Management of scalp psoriasis - Guidelines for corticosteroid use in combination treatment

Scalp psoriasis is a frequent expression of the common skin disease psorias is, and scaling and itching are the two major complaints. Topical treatment s are the mainstay of the treatment of psoriasis of the scalp, with the veh icle as well as the active ingredient relevant to efficacy, tolerability an d compliance. Vehicles can be shampoos, lotions, gels, foams, creams and mo re greasy ointments. Active ingredients are keratolytics, coal tar (liquor carbonis detergens), dithranol, corticosteroids and vitamin D-3 analogues. Some effect has also been described from topical or systemic imidazole deri vatives. Topical corticosteroids remain the mainstay in the treatment of scalp psori asis. The effects are rapid, the formulations are patient friendly and the adverse effects seem limited, although no data are available to support saf ety during prolonged use (more than 4 weeks). Topical vitamin D-3 analogues have been available for the treatment of psor iasis since 1992. In the lotion formulation in particular, vitamin D-3 anal ogues are a patient friendly, tolerable and effective alternative to cortic o steroids, although the effects are optimal after 8 weeks, in contrast to 2-3 weeks for topical corticosteroids. Facial irritation (often temporary) can also be a disadvantage of vitamin D-3 analogues, although only a small proportion of patients stop treatment for this reason. All other treatment options for psoriasis, such as tazarotene, phototherapy and systemic treatment with methotrexate, acitretin and cyclosporin are of ten not indicated or not suitable for treatment of the scalp. In daily practice, to make a choice from the available therapeutic arsenal for psoriasis, each patient should be examined individually. Deteriorating factors have to be excluded. For scaling, keratolysis is the first step. Su bsequently, active treatment can be chosen depending on the clinical pictur e. When the psoriatic lesions are mainly characterised by inflammation, ant i-inflammatory drugs such as topical corticosteroids are indicated. When sc aling is the more important clinical feature, vitamin D-3 analogues are ind icated. Generally, intermittently used topical corticosteroids alternating with vit amin D-3 derivatives either combined or not with liquor carbonis detergens containing shampoo is the most suitable treatment for most patients. Becaus e psoriasis capitis is a chronic disease, long term treatment should, in ad dition to medical advice, also provide patient support and motivation.