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
EFFECTIVE TREATMENT OPTIONS
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 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 http://bmctoday.net/ practicaldermatology/2013/09/article.asp?f=clinicalupdates- on-psoriasis-management.
- Langley RG, Krueger GG, Griffiths CE. Psoriasis: epidemiology, clinical features, and quality of life. Ann Rheum Dis 2005; 64 (Suppl): 18–23.
- Menter A, Korman NJ, Elmets CA, et al. Guidelines of care for the management of psoriasis and psoriatic arthritis. Section 3. Guidelines of care for the management and treatment of psoriasis with topical therapies. J Am Acad Dermatol. 2009;60:643–659.
- Hendricks AGM, Keijsers RRMC, de Jong EMGJ, Seyger MMB, van de Kerkhof PCM. Efficacy and safety of combinations of first-line topical treatments in chronic plaque psoriasis: a systematic literature review. J Euro Acad Dermatol Venereol. 2013;27:931-951.
- Wozel G. Psoriasis treatment in difficult locations: Scalp, nails and intertriginous areas. Clin Dermatol. 2008;26448- 26459.
- Feldman SR, Housman TS. Patients' vehicle preference for corticosteroid treatment of scalp psoriasis. Am J Clin Dermatol. 2003;4:221-224.
- Housman TS, Mellen BG, Rapp SR et al. Patients with psoriasis prefer solution and foam vehicles: a quantitative assessment of vehichle preference. Cutis. 2002;70:327-332.
- Handa S. Newer trends in the management of psoriasis at difficult to treat locations: scalp, palmoplantar disease and nails. Indian J Dermatol Venereol Leprol. 2010;76:634-644.
- Mazzotta A, Esposito M, Carboni I, Schipani C, Chimenti S. Clobetasol propionate foam 0.05% as a novel topical formulation for plaque-type and scalp psoriasis. J Dermatolog Treat. 2007;18:84-7.
- Reid DC, Kimball AB. Clobetasol propionate foam in the treatment of psoriasis. Expert Opin Pharmacother 2005;6:1735- 1740.
- Olsen EA, Cram DL, Ellis CN, Hickman JG, Jacobson C, Jenkins EE, et al. A double-blind, vehicle-controlled study of clobetasol propionate 0.05% (Temovate) scalp application in the treatment of moderate to severe scalp psoriasis. J Am Acad Dermatol 1991;24:443-447.
- Katz HI, Lindholm JS, Weiss JS, Shavin JS, Morman M, Bressinck R, et al. Efficacy and safety of twice daily augmented betamethasone dipropionate lotion versus clobetasol propionate solution in patients with moderate-to-severe scalp psoriasis. Clin Ther 1995;17:390-401.
- Jarratt M, Breneman D, Gottlieb AB, Poulin Y, Liu Y, Foley V. Clobetasol propionate shampoo 0.05%: A new option to treat patients with moderate to severe scalp psoriasis. J Drugs Dermatol 2004;3:367-373.
- Andres P, Poncet M, Farzaneh S, Soto P. Short-term safety assessment of clobetasol propionate 0.05% shampoo: hypothalamic-pituitary-adrenal axis suppression, atrophogenicity, and ocular safety in subjects with scalp psoriasis. J Drugs Dermatol. 2006 Apr;5(4):328-332.
- Barnes L, Altmeyer P, Forstrom L, Stenstrom MH. Long-term treatment of psoriasis with calcipotriol scalp solution and cream. Eur J Dermatol 2000; 10: 199–204.
- Green C, Ganpule M, Harris D et al. Comparative effects of calcipotriol (MC903) solution and placebo (vehicle of MC903) in the treatment of psoriasis of the scalp. Br J Dermatol 1994; 130: 483–487.
- Warren RB, Brown BC, Griffiths CE. Topical treatments for scalp psoriasis. Drugs. 2008;68:2293-2302.
- Jemec GB, Ganslandt C, Ortonne JP, Poulin Y, Burden AD, de Unamuno P, Berne B, Figueiredo A, Austad J. A new scalp formulation of calcipotriene plus betamethasone compared with its active ingredients and the vehicle in the treatment of scalp psoriasis: a randomized, double-blind, controlled trial. J Am Acad Dermatol. 2008;59:455-463.
- Papp K, Berth-Jones J, Kragballe K, Wozel G, de la Brassinne M. Scalp psoriasis: a review of current topical treatment options. J Eur Acad Dermatol Venereol. 2007 Oct;21(9):1151-1160.
- Griffiths CE, Finlay AY, Fleming CJ, Barker JN, Mizzi F, Arsonnaud S. A randomized, investigator-masked clinical evaluation of the efficacy and safety of clobetasol propionate 0.05% shampoo and tar blend 1% shampoo in the treatment of moderate to severe scalp psoriasis. J Dermatolog Treat. 2006;17(2):90-95.
- Barrett C, Lowson D, Blades KJ. Limited benefit of combined use of tar-based shampoo with 50 microg/ml calcipotriol solution in scalp psoriasis. J Dermatol Treat. 2005;16:175.
- Kircik L.Salicylic Acid 6% in an ammonium lactate emollient foam vehicle in the treatment of mild-to-moderate scalp psoriasis. J Drugs Dermatol. 2011;10:270-273.
- Elie R, Durocher LP, Kavalec EC. Efect of salicyclic acid on the activity of betamethasone-17,21-dipropionate in the treatment of erytematous squamouse dermatoses. J Int Med Res. 1983;11:108-112.
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- Chan CS, Van Voorhees AS, Lebwohl MG, et al. Treatment of severe scalp psoriasis: from the Medical Board of the National Psoriasis Foundation. J Am Acad Dermatol. 2009;60:962-971.
- Lebwohl MG, Breneman DL, Goffe BS, Grossman JR, Ling MR, Milbauer J, et al. Tazarotene 0.1% gel plus corticosteroid cream in the treatment of plaque psoriasis. J Am Acad Dermatol 1998;39:590-596.