Psoriasis of the Scalp

Abstract

Psoriasis of the scalp is a frequently occurring condition affecting approximately 2% of the Western population. The sharply demarcated erythematosquamous lesions with silver-white scaling characterize scalp psoriasis. Quality of life can be seriously reduced by this condition and therefore long term treatment is needed in most patients. Coal tar shampoos, containing 2 to 10% coal tar solution, are effective in scalp psoriasis. However, no double-blind studies are available to support such an assumption. Salicylic acid 5 to 10% has a pronounced keratolytic effect. Salicylic acid should be formulated in an ointment, which can be washed off easily. Crude coal tar is the most effective tar available for the treatment of psoriasis. An important feature of coal tar is its potent efficacy against pruritus. At the scalp, the application of crude coal tar is difficult. Therefore coal tar solution is the most frequently applied tar preparation in scalp psoriasis. Dithranol 0.1 to 3% is manufactured in various formulations. Treatment is initiated at a low concentration and the concentration is increased stepwise until a slight irritation, the feeling of warmth, is reached. In the treatment of scalp psoriasis, cream formulations are used. Imidazole antifungals have been used with success in scalp psoriasis. Overgrowth of the scalp with pityrosporon is a well-known feature of scalp psoriasis and seborrheic dermatitis. In case of resistance to other topical treatments use of a topical or systemic imidazole derivative might be helpful. So far, topical corticosteroids are the most frequently used treatments for psoriasis of the scalp. Corticosteroids inhibit epidermal proliferation, inhibit inflammation and modulate immune functions. Topical corticosteroids are fast acting: within 3 to 4 weeks maximal efficacy is reached. No data are available to support the efficacy and safety of topical corticosteroids during long term use. However, from epidemiologic surveys we know that these treatments are used by the majority of patients for more than 8 weeks. Since 1992 vitamin D3 formulations have been developed for the treatment of psoriasis. Calcipotriol is available in most countries. Tacalcitol is available in Japan and several other countries. Vitamin D3 analogues inhibit epidermal proliferation, enhance cornification and inhibit inflammation. Therefore, vitamin D3 analogues have a substantial antipsoriatic effect. Systemic treatments such as methotrexate, cyclosporine and acitretin are indicated in patients with recalcitrant disease. Management of scalp psoriasis requires long term strategies in order to reach an optimal improvement of the condition, while avoiding the adverse effects associated with the long term use of treatments.

Ustekinumab Induces Fast Response and Maintenance of Very Severe Refractory Scalp Psoriasis: Results in Two Greek Patients from the Psoriasis Hospital-Based Clinic

“…The prevalence of scalp psoriasis in 100 patients attending our psoriasis clinic between 2010 and 2012 is 70% which is in line with the previous studies [1,2,3]. We report 2 psoriasis patients with very severe scalp involvement recalcitrant to previous therapies who were treated with ustekinumab.…”

“…Since the use of systemic medications in scalp psoriasis lacks strong evidence-based data, these medications should be reserved for patients with severe refractory scalp psoriasis. Although no studies have specifically evaluated methotrexate in scalp psoriasis, it was found to be effective in scalp psoriasis with an optimal therapeutic effect usually reached after 2-3 months [2]. The use of the systemic retinoid acitretin in the treatment of severe psoriasis has been studied in general [33], but no specific use in the treatment of scalp lesions.…”

“…Positive results are usually observed only after 24 weeks of treatment [34]. Acitretin has a limitation in the treatment of scalp psoriasis in that it may cause hair loss [2]. …”

“…The scalp is one of the most common sites of psoriasis involvement with 50-80% of the patients with psoriasis suffering from scalp psoriasis at the onset or during the disease [1,2,3]. While the head represents only 10% of the body's surface area, the consequences of scalp psoriasis are disproportionate to the area, as it can be seriously debilitating and causes social and emotional distress to the affected individuals.…”

A Study of the Safety and Efficacy of Calcipotriol and Betamethasone Dipropionate Scalp Formulation in the Long-Term Management of Scalp Psoriasis

“…The scalp is one of the most common sites of involvement, affecting more than half of the patients [1, 2]. The visibility and symptoms of scalp psoriasis make this form of the condition one of the most distressing presentations of the disease for many patients, creating a significant psychological and social burden [3].…”