Am J Clin Dermatol 2001; 2 (3): 159-165

REVIEW ARTICLE 1175-0561/01/0003-0159/$22.00/0

© Adis International Limited. All rights reserved.

Psoriasis of the Scalp

Diagnosis and Management
Peter C.M. van de Kerkhof and Manon E. J. Franssen
Department of Dermatology, University Hospital Nijmegen, Nijmegen, The Netherlands

Contents
Abstract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159
1. Psoriasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160
2. Psoriasis of the Scalp . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160
2.1 Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160
2.2 Clinical Appearance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160
2.3 Differential Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160
3. Treatments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161
3.1 Shampoos . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161
3.2 Topical Treatments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161
3.2.1 Salicylic Acid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161
3.2.2 Coal Tar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161
3.2.3 Dithranol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162
3.2.4 Imidazole Antifungals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162
3.2.5 Corticosteroids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162
3.2.6 Vitamin D3 Analogues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163
3.3 Systemic Treatments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163
3.4 Treatment in Pregnancy and Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164
4. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164

Abstract Psoriasis of the scalp is a frequently occurring condition affecting approximately 2% of the Western popu-
lation. The sharply demarcated erythematosquamous lesions with silver-white scaling characterize scalp psori-
asis. Quality of life can be seriously reduced by this condition and therefore long term treatment is needed in
most patients.
Coal tar shampoos, containing 2 to 10% coal tar solution, are effective in scalp psoriasis. However, no
double-blind studies are available to support such an assumption. Salicylic acid 5 to 10% has a pronounced
keratolytic effect. Salicylic acid should be formulated in an ointment, which can be washed off easily. Crude
coal tar is the most effective tar available for the treatment of psoriasis. An important feature of coal tar is its
potent efficacy against pruritus. At the scalp, the application of crude coal tar is difficult. Therefore coal tar
solution is the most frequently applied tar preparation in scalp psoriasis.
Dithranol 0.1 to 3% is manufactured in various formulations. Treatment is initiated at a low concentration
and the concentration is increased stepwise until a slight irritation, the feeling of warmth, is reached. In the
treatment of scalp psoriasis, cream formulations are used. Imidazole antifungals have been used with success
in scalp psoriasis. Overgrowth of the scalp with pityrosporon is a well-known feature of scalp psoriasis and
seborrheic dermatitis. In case of resistance to other topical treatments use of a topical or systemic imidazole
derivative might be helpful.
So far, topical corticosteroids are the most frequently used treatments for psoriasis of the scalp. Corticoste-
roids inhibit epidermal proliferation, inhibit inflammation and modulate immune functions. Topical corticoste-
roids are fast acting: within 3 to 4 weeks maximal efficacy is reached. No data are available to support the
efficacy and safety of topical corticosteroids during long term use. However, from epidemiologic surveys we
know that these treatments are used by the majority of patients for more than 8 weeks. Since 1992 vitamin D3
formulations have been developed for the treatment of psoriasis. Calcipotriol is available in most countries.
160
Tacalcitol is available in Japan and several other countries. Vitamin D3 analogues inhibit epidermal proliferation,
enhance cornification and inhibit inflammation. Therefore, vitamin D3 analogues have a substantial antipsoriatic
effect. Systemic treatments such as methotrexate, cyclosporine and acitretin are indicated in patients with
recalcitrant disease.
Management of scalp psoriasis requires long term strategies in order to reach an optimal improvement of the
condition, while avoiding the adverse effects associated with the long term use of treatments.
1. Psoriasis
Psoriasis is a frequent skin disorder, affecting approximately
2% of the Western population. Psoriasis is a polygenic disorder
and several triggering factors may elicit or aggravate the condi-
tion in genetically predisposed individuals. Triggering factors are:
injury of the skin; some medications such as β-blocking agents,
antimalaria drugs, lithium carbonate, psychologic stress; and fo-
cal infections such as pharyngitis, tonsillitis, sinusitis, infections
of the urogenital tract or cholecystitis.
The skin lesions are characterized by sharply demarcated
erythematosquamous plaques and marked pustule formation in
case the inflammatory component dominates. Nail lesions are
characterized by multiple nail pits, subungual keratoses, and dis-
tal onycholysis. In approximately 5% of the patients arthritis is
observed which may mimic the changes as observed in rheuma-
toid arthritis.
The histopathologic picture is characterized by acanthosis
with elongated rete ridges, parakeratosis and a mixed inflamma-
tory infiltrate around tortuous and elongated capillaries. Penetra-
tion of lymphocytes and polymorphonuclear leucocytes into the
epidermis is a characteristic feature. For a detailed account on
clinical and immunologic aspects of psoriasis the reader is re-
ferred to some reviews.[1-3]
2. Psoriasis of the Scalp
2.1 Epidemiology
Recently, an epidemiologic survey was carried out in The
Netherlands involving patients with psoriasis in order to assess
the frequency of various manifestations of the disease and actual
use of treatments by the patients themselves.[4] A questionnaire
on scalp psoriasis was mailed to all 6000 subscribers to the journal
Psoriasis, a layman’s journal of the Dutch Psoriasis Association
intended for patients. In total 1023 patients returned the question-
naire, despite not being offered any financial compensation. From
an earlier survey we were already informed that 79% of all pa-
tients with psoriasis have involvement of the scalp, indicating that
the scalp is the most frequently affected area.[5] From another
study it appeared that scalp psoriasis represents an important psy-
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van de Kerkhof & Franssen
chosocial handicap. In fact 31% of patients with scalp psoriasis
indicated distress.[6]
From the questionnaire we found that in 2.3% of the patients
with scalp psoriasis who returned the questionnaire psoriasis had
expanded onto the face.[4] Indeed, in 57% of the patients it was
indicated that psoriasis represents an important psychosocial
handicap. The most annoying symptoms were visibility of lesions
(34% of the patients) and itch (26% of the patients). In 81% of
the patients it was indicated that scalp psoriasis had existed al-
ready for more than 5 years. In 48% of the patients psoriasis
affected more than half of the scalp area.
2.2 Clinical Appearance
The sharply demarcated erythematosquamous lesions with
silver-white scaling characterize scalp psoriasis. Another impor-
tant feature is that lesions often advance beyond the hairborder
onto the face or retro-auricular area (figure 1).
Several textbooks indicate that psoriasis of the scalp is not
associated with hairloss.[7] However, it is the experience of the
author that hairloss at psoriatic lesions of the scalp is rather fre-
quent. Trichograms of plucks of hair taken from psoriatic lesions
indicate a telogen effluvium.[8] Several authors have described
scarring alopecia caused by psoriasis.[9,10] Long lasting psoriatic
plaques may cause a scarring alopecia.
In summary, scalp psoriasis is a frequently occurring condi-
tion that causes impairment of quality of life and may cause per-
manent hairloss. Therefore, a precise diagnosis and effective
treatment are of major practical importance.
2.3 Differential Diagnosis
Scaling of the scalp is a frequently experienced discomfort.
Slight scaling of the scalp as dandruff is often difficult to diagnose
as a specific condition, and it is just designated as dandruff.
Often inspection of the entire bodysurface may help further.
Classical psoriatic lesions elsewhere are helpful in the diagnosis
psoriasis. In lupus erythematodes and lichen planus the typical
lesions on sunexposed areas are indicative for these diagnoses.
Several skin disorders may resemble psoriasis in various re-
spects. Seborrheic dermatitis is characterized by erythemato-
squamous lesions preferentially localized on the scalp, on the face
Am J Clin Dermatol 2001; 2 (3)
 Psoriasis of the Scalp
Fig. 1. Scalp psoriasis with involvement of the retro-auricular area.
and upper trunk. The lesions in seborrheic dermatitis have a yel-
lowish colour. Often the differentiation between psoriasis and
seborrhoeic dermatitis is difficult. In these cases histopathologic
investigations do not provide a clear distinction either. Some cli-
nicians designate this condition as ‘seborrhiasis’, a condition
which has features of psoriasis and seborrhoeic dermatitis. In
fungal infections of the scalp hairs often are broken, pustulation
may occur and alopecia may be more prominent. Lichen planus
of the scalp is characterized by violaceous papules, which may
have a more or less follicular arrangement, eventually resulting
in alopecia cicatricialis. In lupus erythematodes atrophy and fol-
licular hyperkeratoses characterize the lesions.
3. Treatments
In a questionnaire given to patients with psoriasis in The
Netherlands the treatments for scalp psoriasis were investi-
gated.[4] This questionnaire revealed that 76% of the prescriptions
for psoriasis capitis were written by a dermatologist. By far the
most frequently prescribed topical treatment was a topical corti-
costeroid (99.6% of the responding patients). Although calci-
potriol was available only as an ointment at the time of the ques-
tionnaire, it was used by 28% of the patients. A tar shampoo was
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161
used by 51% of the patients. Table I provides a summary of actual
use of various treatments of psoriasis from this questionnaire. The
questionnaire revealed that clear instructions with respect to du-
ration and frequency of treatments often had not been given. In
63% of the cases the length of treatment was left up to the patients
and in 35% of the patients the frequency of applications was left
to them.[4] It also revealed that patients tend to use treatments for
prolonged periods of time; 72% of them used topical treatments
for scalp psoriasis for more than 8 weeks. Intermittent treatment
(a few applications per week) was given in 42% of the patients.
The profile of the ideal treatment for scalp psoriasis as indicated
by the patients was: effective following a few applications per
week, emulsion or cream as formulation and safe during long
term treatment.
Regional differences might exist with respect to the prefer-
ence for various treatments. More recently calcipotriol became
available as a lotion, which has increased the use of calcipotriol
in scalp psoriasis substantially.
3.1 Shampoos
Several reports indicate that coal tar shampoos, containing 2
to 10% coal tar solution, are effective in scalp psoriasis.[11,12]
However, no double-blind studies are available to support such
an assumption. It is the impression of the authors that patients,
nevertheless, appreciate the use of tar shampoos. Yet, some res-
ervation is justified, as the secretion of 10-hydroxy pyrene in
urine is increased in patients using tar shampoo, indicating re-
sorption of hydrocarbons through the skin.[13]
Zinc pyrithion shampoo in concentrations between 1 to 2%
has been reported to be effective in the treatment of scalp psori-
asis.[13-15] Although efficacy has not been substantiated by con-
trolled studies, it is the impression of the authors that these sham-
poos are well appreciated by patients.
3.2 Topical Treatments
3.2.1 Salicylic Acid
If scaling is a dominating feature, descaling makes sense.
Salicylic acid 5 to 10% has a pronounced keratolytic effect. Sal-
icylic acid should be formulated in an ointment, which can be
washed off easily. Patients should apply the formulations a few
times during 2 to 3 days and wash off the hair after such an
application period.
3.2.2 Coal Tar
At this moment we do not know more about the actual anti-
psoriatic mode of action of coal tar than we did a century ago.
Coal tar inhibits epidermal proliferation and has various anti-
Am J Clin Dermatol 2001; 2 (3)
162 van de Kerkhof & Franssen

Table I. Actual frequency of use of various treatments in scalp psoriasis (n warmth, is reached. In the treatment of scalp psoriasis, cream
= 922 patients)[4] formulations are used. Patients should be warned that there may
Treatment No. of patients be temporary discoloration of the hair. Dithranol treatment of
Corticosteroids scalp psoriasis is indicated in patients with resistant disease.
Hydrocortisone cream 13 Treatment should be given at specialized day-care centres or in-
Clobetasone cream 14 patient departments.
Hydrocortisone butyrate cream 32
Hydrocortisone butyrate lotion 16
Hydrocortisone butyrate emulsion 18 3.2.4 Imidazole Antifungals
Triamcinolone cream 28 Imidazole antifungals have been used with success in scalp
Betamethasone valerate cream 65 psoriasis. Overgrowth of the scalp with pityrosporon is a well-
Betamethasone valerate emulsion 19 known feature of scalp psoriasis and seborrhoeic dermatitis. In
Betamethasone valerate lotion 125 case of resistance to other topical treatments use of a topical or
Clobetasol cream 106 systemic imidazole derivative might be helpful.[22] The outcome
Clobetasol lotion 101
of clinical trials on the efficacy of imidazoles in psoriasis are
Betamethasone diproprionate hydrogel 26
contradictory. Some studies indicate positive results[23-25] but
Betamethasone diproprionate cream 37
Betamethasone diproprionate lotion 72
other studies indicate that such a treatment might not be effec-
Desoximethasone emulsion 292 tive.[25] Recently, a substantial efficacy has been demonstrated
for the combination of urea 40% and bifonazole 1%.[26]
Other treatments
Calcipotriol ointment 258
Coal tar shampoo 474 3.2.5 Corticosteroids
UVB phototherapy 119 So far, topical corticosteroids are the most frequently used
Salicylic acid 65 treatments for psoriasis of the scalp. Corticosteroids inhibit epi-
Other/unknowna 161
dermal proliferation, inhibit inflammation and modulate immune
a Other/unknown implies a series of alternative treatment approaches.
functions.[27,28] The efficacy of topical corticosteroids is fast:
UVB = ultraviolet B.
within 3 to 4 weeks maximal efficacy is reached. No data are
available to support the efficacy and safety of topical corticoste-
roids during long term use. However, from epidemiologic sur-
inflammatory actions.[16] Crude coal tar is the most effective tar veys[4] we know that these treatments are used by the majority of
available for the treatment of psoriasis. An important feature of patients for more than 8 weeks. In clinical experiments, it has
coal tar is its potent efficacy against pruritus. At the scalp, the been recorded that topical corticosteroids may suppress hair-
application of crude coal tar is difficult. Therefore coal tar solu- growth on the lower arms.[29] It is of importance to realise that
tion is the most frequently applied tar preparation in scalp psori- the skin of the scalp is by far more permeable to topical cortico-
asis. Coal tar solution (5 to 20%) can be formulated in a lotion or steroids than most other regions of the skin.[30]
added to a corticosteroid preparation. Coal tar is particularly in- In particular, the formulation is relevant for treatment of the
dicated in patients with itchy psoriasis. The patients should be scalp. In general a cream or a lotion is preferred above an oint-
informed about the unpleasant smell. In view of the mutagenic ment. In general, bioavailability from a cream is lower than that
potential of tar,[17] in our view, this approach is contra-indicated obtained with an ointment and availability from a lotion is lower
in pregnant or lactating women. However, guidelines on the use than that with a cream. The usual application schedule consists
of tar products may differ between countries. of intermittent applications 3 to 4 times per week. Recently a
foam formulation has become available which appears at least as
3.2.3 Dithranol effective as lotion formulations.[31,32]
Dithranol has been used for more than 8 decades in the treat- In order to enhance the efficacy of topical corticosteroids the
ment of psoriasis.[18,19] Dithranol induces a large series of free following additions are relevant:
radicals.[20] By inducing such a cascade of free radicals, dithranol • salicylic acid 5 to 15% in a corticosteroid enhances penetration
inhibits relevant aspects in the pathogenesis of psoriasis.[21] of the corticosteroid and helps descaling
Dithranol 0.1 to 3% is manufactured in various formulations. • coal tar solution may be added to a corticosteroid formulation
Treatment is initiated at a low concentration and the concentra- when itch is present. Coal tar reduces itch in psoriasis virtually
tion is increased stepwise until a slight irritation, the feeling of instantaneously

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Psoriasis of the Scalp
• plastic occlusion (for example using a shower-cap) may be
very helpful in enhancing the efficacy of a topical corticoste-
roid. However, penetration may be enhanced considerably by
such an approach.
If a fast therapeutic response is required a topical corticoste-
roid is indicated. Several additions may enhance the therapeutic
value of corticosteroids.
3.2.6 Vitamin D3 Analogues
Since 1992 vitamin D3 formulations have been developed for
the treatment of psoriasis. Calcipotriol is available in most coun-
tries. Tacalcitol is available in Japan and several other countries.
Vitamin D3 analogues inhibit epidermal proliferation, enhance
cornification and inhibit inflammation.[33] Therefore, vitamin D3
analogues have a substantial antipsoriatic effect. On the other
hand these analogues may increase serum calcium levels with the
risk of extra-ossal calcifications. In this respect, the advantage of
calcipotriol is relevant as this analogue has a 100 to 200-fold
reduced effect on systemic calcium metabolism, whereas the ef-
fects on epidermal proliferation, cornification and inflammation
are similar to calcitriol, the natural vitamin D3.[34] Therefore, the
risk of hypercalcemia is lower for calcipotriol than other available
vitamin D3 analogues. Up to a maximum of 100g of a calcipotriol
50 µg/g can be applied per week. The safety of calcipotriol has
been demonstrated in long term safety studies of up to 12 months’
duration.[35]
Calcipotriol is a first choice treatment in patients with
chronic plaque psoriasis. This has been accepted by primary care
in The Netherlands.[36] A satisfactory result has been seen by 80%
of the patients treated with this agent who participated in various
trials.[37,38] Further, it has been demonstrated that no tachyphy-
laxis occurs during long term treatment up to 12 months.[35] Com-
parative studies between calcipotriol and betamethasone-17-val-
erate, tar or outpatient treatment with dithranol revealed that
calcipotriol is at least as effective as these treatments.[38] Up to
25% of the patients may experience a more or less severe irritation
of the skin at application sites. In 5% of the patients adverse
effects were reason for discontinuation of the applications.[35]
Combination treatment with a topical corticosteroid may reduce
this irritation substantially.[38]
Calcipotriol can be combined with virtually all antipsoriatic
treatments. A particularly successful combination is combined
treatment of calcipotriol and a corticosteroid. Such a combination
is more effective than corticosteroid or calcipotriol monother-
apy.[38] The atrophogenic effect of corticosteroids is antagonized
by calcipotriol and the irritative effect of calcipotriol is inhibited
by topical corticosteroids.
Recently, a calcipotriol lotion formulation has become avail-
able for the treatment of scalp psoriasis. In a double-blind com-
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163
parative study treatment with calcipotriol lotion for 4 weeks was
effective; however it was less effective than betamethasone lo-
tion.[39] In 73 to 75% of the patients treated with betamethasone
a marked improvement or clearing was observed and in 57 to 58%
of the patients treated with calcipotriol a similar improvement
was reached. The majority of patients in this trial were treated for
another 6 weeks with calcipotriol lotion. At the end of this ex-
tended treatment period, 82.6% experienced marked improve-
ment or clearing. It should be noted that maximum efficacy of
calcipotriol lotion is reached after 8 weeks, whereas maximal
efficacy of a topical corticosteroid is reached after 2 to 3 weeks
treatment.
Calcipotriol lotion in combination with a topical corticoste-
roid formulation after descaling is the most optimal therapeutic
approach for scalp psoriasis.
3.3 Systemic Treatments
In general scalp psoriasis is managed by a topical treatment.
Systemic treatments are indicated in patients with recalcitrant
disease.
Methotrexate is a time honoured treatment for psoriasis. For
a review the readers are referred to the literature.[40,41] Methotrex-
ate is effective in scalp psoriasis. Methotrexate has both anti-
proliferative and anti-inflammatory actions. The optimal thera-
peutic effect is usually reached after 2 to 3 months. Methotrexate
treatment requires intensified follow-up of the patients. Well
known adverse effects are hematopoietic suppression, liver im-
pairment, and gastrointestinal discomfort. In some patients tran-
sient hairloss may be observed.
Cyclosporine is an immunosuppressive drug. The treatment
periods for cyclosporine should be restricted to a few months as
kidney impairment is a serious long term hazard which can not
be excluded with certainty by measuring kidney function.[42]
Acitretin is an effective treatment in pustular and erythro-
dermic psoriasis.[43] In chronic plaque psoriasis a combined ap-
proach of acitretin with photo(chemo)therapy is indicated. A lim-
itation of acitretin in the treatment of scalp psoriasis is that
acitretin may cause a temporary hairloss.
For obvious reasons the therapeutic effect of photo-
(chemo)therapy is self-limiting as hair will shield the scalp from
ultraviolet radiation. The PUVA (psoralen plus ultraviolet A)
comb has been designed to expose the interfollicular skin more
efficiently. However, the efficacy of this approach remains lim-
ited.
Am J Clin Dermatol 2001; 2 (3)
164 van de Kerkhof & Franssen

3.4 Treatment in Pregnancy and Children 11. Olansky S. Whole coal tar shampoo: a therapeutic hair repair system. Cutis 1980;
25: 99-104
In pregnant women and in children, the use of systemic treat- 12. Lowe NJ, Breeding JH, Wortzmann MS. New coal tar extract and coal tar sham-
ments is contraindicated. poos. Arch Dermatol 1982; 118: 487-9
13. Jongeneelen FJ, Bos RP, Azion RBM. Biological monitoring of polycyclic aro-
In children, salicylic acid applications are possible but
matic hydrocarbons. Metabolites in urine. Scand J Work Environ Health 1986;
should be restricted to a concentration of 5%. During pregnancy 12: 137-43
the use of coal tar is contraindicated especially in the first trimes- 14. Snijder FH, Buehler EV, Winek CL. Safety evaluation of zinc-2-pyridine-thiol
ter of pregnancy. Although guidelines may differ between coun- 1-ozide in a shampoo formulation. Toxicol Appl Pharmacol 1965; 7: 425-37
15. Orentreich N. a clinical evaluation of two shampoos in the treatment of seborrhoic
tries, coal tar application during pregnancy is not advisable in
dermatitis. J Soc Cosmet Chem 1972; 23: 189-94
view of the mutagenic potential of coal tar. 16. Arnold WP. Tar. In: Kerkhof PCM van de, editor. The management of psoriasis:
Clin Dermatol 1997; 15: 739-44
17. Wheeler LA, Soperstein MD, Lowe NJ, et al. Mutagenicity of urine from psoralen
4. Conclusion
patients undergoing treatment with coal tar and ultrviolet light. J Invest
The scalp is frequently affected in patients with psoriasis. Dermatol 1981; 77: 180-5
The impact of scalp psoriasis is considerable. Therefore, effective 18. Galewsky E. Ueber Cignolin, ein Ersatzpräparat des Chrysarobins. Dermatol
Wschr 1916; 62: 113-5
treatments are needed. 19. Ashton E, Andre P, Lowe NJ. Anthralin: historical and current perspectives. J Am
The evidence that shampoos containing coal tar or zinc Acad Dermatol 1983; 9: 173-92
pyrithion are effective is poor. However, in our experience, pa- 20. Fuchs J, Packer L. Investigations of anthralin free radicals in model systems and
tients experience benefit from these shampoos and such care con- in skin of hairless mice. J Invest Dermatol 1989; 92: 677-82
21. Mahrle G, Bonnekoh B, Wevers A. Anthralin: how does it act and are there more
tributes to the treatment of scalp psoriasis. favourable derivatives? Acta Derm Venereol Suppl (Stockh) 1994; 186: 83-4
In case of marked scaling, applications of salicylic acid 5 to 22. Farr PM, Krause LB, Marks JM, et al. Response of scalp psoriasis to oral keto-
10% are indicated. First line treatment is calcipotriol in a cream conazole. Lancet 1985; 8461 (II): 921-2
or lotion in combination with a topical corticosteroid. In case of 23. Faergemann J. treatment of sebopsoriasis with itraconazole. Mykosen 1985; 28:
612-8
itch, coal tar formulations are indicated.
24. Rosenberg EW, Belew PW, Skinner RB. Treatment of psoriasis with antimicrobial
Dithranol cream may cause discoloration of the hair and may agents. Semin Dermatol 1985; 4: 307-11
induce considerable irritation. Therefore, this treatment is re- 25. Jury CS, Hugh McL, Shankland GS, et al. A randomized, placebo-controlled trial
stricted to patients whose condition does not respond to first line of oral itraconazole in scalp psoriasis. J Dermat Treat 2000; 11: 85-9
26. Shemer A, Nathansohn N, Kaplan B, et al. Treatment of scalp seborrhoic derma-
treatments. Systemic treatments such as methotrexate or
titis and psoriasis with an ointment of 40% urea and 1% bifonazole. Int J
cyclosporine are indicated in severe recalcitrant cases of scalp Dermatol 2000; 39: 521-38
psoriasis. 27. Maibach H, Stoughton R. Topical corticosteroids. Med Clin North Am 1973; 57:
The selection of the treatment for scalp psoriasis is deter- 1253-64
mined by the severity of the disease. 28. Engel DJC, Marx AF, Rekker RF, et al. Topically active corticosteroids. Arch
Dermatol 1974; 109: 863-5
29. Robertson D, Maibach H. Topical corticosteroids. Semin Dermatol 1983; 2: 238-49
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Correspondence and offprints: Dr Peter van de Kerkhof, Department of Der-
matology, University Hospital Nijmegen, PO Box 9101, 6500 HB Nijmegen,
The Netherlands.
E-mail: P.vandeKerkhof@derma.azn.nl

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