SCALP PSORIASIS

Psoriasis of the Scalp: modern methods of Therapy and the Possibility of long-term control of the Disease

Treatment of scalp psoriasis

 

Introduction

Damage to the scalp is observed in 80% of patients with psoriasis, which significantly affects the quality of life.

Local therapy of scalp psoriasis

Topical Steroids

Topical steroids are the most commonly prescribed medications for scalp psoriasis. They are more effective than preparations with calcipotriol, coal tar, and tazarotene. The scalp is relatively resistant to atrophy induced by topical steroids. Various dosage forms of clobetasol propionate are highly effective in treating psoriasis of the scalp. In a double-blind, randomized trial, it was shown that the use of clobetasol propionate spray for 4 weeks 2 times a day resulted in complete or almost complete remission in 85% of patients compared to 13% in the control group. Another study showed that 0.05% clobetasol propionate lotion was more effective than 0.05% betamethasone dipropionate lotion. The use of 0.05% clobetasol propionate shampoo for 4 weeks was effective in 42.1% of patients compared to 2.1% of those who used the base of the drug. The use of this shampoo 2 times a week for 6 months allowed to extend remission to 141 days on average, compared to 30.5 days in the control group. The use of topical steroids in the form of foam has a number of cosmetic advantages, such as fast drying, convenient application, and minimal residue on the hair after application. In addition, the drug in the form of foam has a high degree of penetration into the skin and, as a result, exceeds the effectiveness of similar drugs in the form of lotions. Clobetasol propionate in foam form was effective in 74% of patients versus 4% in the control group. The bioavailability of betamethasone valerate for 12 hours was 300% greater in foam form than in lotion. However, a study conducted in atopic dermatitis, in which betamethasone valerate foam was applied to 30% of the skin area or more, showed that the drug has little tendency to cause suppression of the hypothalamic-pituitary system. In a 4-week study, twice-daily use of 0.12% betamethasone valerate foam (Luxiq®) was effective in 72% of patients with head psoriasis, while betamethasone valerate lotion was effective in only 47%. In a cross-sectional study involving 210 patients, betamethasone valerate foam was effective in 88%, while mometasone furoate was effective in 70%, betamethasone dipropionate-in 25%, calcipotriol lotion in 45%. Feldman et al. found similar efficacy between single and double daily use of betamethasone valerate foam in the treatment of scalp psoriasis, suggesting that a single daily use of this drug should be sufficient.

Vitamin D Derivatives

Vitamin D derivatives can cause irritation but do not cause atrophy. These drugs take longer to achieve their effect (8 weeks) than topical steroids (2-3 weeks). In a large (n = 3396) study, 80% of individuals with head psoriasis treated with topical calcipotriol achieved a good or very good effect in 8 weeks. One study showed similar efficacy between topical calcipotriol and 1% betamethasone valerate lotion, although, in another study involving 474 patients with head psoriasis, improvements were achieved by more patients (75%) who received 0.1% betamethasone valerate lotion than those who received calcipotriol 50 mcg/ml (58%). Additional studies have shown that calcipotriol is less effective than clobetasol propionate shampoo. The effectiveness of the gel containing 0.005% calcipotriol and 0.05% betamethasone dipropionate (trade names Dovobet®, Xamiol®, Daivobet®, and Taclonex®) was more than 2 times higher than that of calcipotriol. Dayvobet gel was effective after an 8-week course of treatment in 36.4% of patients with severe head psoriasis. However, some patients had difficulty removing daybed gel from their hair.

Treatment with other topical medications

Due to its keratolytic effect, salicylic acid can enhance the penetration of topical corticosteroids. The National Psoriasis Foundation (USA) recommends tazarotene gel as a first-line treatment for head psoriasis based on its effectiveness in practice. However, there are no studies in this direction.

Shampoos

Tar and imidazole shampoos have modest results of effectiveness in the treatment of psoriasis of the scalp. In an 8-week randomized, open-label trial involving 475 patients, a shampoo containing 1% coal tar, 1% coconut oil, and 0.5% salicylic acid was shown to be less effective than calcipotriol. Unpleasant smells, hair coloring and drying, low efficiency, and carcinogenicity limit the use of tar in shampoos. Not all studies have shown the effectiveness of shampoos with imidazoles, which inhibit the growth of pittosporum, contributing to the exacerbation of psoriasis in/h of the head.

Systemic, light, and laser therapy

Steroid Injections

There are no studies on the effectiveness of corticosteroid injections into the scalp for psoriasis. There are separate reports supporting their use in head psoriasis.

Phototherapy and excimer laser treatment

Treatment of the skin with psoriasis in / h of the head with phototherapy or laser is difficult since the hair protects the scalp from ultraviolet radiation. UV combs have been developed for this purpose, and hair dryers can help access the excimer laser (308 nm) rays to the scalp, but there are not enough large controlled trials and treatment can be cumbersome.

Systemic / Biological therapy

Although the traditional systemic agents methotrexate, cyclosporine, and acitretin have been used in patients with moderate to severe scalp psoriasis, there is also insufficient research in this area. Apremilast, an oral phosphodiesterase 4 inhibitor recently approved for the treatment of moderate to severe plaque psoriasis, also improves the scalp condition of psoriasis patients. At week 16, it was effective in 66.7% of patients, and at week 52, it was effective in 73% of patients with psoriasis of the head. Treatment with adalimumab at week 8 was effective in 76.5% of patients with psoriasis of the head, and at week 16, complete cleansing of the head from the rash was observed in 77.6% and treatment was effective in 100% of cases. A 12-week course of etanercept 50 mg twice a week was effective in 86.8% of patients with intravenous psoriasis of the head.

Conclusions

Topical steroids with or without calcipotriol are the mainstay of therapy for scalp psoriasis. Recently, several new forms have emerged, including foams, shampoos, gels, and sprays that improve cosmetic acceptability and usability. In patients with frequent relapses, it is advisable to use these drugs 2 times a week as a maintenance treatment. Systemic treatment should be considered in persistent cases. Studies have shown excellent efficacy of apremilast, adalimumab, and etanercept.

Current Management of Scalp Psoriasis The scalp is involved in up to 80% of individuals with psoriasis. Eighty percent of those with scalp psoriasis experience a negative impact on quality of life. Topical treatment with corticosteroids with or without vitamin D3 analogues is the mainstay of treatment. Topical therapy most suitable for the scalp is formulated as a solution, lotion, gel, foam, spray, oil, or shampoo. Twice weekly maintenance in frequent relapsers may decrease the time to the first relapse. Intralesional steroids, phototherapy, and the excimer laser are occasionally used for resistant cases. In patients with moderate-to-severe psoriasis, apremilast, adalimumab, and etanercept have been shown to significantly improve scalp psoriasis. They should be considered in patients who have failed topical therapy.