Management of scalp psoriasis: guidelines for corticosteroid use in combination treatment.Scalp psoriasis is a frequent expression of the common crsam disease psoriasis, and steroid cream for scalp psoriasis and itching are the two major complaints. Topical treatments are the mainstay of the treatment of psoriasis of the scalp, with the vehicle as well as the active ingredient relevant to efficacy, tolerability and compliance. Vehicles can be shampoos, lotions, gels, foams, creams and more greasy ointments. Active ingredients are keratolytics, coal tar liquor carbonis detergensdithranol, corticosteroids and vitamin D3 analogues. Some effect has also been described from topical or steroid cream for scalp psoriasis imidazole derivatives. Topical corticosteroids remain the mainstay in the treatment tren ace veins scalp psoriasis.
Topical treatments for psoriasis of the scalp | Cochrane
See related patient information handout on psoriasis , provided by an AAFP staff patient education writer. Psoriasis is a common dermatosis, affecting from 1 to 3 percent of the population. Until recently, the mainstays of topical therapy have been corticosteroids, tars, anthralins and keratolytics. Recently, however, vitamin D analogs, a new anthralin preparation and topical retinoids have expanded physicians' therapeutic armamentarium. These new topical therapies offer increased hope and convenience to the large patient population with psoriasis.
Psoriasis, one of the most common dermatoses, occurs in 1 to 3 percent of the population. While patients with extensive and severe disease may require potent oral therapy, less severe psoriasis is typically treated with topical medications. This article reviews both the power and the limitations of topical therapies in the treatment of psoriasis.
For many years, the mechanism of disease in psoriasis was believed to be epidermal hyperproliferation, since the disease manifests as thick plaques Figure 1. Laboratory research has shown that patients with psoriasis have a shortened epidermal cell cycle.
Normally, keratinocytes require 28 to 44 days to migrate from the basal cell layer of the epidermis to the stratum corneum. In patients with psoriasis, however, this migration takes only four days.
However, since lymphocytes are found within the psoriatic epidermis and since the disease can be successfully treated with immunosuppressive medications, psoriasis may be a primary immunologic disorder that leads to secondary epidermal hyper-proliferation.
Topical corticosteroids remain one of the most widely used treatment modalities for psoriasis. Corticosteroids have anti-inflammatory, immunosuppressive and antiproliferative properties.
The efficacy of an individual topical corticosteroid is related to its potency Table 1 and its ability to be absorbed into the skin. Absorption can be enhanced by the use of plastic occlusion or by the type of corticosteroid chosen. Topicals with hydrocortisone, dexamethasone, flumethasone, methyprednisolone and prednisolone. Reprinted with permission from Steroids.
National Psoriasis Foundation, In general, mid-potency corticosteroids are used for lesions on the torso Figure 2 and extremities, while low-potency corticosteroids are used for areas with delicate skin, such as that on the face, genitals or flexures.
These delicate areas are at increased risk for cutaneous atrophy, one of the side effects of topical corticosteroids.
High-potency corticosteroids are usually reserved for use on recalcitrant plaques or lesions on the palms of the hands and soles of the feet. Even then, they should only be used for about two weeks. Ointments are the best choice for dry, scaly, hyperkeratotic plaques; however, they feel oily to the touch and are difficult to wash away from hair. Lotions and gels are best suited for the treatment of the scalp; creams can be used on all areas.
One of the drawbacks of corticosteroid therapy is associated tachyphylaxis, leading to decreased efficacy with continued use and sometimes culminating in an acute flare-up when therapy is terminated.
Tachyphylaxis can be minimized by switching patients to less potent corticosteroids and having them apply the medication less frequently once the lesions have improved.
Another strategy is the use of corticosteroid-free periods. Potential local side effects of topical corticosteroid therapy include acne and localized hypertrichosis.
Skin atrophy can also occur and may lead to striae, telangiectasia and purpura. The use of very potent topical corticosteroids or weaker ones under occlusion may lead to suppression of the pituitary-adrenal axis. Corticosteroids may be used in combination with other treatments Table 2. Can be used in combination with calcipotriene Dovonex or tazarotene Tazorac.
Expensive, may be teratogenic; irritating to uninvolved skin. Food and Drug Administration. Medical Economics Data, Cost to the patient will be higher, depending on prescription filling fee. Keratolytic agents assist in removing scale or hyperkeratosis in patients with psoriasis or other dermatoses. A commonly used keratolytic agent is salicylic acid. It is usually prescribed in concentrations between 2 and 10 percent and should not be applied extensively on the body, especially in children, for fear of inducing salicylism e.
Salicylic acid in concentrations of 5 to 10 percent compounded in petrolatum, acid mantle cream or even mid-strength topical corticosteroids can be used twice daily for several weeks at a time on thick keratotic plaques. Stronger concentrations of keratolytics 20 percent salicylic acid can be applied for about two weeks to remove the thick scale to enable other topical therapies to better penetrate the skin. Urea-containing preparations and alphahydroxy acids, such as glycolic and lactic acids, are also effective keratolytic agents.
Anthralin Anthra-Derm derives its origin from the herbal remedy Goa powder, which was used for refractory skin diseases in India and Brazil. Although its mechanism of action is not well defined, anthralin has been demonstrated to inhibit cell growth and restore cell differentiation. It is traditionally applied once daily at night. The initial concentration of 0.
Although anthralin is an effective antipsoriatic agent without systemic side effects, it can stain hair, skin, nails, clothing and bedding a brownish to purplish color. To minimize staining, patients should be advised to apply the medication wearing plastic gloves and to use old sheets and nightclothes. Furthermore, anthralin can be very irritating to normal skin and must be applied only to affected skin. Contact with the face, eyes or mucous membranes must be avoided. Applying petroleum or zinc oxide ointment around the psoriatic lesion may help prevent anthralin from causing perilesional irritation.
Because of its inconvenience and its tendency to irritate unaffected skin, anthralin has for the most part been supplanted by newer agents, although many patients still derive benefit from its use.
Coal tar is produced by heating coal in the absence of air and removing ammonia from the resulting dark residue. Because coal tar contains as many as 10, different chemical compounds, its precise mechanism of action is not clear. However, it appears to have antiproliferative and anti-inflammatory actions, and clinical use has demonstrated its efficacy. Not only is coal tar beneficial when used alone in patients with mild to moderate psoriasis, it is also useful in combination with ultraviolet B radiation and has been successful in cases that were refractory to other treatment modalities.
The use of coal tar, like anthralin, is limited by its inconvenience. In addition to its unpleasant odor, it can also stain clothing and bedding. Crude coal tar is particularly difficult to use. Some of the purified preparations are more acceptable for outpatient use but may not be as effective. Side effects include folliculitis and contact allergy. If contact allergy is suspected, the patient should undergo patch testing to distinguish between an allergic and an irritant response.
If the patient has an irritant response, treatment with coal tar may continue, but with a lower concentration. There has been one report of severe bronchospasm in an atopic patient with asthma after inhalation of coal tar vapor.
Coal tar can be applied at night and should be allowed to dry on the skin for 10 to 15 minutes before the patient gets in bed to minimize staining of bedding and nightclothes and is showered off in the morning.
Alternatively, coal tar can be applied in the morning and showered off after 10 to 15 minutes. A once-daily application of coal tar is often used in conjunction with a topical corticosteroid applied twice daily.
Although tars have generally been supplanted by newer, more convenient medications, tar-containing shampoos are effective in the treatment of psoriasis of the scalp Figure 3.
The rationale for the use of vitamin D derivatives in the treatment of psoriasis is based on the observation that patients with hypocalcemia often develop various forms of psoriasis, most notably the pustular form.
In one case, a patient who had undergone thyroidectomy developed repeated flares of pustular psoriasis after decreases were made in her dosage of ergocalciferol Vitamin D 2 ; each episode was related to severe hypocalcemia and resolved after her serum calcium levels normalized.
Calcipotriene Dovonex , a topical vitamin D analog, has been available in the United States since Short-term clinical trials have demonstrated that it is at least as effective as betamethasone 17 valerate ointment 17 , 18 and superior to short-contact anthralin cream 19 or 15 percent coal tar. Calcipotriene, applied twice daily, is generally well tolerated, although the face and groin areas should be avoided since it may cause irritant dermatitis. To avoid hypercalcemia, calcipotriene use should not exceed g per week.
Calcipotriene is not associated with tachyphylaxis, and it has been shown to result in greater improvement and fewer side effects when combined with the potent corticosteroid halobetosol Ultravate.
Retinoids mediate cell differentiation and proliferation. Systemic retinoids have been used for the treatment of recalcitrant, severe psoriasis. Oral retinoids, such as etretinate Tegison , are associated with several adverse effects, such as teratogenicity, serum lipid and transaminase elevations, mucocutaneous toxicity, skeletal changes and hair loss. Topical retinoids were developed to avoid many of these systemic side effects. In June , the U. Food and Drug Administration labeled tazarotene Tazorac for the treatment of psoriasis involving up to 20 percent of the body surface area.
Applied topically, tazarotene is rapidly metabolized in the skin and converted to to the active metabolite, tazarotenic acid. Clinical studies have demonstrated the efficacy of both 0. Unlike calcipotriene, tazarotene can be used to treat psoriasis of the face. Local skin irritation and pruritis are frequent side effects of tazarotene, and care must be used to ensure that the medicine is applied only to lesional skin.
Since tazarotene may be teratogenic, women of child-bearing age should be warned of the potential fetal risk and should use adequate birth-control measures. A negative pregnancy test should be confirmed within two weeks of initiating treatment with tazarotene; as an additional precaution, therapy can be started during a normal menstrual period.
Already a member or subscriber? Veterans Administration Medical Center. Federman graduated from New York University School of Medicine and completed a residency as chief resident in internal medicine at the University of Miami School of Medicine.
Kirsner received a medical degree from the University of Miami School of Medicine. He trained in internal medicine for two years before completing a residency in dermatology at the University of Miami. Address correspondence to Daniel G. Reprints are not available from the authors. Autoradiographic analysis of turnover times of normal and psoriatic epidermis. Hughes J, Rustin M. Superpotent topical steroid treatment of psoriasis vulgaris—clinical efficacy and adrenal function.