Psoriasis

• Use class I-II (high-potency) corticosteroids like clobetasol propionate 0.05% shampoo. 2
• 81% of patients achieve 50% or better clearing with twice-daily clobetasol solution after 2 weeks, though once daily is typically sufficient. 1

Treatment-Resistant Cases

• If topical therapy fails after 4-8 weeks of optimized treatment, consider systemic therapy—scalp psoriasis is considered a "vulnerable area" warranting systemic treatment when symptomatic or impacting quality of life. 2, 6

Critical Safety Warnings

• Never use clobetasol propionate continuously beyond 4 weeks without tapering. 1, 6
• Folliculitis is the most common side effect with scalp application of ultrapotent corticosteroids. 1
• Monitor for skin atrophy, telangiectasia, striae, and tachyphylaxis (loss of effectiveness) with extended use. 1
• Burning sensation is significantly more common with calcipotriol solution compared to clobetasol propionate shampoo. 3

Common Pitfalls to Avoid

• Do not apply calcipotriene simultaneously with salicylic acid—the acidic pH inactivates calcipotriene. 6
• Do not assess treatment failure with vitamin D analogues at 4 weeks—they show efficacy at 8 weeks but not at 4 weeks. 2, 6
• Do not assume poor response means treatment failure—poor adherence is common due to inconvenience and messy formulations; shampoo formulations specifically address this barrier. 2
• If using phototherapy, apply calcipotriene after UVA exposure, as UVA radiation decreases calcipotriene concentration on skin. 2