Current Management of Scalp Psoriasis
Current Management of Scalp Psoriasis
There are no studies of intralesional corticosteroids in scalp psoriasis, although anecdotal reports support their use for localized disease.
Treatment of scalp psoriasis with phototherapy or laser is difficult since hair shields the scalp from ultraviolet (UV) radiation. UV combs have been developed for scalp use, and blow dryers may help expose the scalp for excimer laser (308 nm) treatment, but large controlled trials are lacking and treatment may be cumbersome.
Although the traditional systemic agents methotrexate, cyclosporine and acitretin have been used in patients with moderate-to-severe psoriasis with scalp involvement, studies in scalp psoriasis are lacking.
Apremilast, an oral phosphodiesterase 4 inhibitor, which has recently received approval for treatment of moderate-to-severe plaque psoriasis, improves scalp psoriasis. In the ESTEEM I phase 3 trial, at week 16 [n=374 on apremilast and n=189 on placebo, who had a baseline Scalp Physician's Global Assessment (ScPGA) score of at least 3; 66.7% of total patients], 46.5% on apremilast achieved an ScPGA of 0 or 1 compared to 17.5% on placebo (p<0.0001). At week 52, ScPGA response was achieved by 73% of apremilast patients.
A subanalysis of the phase 3 adalimumab BELIEVE trial showed that by week 8, 76.5% of patients with scalp psoriasis at baseline had achieved a Psoriasis Scalp Severity Index (PSSI) response (PSSI 4 or less). At week 16, the median and mean decreases in PSSI were 100% and 77.2% respectively. Patients with scalp involvement had a lower Psoriasis Area and Severity Index (PASI) 75 response early in treatment, but differences declined with time and at week 16, PSSI scores correlated with PASI 75.
A double-blind, placebo-controlled study of etanercept in 124 adults with moderate-to-severe psoriasis involving 10% or more body surface area, a PASI score of at least 10, and 30% or more scalp involvement with a PSSI of at least 15, showed 86.8% improvement in PSSI after 12 weeks of etanercept 50 mg twice weekly compared to 20.4% for the placebo arm. From week 12 to 24, the etanercept arm was stepped down to 50 mg once a week, while the placebo arm was treated with etanercept 50 mg twice weekly. At week 24, the mean PSSI improvements were 90.6% for the etanercept/etanercept arm and 79.1% for the placebo/etanercept arm.
Systemic, Light and Laser Therapies
Intralesional Corticosteroids
There are no studies of intralesional corticosteroids in scalp psoriasis, although anecdotal reports support their use for localized disease.
Phototherapy and Excimer Laser Treatment
Treatment of scalp psoriasis with phototherapy or laser is difficult since hair shields the scalp from ultraviolet (UV) radiation. UV combs have been developed for scalp use, and blow dryers may help expose the scalp for excimer laser (308 nm) treatment, but large controlled trials are lacking and treatment may be cumbersome.
Systemic/Biologic Treatment
Although the traditional systemic agents methotrexate, cyclosporine and acitretin have been used in patients with moderate-to-severe psoriasis with scalp involvement, studies in scalp psoriasis are lacking.
Apremilast, an oral phosphodiesterase 4 inhibitor, which has recently received approval for treatment of moderate-to-severe plaque psoriasis, improves scalp psoriasis. In the ESTEEM I phase 3 trial, at week 16 [n=374 on apremilast and n=189 on placebo, who had a baseline Scalp Physician's Global Assessment (ScPGA) score of at least 3; 66.7% of total patients], 46.5% on apremilast achieved an ScPGA of 0 or 1 compared to 17.5% on placebo (p<0.0001). At week 52, ScPGA response was achieved by 73% of apremilast patients.
A subanalysis of the phase 3 adalimumab BELIEVE trial showed that by week 8, 76.5% of patients with scalp psoriasis at baseline had achieved a Psoriasis Scalp Severity Index (PSSI) response (PSSI 4 or less). At week 16, the median and mean decreases in PSSI were 100% and 77.2% respectively. Patients with scalp involvement had a lower Psoriasis Area and Severity Index (PASI) 75 response early in treatment, but differences declined with time and at week 16, PSSI scores correlated with PASI 75.
A double-blind, placebo-controlled study of etanercept in 124 adults with moderate-to-severe psoriasis involving 10% or more body surface area, a PASI score of at least 10, and 30% or more scalp involvement with a PSSI of at least 15, showed 86.8% improvement in PSSI after 12 weeks of etanercept 50 mg twice weekly compared to 20.4% for the placebo arm. From week 12 to 24, the etanercept arm was stepped down to 50 mg once a week, while the placebo arm was treated with etanercept 50 mg twice weekly. At week 24, the mean PSSI improvements were 90.6% for the etanercept/etanercept arm and 79.1% for the placebo/etanercept arm.
