It’s Time to Get Serious About Scalp Psoriasis Treatment
Largely due to adherence issues, topical treatments don’t work for many scalp psoriasis patients.
At least 50 percent of all people with psoriasis have scalp psoriasis that can run the gamut from mild to severe. Although scalp psoriasis affects just two to three percent of the body, it has a major impact on our patients’ quality of life. They will never wear black due to embarrassing flaking, and the itching and scratching disrupts sleep, which increases rates of both absenteeism and presenteeism in multiple settings.
First-line therapy is often topical lotions, foams, gels, solutions, and sprays; many of which are thick, gooey, and difficult to wash out. This creates significant adherence hurdles, even for the most engaged patients. Efficacy of phototherapy to the scalp is hindered by the hyperkeratotic epidermis, which prevents ultraviolet B light from penetrating the dermis and basal layer. Moreover, lack of treatment efficacy initiates a vicious cycle, as head scratching induces koebnerization and further exacerbates the condition.
Principles and Approaches to Topical Treatment of Scalp Psoriais
• OTC options can be effective, if used as needed and applied properly.
– Tar or salicylic acid can help slow skin hyperkeratinization and reduce inflammation, itching, and scaling.
• If using medicated shampoos, patients should be sure to adequately apply to the scalp, and leave in for some time before rinsing out.
• Topical prescription options also depend on proper, frequent use.
– Dovonex Cream (calcipotriene 0.005%, Leo)
– Taclonex Ointment (calcipotriene 0.005% and betamethasone dipropionate 0.064%, Leo)
– Tazorac Cream or Gel (tazarotene 0.1%, Allergan)
– Enstilar Foam (calcipotriene and betamethasone dipropionate, Leo)
• Consider topical steroids in various strengths and formulations.
• Instruct patients to apply medication to the scalp, not just the hair. They should part the hair to reach the scalp skin.
There is often some trial and error involved in reining in the itch and inflammation of scalp psoriasis. Certain over-the-counter (OTC) products and shampoos that contain tar or salicylic acid can help slow skin hyperkeratinization and reduce inflammation, itching, and scaling. If these OTC topical products aren’t effective, a dermatologist may prescribe Dovonex Cream (calcipotriene 0.005%, Leo), Taclonex Ointment (calcipotriene 0.005% and betamethasone dipropionate 0.064%, Leo) , Tazorac Cream or Gel (tazarotene 0.1%, Allergan), or Enstilar Foam (calcipotriene and betamethasone dipropionate, Leo). Topical steroids are also available in various strengths and formulations.
Patients will need detailed instructions on how to apply these topical products, as it is not necessarily intuitive. Patients need to be told topical therapy is not a hair product. I advise my scalp psoriais patients to gently massage the treatment into the scalp by parting the hair and applying to the scalp. This process of parting the hair and applying medication day after day gets old very fast. Removing the product from the scalp and hair is also a challenge. It’s best to advise patients to wet their scalp in the morning and then apply therapeutic shampoo and leave it in for 10 minutes before washing it out.
For the reasons highlighted above, topicals can be effective but sometimes impractical. Therefore, it’s important to start to think about scalp psoriasis as moderate to severe disease, and consider using Otzela (apremilast, Celgene) or biologics to address it properly and improve our patients’ lives.
Watch Dr. Bagel discuss topical management strategies, including cosniderations for scalp psoriasis care.
Many of the currently available systemic treatments have shown tremendous efficacy in scalp psoriasis. In Phase 2b and Phase 3 clinical trials for Otzela, 50 percent of patents were clear or almost clear at 16 weeks, and 73 percent were clear or almost clear at one year.1
Biologics can also play a role in scalp psoriasis treatment. In one study,2 120 scalp psoriasis patients received 50mg of Enbrel (etanercept, Amgen) twice weekly by subcutaneous injection for 12 weeks, followed by Enbrel 50mg once weekly. These subjects showed an 86.8 percent improvement in Psoriasis Scalp Severity Index (PSSI) at week 12, and a 90 percent improvement in PSSI by week 24. The therapy was also well tolerated.
In a 24-week study of Cosentyx (secukinumab, Novartis),3 patients who received 300mg of the IL-17A treatment showed a significant reduction in itch, scaling, and improvements in quality of life, compared with their counterparts who recieved placebo. Fifty three percent of patients were either clear or almost clear at week 12. The FDA just approved a label update for Cosentyx to include moderate to severe scalp psoriasis, a nod that is based, in part, on the results of this study.
Trials of Taltz (ixekizumab, Lilly) also showed significant improvement in scalp psoriasis, with 75 percent of patients clear at week 12.4
If you don’t want to be yet another dermatologist who prescribes topicals for scalp psoriasis, consider a biologic or at the very least Otezla. While these systemic drugs do confer their share of risks as they modulate the immune system, they can dramatically improve scalp psoriasis symptoms and enhance quality of life. The risks are mitigated by smart prescribing and judicious monitoring.
Jerry Bagel, MD is Director of the Psoriasis Treatment Center of Central New Jersey.
1. Nguyen CM, et al. Improvement of Nail and Scalp Psoriasis Using Apremilast in Patients. J Drugs Dermatol. 2016 Mar;15(3):272-6
2. Bagel J, et al. Moderate to severe plaque psoriasis with scalp involvement: a randomized, double-blind, placebo-controlled study of etanercept. J Am Acad Dermatol. 2012 Jul;67(1):86-92. doi: 10.1016/j.jaad.2011.07.034. Epub 2011 Oct 20.
3. Feldman SR, et al. Secukinumab improves scalp pain, itching, scaling and quality of life in patients with moderate-to-severe scalp psoriasis. J Dermatolog Treat. 2017 Dec;28(8):716-721. doi: 10.1080/09546634.2017.1329502. Epub 2017 Aug 3.
4. Reich K, et al. Sustained response with ixekizumab treatment of moderate-to-severe psoriasis with scalp involvement: results from three phase 3 trials (UNCOVER-1, UNCOVER-2, UNCOVER-3). J Dermatolog Treat. 2017 Jun;28(4):282-287. doi: 10.1080/09546634.2016.1249820. Epub 2016 Nov 13.