**4. The difficulty of the treatment**

Head and neck Psoriasis treatment is still a challenge because its difficult to get topical agents through hair to be absorbed by the scalp. In fact, scalp is not susceptible to many topical Psoriasis treatment or phototherapy because hair prevent adequate contact with the affected tissue. Moreover current therapies can only bring some relief to the symptoms without any cure to the disease and treatments can carry important side effects in face of high therapeutic costs.

Medications for scalp Psoriasis include those to be left on the scalp and wash off products. Left on products are gels, lotions and ointments containing steroids, coal tar, salicylic acid or vitamin D analogs.

Wash off products are shampoos containing coal tar, salicylic acid, sulfur, selenium, ketoconazole or zinc pyrithione. Recently, Handa (2010) proposed a treatment algorithm for scalp Psoriasis (see Tab. 1), dividing a first line and a second line therapies.

In 2009 van de Kerkhof & al. divided treatment of scalp Psoriasis into four phases. First phase involves descaling using salicylic acid or urea preparations. The second phase is the

Head and Neck Psoriasis 89

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

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

These are vitamin D 3 derivatives used for chronic, moderately/severe Psoriasis of the scalp. The 0.005% solution is applied to the affected area and rubbed gently onto the scalp twice a day. Response to therapy takes about 8 weeks. It is not recommended in patients with acute psoriatic eruptions on the scalp, those with hypercalcemia or hypervitaminosis D. The main side effects are burning, itching, irritation and dryness. Irritation tends to decrease with time. Clearance has been observed even with 8 weeks of once a day treatment in up to 60%

Anthralin 0.1-3% cream has been used for long-term treatment of scalp Psoriasis. Concentration should be gradually increased according to body response and tolerance of the patient. Anthralin is applied in a thin layer to the psoriatic area once a day, rubbed in well and left on the scalp for 5-10 minutes before washing with a shampoo and rinsing well. It is not used for acutely inflamed scalp Psoriasis. Redness or irritation of the treated scalp is common. Anthralin may temporarily stain the fingernails, gray/white hair, skin and fabrics. Caution is advised in patients having history of allergy to anthralin or to condoms (e.g.,

Coal tar is an effective and cheap treatment modality for scalp Psoriasis but staining and an acrid smell associated with its use may have an important impact on patients QOL. Topical tar solution (liquor picis carbonis-LPC, or liquor carbonis detergens-LCD) is widely available and commonly used for scalp Psoriasis. Newer preparations specifically meant for scalp include coconut oil compound ointment (coal tar solution with precipitated sulfur, salicylic acid, coconut oil, yellow soft paraffin and emulsifying wax) and tar pomades (contain LCD, Tween 20 and salicylic acid in a hydrophilic ointment). Compound ointment should be applied once at night and washed off the next morning with a coal tar shampoo. Coal tar shampoos contain 1-20% coal tar extract. They are used twice a week. A tar blend 1% shampoo Polytar (Steifel, Johannesburg, South Africa) is made of coal tar, juniper tar (cade oil) and pine tar. In a comparative 4-week study of tar blend 1% shampoo (Polytar)

This group includes: Calcipotriene/calcipotriol, Anthralin, Coal Tar, Tazarotene.

other prescriptions they had used before for their scalp Psoriasis.

is safe if a careful treatment schedule is followed.

**4.2 Non steroidal topical preparations** 

**4.2.1 Calcipotriene/calcipotriol** 

of patients.

parabens).

**4.2.3 Coal tar** 

**4.2.2 Anthralin** 

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 D analog alone or with a tar shampoo.


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