Journal of Dermatological Treatment, 2013; 24: 188–192 © 2013 Informa Healthcare USA on behalf of Informa UK Ltd. ISSN: 0954-6634 print / 1471-1753 online DOI: 10.3109/09546634.2012.681017 REVIEW ARTICLE Long-term management of scalp psoriasis: perspectives from the international psoriasis council Knud Kragballe 1 , Alan Menter 2 , Mark Lebwohl 3 , Paul W. Tebbey 4 , Peter C. M. van de Kerkhof 5 & International Psoriasis Council 6 1 Department of Dermatology, Århus University Hospital, Århus, Denmark, 2 Baylor Institute of Research, Baylor University Medical Center, Dallas, TX, USA, 3 Department of Dermatology, Mount Sinai School of Medicine, New York, NY, USA, 4 International Psoriasis Council, Dallas, TX, USA, 5 Department of Dermatology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands and 6 www.psoriasiscouncil.org The scalp is a well-known predilection site for psoriasis. Epidemiological data on the various manifestations of scalp psoriasis as well as on its therapeutic management are sparse. The understanding of the natural course of scalp psoriasis is relevant for its therapeutic management. In over 25% of patients, scalp psoriasis is the first signal of the psoriatic condition. Nevertheless, few of the therapies currently used for the treatment of scalp psoriasis have been evaluated for efficacy in the setting of well-designed, well-controlled clinical studies. The lack of comparative data impedes the interpretation of the results from studies of scalp psoriasis. Long-term studies of the efficacy and safety of scalp treatments are lacking. Moreover, clinical studies generally do not incorporate quality of life impact or mechanisms to enhance adherence thus hindering the optimal management of the patient over the long-term. Consequently, this report will evaluate the available data and the associated factors to be considered in the development of a treatment paradigm for the long-term management of the scalp psoriasis patient. Key words: quality of life, adherence, topical, systemic The natural course of scalp psoriasis A significant number of psoriasis patients present with scalp involvement ab initio, even in infancy where “cradle cap” may indeed be a marker for the later development of psoriasis. In one clinical and epidemiological observational study of 1220 patients with psoriasis, the scalp was described as the first site of onset in 25% of patients (1). In a review of the clinical locations of psoriasis involvement, 80% of patients had scalp psoriasis (2). Scalp psoriasis, like psoriasis on the trunk and limbs has many phe- notypical variants (3). It is frequently asymmetric due to the inevitable Koebnerization of one localized region due to scratch- ing, picking, scrubbing, harsh shampooing, etc., a clinical man- ifestation seen in a majority of patients (Figure 1A). Disease severity on the scalp can be highly variable ranging from mild scaling and erythema with minimal induration to more inflam- matory crusted plaque-type forms (Figure 1B) and even Tinea amiantacea with severe crusting enveloping the proximal hair shafts (Figure 1C). In addition, the areas adjacent to the scalp (forehead, temples, ears and nape of neck) are also frequently involved either by direct extension from the scalp or indepen- dently (Figure 1D). The dynamics of scalp psoriasis mirror chronic plaque psori- asis at other sites with respect to duration of the disease and exacerbations or remissions. A questionnaire study on scalp psoriasis was performed in the Netherlands and included a total of 1023 patient evaluations (4). A relatively high occurrence of facial psoriasis (25%) and nail psoriasis (40%) was recorded. In 57% of the patients, psoriasis was psychologically and socially distressing, at least occasionally. Itch and scaling proved to be the leading symptoms, in terms of frequency of occurrence as well as in terms of distress. Therefore, these parameters should be regarded as primary efficacy criteria in the treatment of scalp psoriasis. On average, patients were seen by the dermatologist five times a year. The majority of prescriptions (76%) were provided by the dermatologist. The application of topical corticosteroids was the most frequent treatment modality. Tar shampoos were used by 51% of the patients, although the clinical efficacy of such a shampoo has never been demonstrated in a controlled study. A remarkable observation was the lack of instruction on the duration of treatment and the frequency of applications. In fact, 72% of the patients used topical treatments, including topical corticosteroids, for more than 8 weeks, and 42% of the patients used an intermittent schedule of a few applications per week. Long-term efficacy and safety of treatments for scalp psoriasis In general practice, when psoriasis is limited to the scalp, topical therapy is utilized as the treatment of choice. With severe recalcitrant involvement, either localized or involving the total scalp, intralesional steroid injections, phototherapy (including laser devices) and even systemic therapy are utilized, the latter in response to significant impairment of patient’s quality of life. While many therapeutic approaches for scalp psoriasis have been investigated in the past, the level of evidence supporting their efficacy and safety do not meet the standards of modern evidence- based medicine. Further, few of the therapies currently used for the treatment of scalp psoriasis have been evaluated for efficacy in the setting of well-designed, well-controlled clinical studies. The lack of comparative studies makes comparison of the results of Correspondence: Knud Kragballe, Department of Dermatology, Århus University Hospital, Århus Sygehus, P.P. Ørums Gade 11, 8000 Århus C, Denmark. Tel: +45 8949 1855. E-mail: knudkrag@rm.dk (Received 1 March 2012; accepted 6 March 2012)