If the scalp is involved as part of severe psoriasis deemed too extensive to be treated practically with topical medications, then medications delivered orally or by injection may be necessary. All these medications comprise more risk when compared to topical medication. They include oral drugs like methotrexate ( Rheumatrex , Trexall ), cyclosporine ( Sandimmune ), acitretin ( Soriatane ), apremilast ( Otezla ), and some of the so-called biological drugs that are administered by infusion into a vein ( infliximab [ Remicade ]) or by injection into the deeper layers of the skin like etanercept ( Enbrel ), adalimumab ( Humira ), ustekinumab ( Stelara ), secukinumab (Cosentyx), and ixekizumab (Taltz). Regular laboratory work may be necessary to monitor for the toxicities associated with some of these systemic therapies.
Different formulations have been developed in an effort to enhance the delivery of topical corticosteroids. Betamethasone valerate in a foam had superior efficacy for scalp psoriasis and was preferred by patients when compared with betamethasone valerate lotion [ 20 ]. The foam becomes a liquid on contact with skin and is also well tolerated by patients with trunk and extremity psoriasis [ 21 ]. A clobetasol propionate spray is also available; like foams, sprays are easy to apply to large areas [ 22 ]. The main advantage of these newer preparations is likely greater patient acceptance, which may translate into greater adherence; the main disadvantage is cost.