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Nail and scalp involvement

Table 2: Safety issues for topical therapy in scalp psoriasis Topical corticosteroids

Drug-specific adverse reactions Systemic exposure toxicities Irritation

Allergic reaction Hair growth

Suitable for pregnant women Adapted from Ortonne et al16

Hypothalamic–pituitary–adrenal axis suppression; iatrogenic Cushing’s syndrome; glaucoma

Moderate; erythema, peeling/scaling, stinging/burning, pruritus

Rare Hypertricosis

FDA category C (risk cannot be ruled out)


Frequent; erythema, pruritus, stinging/burning, dry skin

Very rare None

FDA category C

Topical vitamin D analogues

Erythema, telangiectasia, skin atrophy Irritancy, effect on calcium metabolism

was used in the treatment of moderate to severe psoriasis in a total of 1462 patients in order to analyse its effectiveness in different areas of the body surface. The authors concluded that the improvement in any of the regions evaluated (head– neck, upper limbs, trunk and lower extremities) was parallel to the global PASI response in patients treated with infliximab for ten weeks.17

of patients. In a proposed consensus algorithm, it was concluded that potent or very potent corticosteroids (with or without vitamin D derivatives) in a short-contact formulation could be a good option in the maintenance strategy both in an intermittent (as needed) or continuous (on a regular bases, that is, twice weekly in a patient with frequent relapses) use.16 Vitamin D analogs are a safe and effective alternative for the treatment of psoriasis of the scalp despite being potentially less effective than corticosteroid. Topical treatment combining a corticosteroid and a vitamin D analogue (calcipotriol and betamethasone in gel) offers advantages over monotherapy with either of the components because it is more effective and minimises the adverse effects. By contrast, there is some evidence that combined calcipotriol and betamethasone

dipropionate is better tolerated than calcipotriol alone.15

Despite topical therapy

being generally safe and well tolerated, the effectiveness of topical corticosteroids and vitamin D derivatives has to be balanced with a few safety issues (Table 2). There seems to be a lack of evidence to support the use of a tar-based shampoo (with or without a keratolytic, such as salicylic acid) as a first-line current formulary recommendation.3

Systemic therapy

No specific evaluation of conventional systemic therapy regarding SP has been performed.

There are some reports regarding the potential value of biologic therapy on SP (Table 1). Menter et al drafted a subanalysis of three randomised, double-blind studies where infliximab

In a 54-week open study, 711 patients with SP were randomised to either a continuous or an intermittent treatment regimen with etanercept. Psoriasis Scalp Severity Index (PSSI), used to measure the impact of the treatment, improved significantly from a mean baseline score of 2.78 in both regimens, although the improvement was greater in the patients receiving continuous treatment (final follow up PSSI, 0.89) than in those treated intermittently (final follow-up PSSI, 1.28). With a similar strategy, Psoriasis Global Assesment of the scalp showed a decrease of 58% after 12 weeks of treatment equal in both groups – continuous treatment (n=1272) versus intermittent therapy (n=1274) – in an open randomised study in which the efficacy and safety of etanercept was evaluated. However, the efficacy was higher after 24 weeks in the continuous treatment group.

In the BELIEVE study, the scalp was affected in 90% of the patients and the active treatment with adalimumab reduced the PSSI from 17.9 at baseline


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