Although plaque psoriasis affects roughly two percent of the adult population in the US, most patients with psoriasis have less than five percent of their total body surface area affected. Thus, while the development of systemic and biologic therapies for those affected by moderate to severe psoriasis has been a notable development, a vast majority of our patients are treated with topical medications.1,2,3 With a growing number of topical agents now available, researchers and clinicians have explored a variety of combination approaches that may yield more successful outcomes with a diminished likelihood for adverse events. And, while sequential therapy has been found to offer benefits in many cases of mild to moderate psoriasis, its utility is often tied to the location of the psoriasis on the patient's body. One area that has consistently proven to be a treatment challenge is the scalp. In addition to the environment being different on the scalp, the density of the skin is also notably different, which often makes topical treatment difficult. Patients with scalp psoriasis are often unhappy with many of the existing therapeutic options, due in part to the cosmetic appearance of their hair after application. 4 Topical agents such as ointments that leave a greasy residue tend to be associated with non-adherence, with patients generally favoring newly developed and often cosmetially elegant vehicles, such as gels, foams, and sprays.5,6


Corticosteroids and Vitamin D Analogues. In the topical steroid arena, clobetasol propionate 0.05% is one of the most potent topical corticosteroid preparations commonly prescribed for patients with scalp psoriasis.7 In an open label study involving 12 patients with scalp psoriasis, all patients had at least a 50 percent reduction in their PASI score for the scalp after clobetasol propionate foam 0.05% (Olux-E, Prestium Pharma) was applied twice daily for four weeks.8 Additionally, the efficacy and safety results for clobetasol propionate 0.05% spray for the treatment of scalp psoriasis are consistent with results from other trials involving treatment of psoriasis at other body sites.9-13 The shampoo formulation of clobetasol propionate 0.05% (Clobex Shampoo, Galderma) is also one of the newer options for the effective treatment of scalp psoriasis.

Calcipotriol has also shown some utility in scalp psoriasis. In a 52-week study involving twice-daily application of either calcipotriol solution or calcipotriol cream, the mean total score for scalp psoriasis had improved by 58 percent after 28 weeks of treatment.14 Another study found that twice daily application of calcipotriol solution for a four week period was rated significantly better than placebo by both investigator and patient.15

One of the common side effects of vitamin D analogues is skin irritation. However, studies have shown that irritation associated with calcipotriol is noticeably diminished when combined with corticosteroids.16 In a double-blind study, patients were randomized to receive once-daily treatment with calcipotriene 50μg/g plus betamethasone 0.5mg/g, betamethasone 0.5mg/g, calcipotriene 50μg/g, or vehicle alone for scalp psoriasis. After eight weeks of treatment, 71.2 percent of patients receiving the vitamin D analogue/ corticosteroid formulation had zero disease or very little compared to betamethasone 0.5mg/g, calcipotriene 50μg/g, or vehicle alone.17

Coal tar and other options. Coal tar has long been used in the treatment of scalp psoriasis, due to its affordability and ability to penetrate the environment. The underlying mechanism to its efficacy involves inhibition of epidermal growth and inflammation. However, patients reportedly dislike the cosmetic appearance, pungent odor, and staining properties associated with its use.18 In an investigator-blinded study, 162 patients were randomized to receive either CP 0.05% shampoo or a tar blend 1% shampoo to apply once daily for their scalp psoriasis. After four weeks of treatment, patients using CP 0.05 shampoos had a 50 percent decrease in total severity, compared to a 14.5 percent decrease in the group treated with tar shampoo.19 In an eight-week study, patients were randomized to receive either calcipotriene scalp solution with a tar-based shampoo or calcipotriol with a non-medicated shampoo. Although both groups' scores for scalp psoriasis improved by greater than 50 percent, no significant difference in efficacy was found between the two treatment groups.20

Keratolytics such as salicyclic acid may also be useful in treating scalp psoriasis.16 In an open label study, 10 patients treated their scalp psoriasis with 6% salicylic acid in an ammonium lactate foam vehicle. The mean score for erythema, thickness, and scaling was reduced significantly from 5.4 to 1.7 after four weeks of treatment. By the end of the study, 60 percent of patients were characterized as clear or almost clear.21 Thus, this agent in an ammonium lactate foam vehicle may be powerful when used in combination with topical corticosteroids and/or vitamin D analogues. 22,23 Finally, despite the lack of clinical studies evaluating its effectiveness in scalp psoriasis, tazarotene may be effective in combination with topical corticosteroids in order to reduce the occurrence of skin atrophy.24,25

When selecting a treatment for patients with scalp psoriasis, it is important to recognize not only the clinical differences in treating scalp psoriasis versus psoriasis in other locations, but also to take account the psychosocial element for patients. Scalp psoriasis is not only physically irritating but also very difficult to cover up. Therefore it is essential to devise a treatment plan that is both sensible and aggressive that will bring patients relief.

Dr. Haddican has no conflicts to disclose. Dr. Goldenberg has served as a consultant or speaker for AbbVie, Bayer, Genentech, LEO Pharma, and Medicis.

gary goldenburg

Gary Goldenberg, MD is Assistant Professor of Dermatology and Pathology, Mount Sinai School of Medicine, Department of Dermatology Pathology.

Madelaine Haddican, MD is a Dermatology Resident at Icahn School of Medicine at Mount Sinai Hospital in New York.

Adapted from an article appearing in Practical Dermatology®. To read more, visit practicaldermatology/2013/09/article.asp?f=clinicalupdates- on-psoriasis-management.

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