**4.1 Corticosteroids**

Topical corticosteroids are the recommended first-line therapy for short-term use. Response to treatment is quick but high potential for side effects, such as atrophy, striae, telangiectasias and tachyphylaxis, limits the period of use. These side effects are virtually never seen in the scalp. Use of potent steroids (twice a day) should be limited to 4 weeks. The choice of preparation such as ointment, cream, gel, lotion, foam, spray or shampoo should be patient oriented.

In any single patient the lowest strength preparation that allows clinical clearing should be used for the shortest time, in order to minimize side effects and tachyphylaxis. Nevertheless, long-term use of mid-potency preparations or intermittent use of potent steroids is more commonly practiced by physicians. Clobetasol propionate (CP) 0.05% and betamethasone dipropionate 0.05% are the most potent topical corticosteroid preparations currently used. Exceptionally intralesional corticosteroids can be used for one or two localized patches not responding to topical steroids. Foam vehicles are the new alternatives to traditional topical preparations because of the advantage of minimal residue and increased ease of application. They are absorbed more rapidly, have a higher bioavailability, are not associated with suppression of the hypothalamic pituitary adrenal (HPA) axis and once-daily administration has been seen to be as effective as twice daily administration. They are also associated with better patient compliance. CP foam 0.05% is generally as effective as CP solution for scalp Psoriasis and may produce superior results against scaling. Dose is limited to 50 g/week. Mid-potency corticosteroid betamethasone valerate (BMV) has also become available in a new thermolabile, low-residue foam vehicle, BMV 0.12% foam. In a recent study BMV foam produced greater improvement in the primary signs of scalp Psoriasis than BMV lotion, placebo or other standard topical therapies (Stein, 2005). Shampoo preparations

clearing phase in which topical corticosteroids, vitamin D analogs, tar, dithranol, antifungal treatment, ultraviolet B light therapy or systemic treatment are used. The third phase is stabilization using a steroid-sparing vitamin D analog during the week and a super potent topical corticosteroid at weekends. Finally, the fourth phase is maintenance, using a vitamin

**First line therapies** 

**Second line therapies (for recalcitrant or severe disease)** 

Topical corticosteroids are the recommended first-line therapy for short-term use. Response to treatment is quick but high potential for side effects, such as atrophy, striae, telangiectasias and tachyphylaxis, limits the period of use. These side effects are virtually never seen in the scalp. Use of potent steroids (twice a day) should be limited to 4 weeks. The choice of preparation such as ointment, cream, gel, lotion, foam, spray or shampoo

In any single patient the lowest strength preparation that allows clinical clearing should be used for the shortest time, in order to minimize side effects and tachyphylaxis. Nevertheless, long-term use of mid-potency preparations or intermittent use of potent steroids is more commonly practiced by physicians. Clobetasol propionate (CP) 0.05% and betamethasone dipropionate 0.05% are the most potent topical corticosteroid preparations currently used. Exceptionally intralesional corticosteroids can be used for one or two localized patches not responding to topical steroids. Foam vehicles are the new alternatives to traditional topical preparations because of the advantage of minimal residue and increased ease of application. They are absorbed more rapidly, have a higher bioavailability, are not associated with suppression of the hypothalamic pituitary adrenal (HPA) axis and once-daily administration has been seen to be as effective as twice daily administration. They are also associated with better patient compliance. CP foam 0.05% is generally as effective as CP solution for scalp Psoriasis and may produce superior results against scaling. Dose is limited to 50 g/week. Mid-potency corticosteroid betamethasone valerate (BMV) has also become available in a new thermolabile, low-residue foam vehicle, BMV 0.12% foam. In a recent study BMV foam produced greater improvement in the primary signs of scalp Psoriasis than BMV lotion, placebo or other standard topical therapies (Stein, 2005). Shampoo preparations

Systemic drugs (Methotrexate, Acitretin, Cyclosporine)

Table 1. Treatment algorithm for scalp Psoriasis (from Hanna S., 2010)

D analog alone or with a tar shampoo.

Topical corticosteroids (short term use)

Salicylic acid/Urea

Dithranol/Anthralin

Combination therapies

Coal tar (Shampoo/pomade)

Calcipotriol

Tazarotene

Phototherapy

Biologics

**4.1 Corticosteroids** 

should be patient oriented.

are another new development. When clobetasol shampoo 0.05% was tried in a patient experience program, 50% of the patients said that the shampoo was easy to use and did not interfere with their daily routine. Almost 90% of patients found the shampoo better than other prescriptions they had used before for their scalp Psoriasis.

Medication used to treat facial Psoriasis should be applied carefully and sparingly; creams and ointments can irritate eyes. Because facial skin is delicate, prolonged use of steroids may cause it to become thin, shiny and/or prone to enlarged capillaries. Treatment with steroids is safe if a careful treatment schedule is followed.
