Dermatology: Practical and Conceptual Review | Dermatol Pract Concept. 2025;15(2):4793 1 Biologic and Non-Biologic Therapies for Scalp Psoriasis: A Network Meta-analysis of Randomized Controlled Trials Hargun Kaur1*, Tara Behroozian1*, Rafael Paolo Lansang1, Saverio Caini2, Chiara Doccioli3, Mohannad Abu-Hilal4 1 Michael G. DeGroote School of Medicine, Hamilton, Ontario, Canada 2 Cancer Risk Factors and Lifestyle Epidemiology Unit, Institute for Cancer Research, Prevention, and Clinical Network (ISPRO), Florence, Italy 3 Clinical Epidemiology Unit, Institute for Cancer Research, Prevention, and Clinical Network (ISPRO), Florence, Italy 4 Division of Dermatology, McMaster University, Hamilton, Ontario, Canada *Authors have contributed equally to this work. Key words: scalp psoriasis, treatment outcome, biologic agents, antipsoriatic agents, network meta-analysis, randomized controlled trials, comparative efficacy, systematic review Citation: Kaur J, Behroozian T, Lansang RP, Caini S, Doccioli C, Abu-Hilal M. Biologic and Non-Biologic Therapies for Scalp Psoriasis: A Network Meta-analysis of Randomized Controlled Trials. Dermatol Pract Concept. 2025;15(2):4793. DOI: https://DOI.org/10.5826 /dpc.1502a4793 Accepted: February 5, 2025; Published: April 2025 Copyright: ©2025 Kaur et al. This is an open-access article distributed under the terms of the Creative Commons Attribution- NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original authors and source are credited. Funding: None. Competing Interests: TB, HK PL, SC, and DC declare no conflict of interest. MAH has been speaker, advisor, and/or received honoraria from: AbbVie, Biojamp, Boehringer Ingelheim, Bristol Myers Squibb, Celltrion, Eli Lilly, Galderma, Hikma Pharmaceuticals, Incyte, Janssen, Leo, L’Oreal, La Roche Posay, Medexus, Novartis, Pfizer, Recordati, Sanofi Regeneron, Sun Pharma. Authorship: All authors have contributed significantly to this publication. Acknowledgements: Ms. Behroozian received funding support for this project as a recipient of the McMaster Medical Student Research Excellence Scholarships. Corresponding Author: Dr. Mohannad Abu-Hilal. Division of Dermatology, Department of Medicine, McMaster University. 100 Main Street West, Hamilton, Ontario, Canada, L8P 1H6. ORCID ID: 0000-0001-9702-2086. E-mail: abuhilm@mcmaster.ca. Introduction: Scalp psoriasis affects up to 80% of patients with plaque-type psoriasis and is often resistant to topical and conventional systemic agents. There is a lack of consensus on a “gold standard” treatment. Objective: This comprehensive review and network meta-analysis aimed to compare the efficacy and safety of studied interventions. Methods: The Ovid MEDLINE(R), Embase, and Cochrane databases were searched from 01 January 2000 to 05 October 2022. All English-language randomized controlled trials evaluating an interven- tion for scalp psoriasis were included if they reported one of the following clinical outcomes: Psoriasis Scalp Severity Index (PSSI), scalp Physician Global Assessment (ScPGA), scalp-specific Investigator or Physician Global Assessment (IGA/PGA), and Total Sign Score (TSS), and adverse events. A random effects network meta-analysis was performed where possible, and network plots were generated. ABSTRACT 2 Review | Dermatol Pract Concept. 2025;15(2):4793 Introduction Up to 80% of patients with plaque-type psoriasis have scalp involvement [1]. Scalp psoriasis can cause significant physical and social distress, with up to 97% reporting that the condi- tion interferes in their daily life [2]. Many individuals experi- ence intense pruritus and pain associated with their disease, and the shedding of scale as dandruff can cause significant social embarrassment for affected individuals [3]. Notably, patients have reported significant psychosocial distress and withdrawal from social activities as a result of embarrassment from not being able to hide their lesions [1, 4-6]. Scalp psoria- sis is also often refractory to topical agents [1, 7, 8]. Overall, scalp psoriasis continues to pose a significant challenge for dermatologists due to the lack of effective therapies and the severe physical and psychosocial impact on affected patients. Additionally, outcome measures to quantify the severity of scalp psoriasis are heterogeneous and have varied across various clinical studies. Commonly-used scalp psoriasis tools include the Psoriasis Scalp Severity Index (PSSI), scalp Physi- cian Global Assessment (ScPGA), scalp-specific Investigator or Physician Global Assessment (IGA/PGA), and Total Sign Score (TSS). The PSSI score is calculated by assessing ery- thema, scaliness, induration, and extent of scalp psoriasis in- volvement [5]. ScPGA is a seven-point scale assessing plaque elevation, scaling, and erythema [9]. The TSS has been used differently in the studies, with some including only erythema, scaling, and thickness, and others also including pruritus [8]. Instruments that measure patient-reported outcomes such as quality of life and symptom burden also exist but are less of- ten used. These include the Dermatology Life Quality Index (DLQI) and Scalpdex [5]. Previous reviews and meta-analyses on scalp psoriasis found a therapeutic benefit among biologics and small mol- ecule agent (SMAs) treatments compared to placebo [4, 7]. There is a lack of consensus on the optimal or most effec- tive treatment for scalp psoriasis mostly due to the limited number of head-to-head trials comparing biologics and SMAs. We conducted a systematic review and network meta- analysis on systemic therapies for scalp psoriasis. Objectives The objective of this study was to compare the efficacy of various therapies for the treatment of scalp psoriasis. Methods Search Strategy and Selection Criteria A systematic review of the literature was conducted of the Ovid MEDLINE(R), Embase, and Cochrane Central Regis- ter of Controlled Trials databases from 01 January 2000 to 05 October 2022. All full-text works published in English were included in the analysis if they answered the research question outlined using the Population, Intervention, Com- parison, and Outcome (PICO) method: P) patients with any severity of scalp psoriasis; I and C) any therapy type (topi- cal agents, SMAs, biologics, phototherapy, and other); and O) change in scalp psoriasis as determined by improvement and changes in PSSI score, IGA score, ScPGA, modified Psoria- sis Area and Severity Index (mPASI) score, or TSS [10]. Works were excluded for the following reasons: only reporting out- comes beyond 24 weeks from baseline (denoted as “remission therapy”), non-randomized studies, abstract-only studies, non-English language, pediatric populations, or non-human models. In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement, two authors (TB and RPL) screened all titles and abstracts inde- pendently for eligibility and discussed any discrepancies [11]. All full texts of studies were then for eligibility, and all extracted data were cross-referenced by two reviewers (TB and RPL) to ensure accuracy. For each outcome, data were only extracted between baseline and the 24-week time point, which was denoted as “induction therapy.” Data Collection Across studies included, data were extracted on demograph- ics, sample size, publication year, treatment characteristics (dosing, frequency), comparison group, timing of outcome assessment, key findings, and others. PSSI, IGA/PGA, ScPGA, mPASI, TSS, and adverse event outcome data were also Results: Of 1,046 studies identified, 35 met the inclusion criteria, with seven in the PSSI analysis and 16 in the IGA analysis. All interventions led to an improvement in all outcomes when compared to pla- cebo in the PSSI and PGA/IGA. For the PSSI response, secukinumab 300 mg every four weeks (Q4W) was the most effective (SUCRA 0.991). For the PGA/IGA response, bimekizumab 320 mg Q4W was the most effective (SUCRA 0.975). Conclusions: Several systemic therapies are superior to placebo in improving clinical outcomes, with secukinumab 300 mg Q4W and bimekizumab 320 mg Q4W deemed the most effective among bio- logic agents analyzed. Efforts to enhance research standardization, including head-to-head trials with standardized outcome measures, diverse patient recruitment, and long-term follow-up, are crucial next steps in assessing treatment efficacy and adverse events. Review | Dermatol Pract Concept. 2025;15(2):4793 3 extracted. Outcomes assessed at 12 weeks were included in the analysis. For studies that did not report 12-week data, the time point closest to 12 weeks was included for analysis purposes (ranging from four to sixteen weeks). The risk of bias of each trial was also assessed in accordance with the Cochrane Risk of Bias Tool for Randomized Controlled Tri- als (RoB 2) [12]. Statistical Analysis A random-effects network meta-analysis was performed using R statistical software (Netmeta package). Within the outcome domain, standardized mean differences (SMD) were employed to combine different scales to allow for the consid- eration of all the studies reporting a given outcome. Studies of four to sixteen weeks of treatment were pooled, and the analysis was conducted using intention-to-treat (ITT) data. In these analyses, dosing schedules were treated as their own net- work nodes (i.e., results of different administration schedules of medications were not pooled). Network plots were gener- ated for the analysis. Summary results are presented as SMDs with a 95% confidence interval (CI). Effect estimates for all pairwise comparisons in the network were also calculated. Results Characteristics of Included Studies Through an initial search of the databases, 1,046 studies were identified, of which 702 remained after duplicates were removed (Figure 1); 184 studies were assessed for eligibility, and a total of 35 RCTs were selected for inclusion in the sys- tematic review, of which 19 were included in the network meta-analysis [9, 13-46]. The study characteristics for all in- cluded RCTs are summarized in Table S1. Across included studies, there was only sufficient evidence available on sys- temic agents to include PSSI and scalp or scalp-specific IGA outcomes in a network meta-analysis. Twenty-two studies in- cluded a biologic as part of the treatment arm (62.3%), with guselkumab being the most commonly used (N=4, 11.4%). A similar number of studies had nonsteroidal topical therapy as part of at least one treatment arm (N=25, 71.4%). Fifteen studies included a topical corticosteroid as part of the treat- ment arms (42.9%), with betamethasone dipropionate used in almost half of these trials (N=7, 20%). Placebo was used as the control arm in the majority of the studies (N=23, 65.7%). Of the studies for which the blinding status was known, the majority of the studies were double-blinded (N=23, 65.7%). Detailed baseline demographic characteristics for each in- cluded study are included in Table 1. Of note, studies that reported on topical therapies only were not included in the network meta-analysis. In total, 11 studies examined only these agents, which included betamethasone valerate, beta- methasone dipropionate, calcipotriol, calcipotriene, and combinations of these therapies [9, 23-25, 27-32, 40]. Network Meta-Analysis Results PSSI Response From all studies measuring PSSI response as an outcome, seven studies were included in the analysis [13-19]. One study was excluded due to a lack of information on the standard deviation of the mean PSSI [20], and two additional studies were excluded for including three treatments that formed a separate subnetwork which was not connected to the other treatments in the network [21, 22]. The treatments included in the analysis were: etanercept 50 mg twice weekly, secuki- numab 300 mg every four weeks (Q4W), brodalumab 210 mg every two weeks (Q2W), ixekizumab 150 mg Q2W, ixeki- zumab 160 mg followed by 80 mg Q2W, and ixekizumab 160 mg followed by 80 mg Q4W. The treatment network formed by the included studies is depicted in Figure 2A. All interventions led to a statistically significant improvement in PSSI response compared to placebo, indicating a poten- tially beneficial effect in reducing the extent and severity of psoriasis involvement (Figure 2B and Table S1). When com- pared to each other, secukinumab 300 mg Q4W was found to be the safest and most effective (SUCRA 0.991) followed by ixekizumab 160 mg Q2W, (SUCRA 0.701), ixekizumab 150 mg Q2W, (SUCRA 0.671), ixekizumab 160 mg Q4W (SUCRA 0.605), brodalumab 210 mg Q2W, (SUCRA 0.302), and etanercept 50 mg twice weekly (SUCRA 0.230). Scalp or Scalp-Specific PGA/IGA Response Seven studies were included in the analysis for the outcome of the IGA response [9, 13, 16 23-39]. Guselkumab 50 mg every eight weeks (Q8W), guselkumab 100 mg Q8W, adali- mumab 80 mg Q2W, apremilast 30 mg twice daily, secuk- inumab 300 mg Q4W, bimekizumab 320 mg Q4W, and ustekinumab 90 mg Q12W were the treatments included in the analysis (Figure 3A). In comparison to the placebo, all interventions led to a reduction in IGA, indicating a potentially beneficial effect in improving symptoms (Figure 3B and Table S1). Aside from guselkumab 50 mg Q8W, all interventions had a statistically significant benefit when compared to placebo. According to the SUCRA analysis, bimekizumab 320 mg Q4W had the highest likelihood of improving IGA scores (SUCRA 0.975), followed by ustekinumab 90 mg Q12W (SUCRA 0.7050), secukinumab 300 mg Q4W (SUCRA 0.6374), guselkumab 100 mg Q8W (SUCRA 0.5194), apremilast 30 mg twice daily (SUCRA 0.5071), adalimumab 80 mg Q2W, (SUCRA 0.4384), and guselkumab 50 mg Q8W (SUCRA 0.2023). Risk of Bias Assessment The risk of bias assessment for the included studies in the network meta-analysis revealed varying degrees of method- ological quality across different trials. Overall, most studies exhibited a low risk of bias in random sequence generation, blinding of participants and personnel, blinding of outcome 4 Review | Dermatol Pract Concept. 2025;15(2):4793 effects, including skin lesions and atrophy, highlighting a need for newer, systemic therapeutic modalities [6, 47, 48]. In this analysis, all included therapies showed significant ef- ficacy when compared to placebo through various measures, including PSSI response and IGA response. When all inter- ventions were compared against each other, secukinumab 300 mg and bimekizumab 320 mg were found to be the most effective in improving the PSSI and PGA/IGA scores, respectively. Among biologics compared in the PSSI and IGA response analyses, biologic agents outperformed other small mole- cules, aside from a 50-mg dosing of guselkumab, which is assessment, and incomplete outcome data. However, there were instances of unclear or high risk of bias in certain do- mains, particularly in the allocation concealment, selective reporting, and other biases domains. In total, six out of 24 studies had a high risk of bias in at least one domain, while 20 studies had an unclear risk of bias in at least one domain. Conclusions Though corticosteroids are commonly used in the treatment of scalp psoriasis, they are suboptimal in severe or resistant cases, and long-term use is associated with adverse side Figure 1. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram. Review | Dermatol Pract Concept. 2025;15(2):4793 5 T ab le 1 . B as el in e C ha ra ct er is ti cs o f In cl ud ed S tu di es . A ut ho r A rm s C au ca si an (% ) M al e (% ) A ge [ m in -m ax ] (y ea rs ) M ea n B M I Ps or ia si s D ur at io n (Y ea rs ) Sc al p in vo lv em en t (% ) PS SI T SS IG A /P G A s co re of 3 -5 ( % ) B ag el J [ 13 ] Se cu ki nu m ab 3 00 m g 86 .3 52 .9 42 .7 * 31 .2 * 14 .4 * 61 .6 * 33 .4 * N R 84 .3 , 7 0. 6, N R Pl ac eb o 74 .5 41 .2 41 .1 * 31 .9 * 15 .4 * 59 .3 * 33 * N R 15 .7 , 2 9. 4, N R B uc kl ey C [ 23 ] C al ci po tr io l/e ne + B et am et ha so ne D ip ro pi on at e 97 .2 43 .5 48 .4 * N R 16 * N R N R 6. 79 * N R B et am et ha so ne D ip ro pi on at e 98 .2 46 .4 48 .4 * N R 13 .2 * N R N R 6. 81 * N R E le w sk i B [ 14 ] B ro da lu m ab 2 10 m g N R N R N R N R 20 .4 * N R 16 .7 - N R N R Pl ac eb o N R N R N R N R 20 .7 * N R 20 * N R N R B ag el J [ 15 ] E ta ne rc ep t 50 m g 69 .5 53 .2 39 - [ 18 -7 1] 30 .2 - 17 .5 - 72 .5 - 35 - N R N R Pl ac eb o 75 .8 58 .1 42 - [ 18 -7 0] 30 .1 - 11 .9 - 60 - 30 - N R N R B ah ra in i P [ 41 ] Tu rm er ic t on ic N R 40 29 - [ 27 -3 5] N R N R N R N R N R N R Pl ac eb o N R 20 44 - [ 29 -5 0] N R N R N R N R N R N R Fe ld m an S R [ 9] B et am et ha so ne va le ra te B ID N R 45 .5 7 50 * [1 7- 90 ] N R N R N R N R 7. 7* N R B et am et ha so ne va le ra te Q D N R 45 .5 7 50 * [1 7- 90 ] N R N R N R N R 8. 1* N R Je m ec G B E [ 24 ] C al ci po tr io l/e ne + B et am et ha so ne D ip ro pi on at e 95 .7 47 .9 47 .9 * [1 8- 83 ] N R 15 .4 * N R N R 6. 7* 56 .2 , 2 8. 2, 6 .3 C al ci po tr ie ne /o l 97 .4 44 .5 50 .1 * [1 7- 91 ] N R 16 .7 * N R N R 6. 8* 57 .4 , 3 2, 4 .8 B et am et ha so ne D ip ro pi on at e Q D 96 .8 41 .9 49 .5 *[ 18 -9 1] N R 17 .4 * N R N R 6. 9* 57 , 3 2. 9, 5 .6 Pl ac eb o 94 .9 44 .9 49 .6 * [1 8- 97 ] N R 16 .3 * N R N R 7* 50 .7 , 3 6, 5 .9 Ju ry C S [4 2] It ra co na zo le N R 42 .8 5 47 - N R N R N R N R N R N R Pl ac eb o N R 42 .8 5 47 - N R N R N R N R N R N R K ra gb al le K [ 25 ] C al ci po tr io l/e ne + B et am et ha so ne D ip ro pi on at e 99 43 .5 50 .8 * [1 8- 91 ] N R 18 .4 * N R N R 7. 4* 54 .6 , 3 7. 7, 7 .7 C al ci po tr ie ne /o l 99 41 .9 51 .4 * [2 4- 85 ] N R 19 .3 * N R N R 7. 1* 61 , 3 2. 4, 6 .7 L iu L [ 26 ] C al ci po tr io l/e ne + B et am et ha so ne D ip ro pi on at e 0 67 .6 40 .9 * [1 8- 81 ] 24 .0 5* 8. 27 8* N R N R N R 56 .7 , 2 7. 1, 1 .8 C al ci po tr ie ne /o l 0 66 .1 39 .9 * [1 8- 76 ] 24 .0 5* 7. 51 7* N R N R N R 56 , 2 3. 6, 1 T ab le 1 co nt in ue s 6 Review | Dermatol Pract Concept. 2025;15(2):4793 A ut ho r A rm s C au ca si an (% ) M al e (% ) A ge [ m in -m ax ] (y ea rs ) M ea n B M I Ps or ia si s D ur at io n (Y ea rs ) Sc al p in vo lv em en t (% ) PS SI T SS IG A /P G A s co re of 3 -5 ( % ) M a L [ 27 ] C al ci po tr io l/e ne + B et am et ha so ne D ip ro pi on at e N R 60 .8 39 .9 * N R 7. 4* 54 .1 * N R 6. 8* 69 .2 , 2 4. 4, 6 .7 C al ci po tr ie ne /o l N R 55 .6 38 .7 * N R 7. 5* 48 .6 * N R 6. 9* 70 .2 , 2 5. 8, 4 O ku bo Y [ 40 ] B et am et ha so ne bu ty ra te p ro pi on at e + m ax ac al ci to l (8  w ee ks ) N R 87 .5 49 .6 * [2 4- 78 ] N R 14 .1 * N R N R 5. 6* N R B et am et ha so ne bu ty ra te p ro pi on at e + m ax ac al ci to l (4 w ee ks ) N R 80 46 .1 * [2 6- 76 ] N R 7. 3* N R N R 5. 4* N R va n de K er kh of P C [2 8] C al ci po tr io l/e ne + B et am et ha so ne D ip ro pi on at e 98 .4 41 .9 48 .5 * [1 8- 92 ] N R 15 .7 * N R N R 6. 8* 54 .8 , 2 9. 9, 5 .5 B et am et ha so ne D ip ro pi on at e Q D 96 .8 46 .2 47 .9 * [1 8- 85 ] N R 16 .1 * N R N R 6. 9* 53 .6 , 3 3. 6, 4 .8 C al ci po tr ie ne /o l 95 .8 47 .9 48 .7 * [1 8- 88 ] N R 15 .8 * N R N R 6. 8* 51 .4 , 3 2. 9, 3 .5 Pa te l D S [2 9] C al ci po tr io l/e ne + B et am et ha so ne D ip ro pi on at e 93 53 47 .4 * [2 0- 81 ] N R 14 .6 * N R N R N R 65 , 1 7, N R C al ci po tr ie ne /o l 91 .1 60 .4 50 .7 * [2 1- 85 ] N R 18 .4 * N R N R N R 62 .4 , 1 4. 9, N R B et am et ha so ne D ip ro pi on at e Q D 82 .2 55 .4 49 * [2 0- 85 ] N R 16 .2 * N R N R N R 71 .3 , 9 .9 , N R R at ta na ka em ak or n P [2 1] E xc im er la m p + 10 % L C D c re am N R 46 .7 35 .5 3* 27 .1 5* N R N R 12 - N R N R E xc im er la m p N R 40 47 * 29 .1 * N R N R 18 - N R N R R ei ch K [ 16 ] E ta ne rc ep t 50 m g 92 .4 68 .7 45 .4 * N R 18 .6 * N R 19 .9 * N R N R Ix ek iz um ab Q 2W 93 .2 65 .3 44 .8 * N R 18 .7 * N R 20 .3 * N R N R Ix ek iz um ab Q 4W 92 .2 67 .9 45 .2 * N R 18 .7 * N R 20 .1 * N R N R Pl ac eb o 91 .4 71 .2 46 * N R 18 .8 * N R 20 .8 * N R N R R ey ga gn e P [3 0] C lo be ta so l pr op io na te s ha m po o N R 49 44 .9 * N R N R 46 * N R 4. 86 * N R C al ci po tr ie ne /o l N R 45 45 .7 * N R N R 44 * N R 4. 95 * N R R ic h P [4 3] A pr em ila st 3 0 m g N R 65 .2 44 .9 * N R 19 .1 4* N R N R N R 64 .7 , 3 5. 3, N R Pl ac eb o N R 65 .1 45 .1 * N R 17 .4 1* N R N R N R 62 .4 , 3 7. 6, N R A pr em ila st 3 0 m g N R 58 .5 44 .7 * N R 17 .7 8* N R N R N R 68 .8 , 3 1. 3, N R Pl ac eb o N R 75 .3 44 .1 * N R 17 .5 2* N R N R N R 58 .1 , 4 1. 9, N R Sa ra ce no R [ 31 ] C al ci po tr io l/e ne + B et am et ha so ne D ip ro pi on at e N R 51 44 .1 * [1 8- 85 ] N R N R 37 .3 * N R 6. 9* N R C al ci po tr io l/e ne + B et am et ha so ne D ip ro pi on at e N R 59 .2 45 .7 * [1 8- 84 ] N R N R 36 .8 * N R 6. 8* N R Ty ri ng S [ 32 ] C al ci po tr io l/e ne + B et am et ha so ne D ip ro pi on at e 0 62 .2 44 .4 * [1 8- 75 ] N R 10 .5 * N R N R 6. 3* 81 .5 , N R , N R Pl ac eb o 0 66 .7 45 .8 * [2 2- 76 ] N R 11 .8 * N R N R 6. 2* 76 .2 , N R , N R V an V oo rh ee s S [3 3] A pr em ila st 3 0 m g 76 .6 62 .2 47 * 30 .7 * 15 .7 * 61 .9 * N R N R 76 .1 , 2 3. 9, N R Pl ac eb o 73 .5 60 .8 46 .7 * 31 .7 * 14 .8 * 58 .2 * N R N R 74 .5 , 2 5. 5, N R Z ho u J [2 2] U V A 1 ph ot ot he ra py N R 61 .7 6 32 .7 * [2 1- 53 ] N R 3. 02 * N R 15 .2 8* N R N R N ar ro w b an d U V B ph ot ot he ra py N R 61 .7 6 32 .7 * [2 1- 53 ] N R 3. 02 * N R 15 .5 * N R N R T ha çi D [ 20 ] R is an ki zu m ab 1 50 m g N R N R 42 * [1 8- 73 ] N R N R N R 23 .1 * N R N R Fu m ar ic a ci d es te rs N R N R 42 .5 * [1 9- 69 ] N R N R N R 20 .2 * N R N R B la uv el t A [ 44 ]  P la ce bo N R N R N R N R N R N R N R N R 59 .3 , 1 6. 7, N R G us el ku m ab 1 00 m g N R N R N R N R N R N R N R N R 58 .8 , 1 9. 6, N R A da lim um ab 8 0 m g N R N R N R N R N R N R N R N R 59 .3 , 1 9. 3, N R R ei ch K [ 34 ] Pl ac eb o N R N R N R N R N R N R N R N R N R G us el ku m ab 1 00 m g N R N R N R N R N R N R N R N R N R A da lim um ab 8 0 m g N R N R N R N R N R N R N R N R N R O ht su ki M [ 35 ] Pl ac eb o N R N R N R N R N R N R N R N R N R G us el ku m ab 5 0 m g N R N R N R N R N R N R N R N R N R G us el ku m ab 1 00 m g N R N R N R N R N R N R N R N R N R T ha çi D [ 36 ] G us el ku m ab 1 00 m g N R N R N R N R N R N R N R N R N R Fu m ar ic a ci d es te rs N R N R N R N R N R N R N R N R N R Se o SJ [ 17 ] Pl ac eb o N R N R N R N R N R N R 28 * N R N R B ro da lu m ab 2 10 m g N R N R N R N R N R N R 24 .6 * N R N R T ab le 1 . B as el in e C ha ra ct er is ti cs o f In cl ud ed S tu di es . ( co nt in ue d) Review | Dermatol Pract Concept. 2025;15(2):4793 7 A ut ho r A rm s C au ca si an (% ) M al e (% ) A ge [ m in -m ax ] (y ea rs ) M ea n B M I Ps or ia si s D ur at io n (Y ea rs ) Sc al p in vo lv em en t (% ) PS SI T SS IG A /P G A s co re of 3 -5 ( % ) M a L [ 27 ] C al ci po tr io l/e ne + B et am et ha so ne D ip ro pi on at e N R 60 .8 39 .9 * N R 7. 4* 54 .1 * N R 6. 8* 69 .2 , 2 4. 4, 6 .7 C al ci po tr ie ne /o l N R 55 .6 38 .7 * N R 7. 5* 48 .6 * N R 6. 9* 70 .2 , 2 5. 8, 4 O ku bo Y [ 40 ] B et am et ha so ne bu ty ra te p ro pi on at e + m ax ac al ci to l (8  w ee ks ) N R 87 .5 49 .6 * [2 4- 78 ] N R 14 .1 * N R N R 5. 6* N R B et am et ha so ne bu ty ra te p ro pi on at e + m ax ac al ci to l (4 w ee ks ) N R 80 46 .1 * [2 6- 76 ] N R 7. 3* N R N R 5. 4* N R va n de K er kh of P C [2 8] C al ci po tr io l/e ne + B et am et ha so ne D ip ro pi on at e 98 .4 41 .9 48 .5 * [1 8- 92 ] N R 15 .7 * N R N R 6. 8* 54 .8 , 2 9. 9, 5 .5 B et am et ha so ne D ip ro pi on at e Q D 96 .8 46 .2 47 .9 * [1 8- 85 ] N R 16 .1 * N R N R 6. 9* 53 .6 , 3 3. 6, 4 .8 C al ci po tr ie ne /o l 95 .8 47 .9 48 .7 * [1 8- 88 ] N R 15 .8 * N R N R 6. 8* 51 .4 , 3 2. 9, 3 .5 Pa te l D S [2 9] C al ci po tr io l/e ne + B et am et ha so ne D ip ro pi on at e 93 53 47 .4 * [2 0- 81 ] N R 14 .6 * N R N R N R 65 , 1 7, N R C al ci po tr ie ne /o l 91 .1 60 .4 50 .7 * [2 1- 85 ] N R 18 .4 * N R N R N R 62 .4 , 1 4. 9, N R B et am et ha so ne D ip ro pi on at e Q D 82 .2 55 .4 49 * [2 0- 85 ] N R 16 .2 * N R N R N R 71 .3 , 9 .9 , N R R at ta na ka em ak or n P [2 1] E xc im er la m p + 10 % L C D c re am N R 46 .7 35 .5 3* 27 .1 5* N R N R 12 - N R N R E xc im er la m p N R 40 47 * 29 .1 * N R N R 18 - N R N R R ei ch K [ 16 ] E ta ne rc ep t 50 m g 92 .4 68 .7 45 .4 * N R 18 .6 * N R 19 .9 * N R N R Ix ek iz um ab Q 2W 93 .2 65 .3 44 .8 * N R 18 .7 * N R 20 .3 * N R N R Ix ek iz um ab Q 4W 92 .2 67 .9 45 .2 * N R 18 .7 * N R 20 .1 * N R N R Pl ac eb o 91 .4 71 .2 46 * N R 18 .8 * N R 20 .8 * N R N R R ey ga gn e P [3 0] C lo be ta so l pr op io na te s ha m po o N R 49 44 .9 * N R N R 46 * N R 4. 86 * N R C al ci po tr ie ne /o l N R 45 45 .7 * N R N R 44 * N R 4. 95 * N R R ic h P [4 3] A pr em ila st 3 0 m g N R 65 .2 44 .9 * N R 19 .1 4* N R N R N R 64 .7 , 3 5. 3, N R Pl ac eb o N R 65 .1 45 .1 * N R 17 .4 1* N R N R N R 62 .4 , 3 7. 6, N R A pr em ila st 3 0 m g N R 58 .5 44 .7 * N R 17 .7 8* N R N R N R 68 .8 , 3 1. 3, N R Pl ac eb o N R 75 .3 44 .1 * N R 17 .5 2* N R N R N R 58 .1 , 4 1. 9, N R Sa ra ce no R [ 31 ] C al ci po tr io l/e ne + B et am et ha so ne D ip ro pi on at e N R 51 44 .1 * [1 8- 85 ] N R N R 37 .3 * N R 6. 9* N R C al ci po tr io l/e ne + B et am et ha so ne D ip ro pi on at e N R 59 .2 45 .7 * [1 8- 84 ] N R N R 36 .8 * N R 6. 8* N R Ty ri ng S [ 32 ] C al ci po tr io l/e ne + B et am et ha so ne D ip ro pi on at e 0 62 .2 44 .4 * [1 8- 75 ] N R 10 .5 * N R N R 6. 3* 81 .5 , N R , N R Pl ac eb o 0 66 .7 45 .8 * [2 2- 76 ] N R 11 .8 * N R N R 6. 2* 76 .2 , N R , N R V an V oo rh ee s S [3 3] A pr em ila st 3 0 m g 76 .6 62 .2 47 * 30 .7 * 15 .7 * 61 .9 * N R N R 76 .1 , 2 3. 9, N R Pl ac eb o 73 .5 60 .8 46 .7 * 31 .7 * 14 .8 * 58 .2 * N R N R 74 .5 , 2 5. 5, N R Z ho u J [2 2] U V A 1 ph ot ot he ra py N R 61 .7 6 32 .7 * [2 1- 53 ] N R 3. 02 * N R 15 .2 8* N R N R N ar ro w b an d U V B ph ot ot he ra py N R 61 .7 6 32 .7 * [2 1- 53 ] N R 3. 02 * N R 15 .5 * N R N R T ha çi D [ 20 ] R is an ki zu m ab 1 50 m g N R N R 42 * [1 8- 73 ] N R N R N R 23 .1 * N R N R Fu m ar ic a ci d es te rs N R N R 42 .5 * [1 9- 69 ] N R N R N R 20 .2 * N R N R B la uv el t A [ 44 ]  P la ce bo N R N R N R N R N R N R N R N R 59 .3 , 1 6. 7, N R G us el ku m ab 1 00 m g N R N R N R N R N R N R N R N R 58 .8 , 1 9. 6, N R A da lim um ab 8 0 m g N R N R N R N R N R N R N R N R 59 .3 , 1 9. 3, N R R ei ch K [ 34 ] Pl ac eb o N R N R N R N R N R N R N R N R N R G us el ku m ab 1 00 m g N R N R N R N R N R N R N R N R N R A da lim um ab 8 0 m g N R N R N R N R N R N R N R N R N R O ht su ki M [ 35 ] Pl ac eb o N R N R N R N R N R N R N R N R N R G us el ku m ab 5 0 m g N R N R N R N R N R N R N R N R N R G us el ku m ab 1 00 m g N R N R N R N R N R N R N R N R N R T ha çi D [ 36 ] G us el ku m ab 1 00 m g N R N R N R N R N R N R N R N R N R Fu m ar ic a ci d es te rs N R N R N R N R N R N R N R N R N R Se o SJ [ 17 ] Pl ac eb o N R N R N R N R N R N R 28 * N R N R B ro da lu m ab 2 10 m g N R N R N R N R N R N R 24 .6 * N R N R T ab le 1 co nt in ue s 8 Review | Dermatol Pract Concept. 2025;15(2):4793 A ut ho r A rm s C au ca si an (% ) M al e (% ) A ge [ m in -m ax ] (y ea rs ) M ea n B M I Ps or ia si s D ur at io n (Y ea rs ) Sc al p in vo lv em en t (% ) PS SI T SS IG A /P G A s co re of 3 -5 ( % ) N ak ag aw a H [ 18 ] Pl ac eb o N R N R N R N R N R N R 26 .2 * N R N R B ro da lu m ab 7 0 m g N R N R N R N R N R N R 25 .8 * N R N R B ro da lu m ab 1 40 m g N R N R N R N R N R N R 26 .5 * N R N R B ro da lu m ab 2 10 m g N R N R N R N R N R N R 24 .3 * N R N R R ei ch K [ 37 ] B im ek iz um ab N R N R N R N R N R N R N R N R N R U st ek in um ab 4 5 or 90 m g N R N R N R N R N R N R N R N R N R Pl ac eb o N R N R N R N R N R N R N R N R N R G or do n K B [ 38 ] B im ek iz um ab 3 20 m g N R N R N R N R N R N R N R N R N R Pl ac eb o N R N R N R N R N R N R N R N R N R L an gl ey R G [ 19 ] Ix ek iz um ab 1 0 m g N R N R N R N R N R N R 19 .5 * N R N R Ix ek iz um ab 2 5 m g N R N R N R N R N R N R 20 .5 * N R N R Ix ek iz um ab 7 5 m g N R N R N R N R N R N R 13 .8 * N R N R Ix ek iz um ab 1 50 m g N R N R N R N R N R N R 20 .1 * N R N R Pl ac eb o N R N R N R N R N R N R 18 .8 * N R N R L eb w oh l M G [ 39 ] C al ci po tr io l/e ne + B et am et ha so ne D ip ro pi on at e N R N R N R N R N R N R N R N R N R C al ci po tr ie ne /o l N R N R N R N R N R N R N R N R N R B et am et ha so ne D ip ro pi on at e Q D N R N R N R N R N R N R N R N R N R B er gs tr om K B [ 45 ] C lo be ta so l p ro pi on at e fo am N R N R N R N R N R N R N R N R N R C lo be ta so l pr op io na te s ol ut io n N R N R N R N R N R N R N R N R N R St ei n G ol d L [ 46 ] A pr em ila st 3 0 m g N R N R N R N R N R N R N R N R N R Pl ac eb o N R N R N R N R N R N R N R N R N R A bb re vi at io ns : B ID : t w ic e a da y; C al ci po tr io l/e ne : c om bi na ti on t he ra py o f ca lc ip ot ri ol a nd c al ci po tr ie ne ; C al ci po tr ie ne /o l: co m bi na ti on t he ra py o f ca lc ip ot ri en e an d ca lc ip ot ri ol ; Q D ; o nc e da ily , * in di ca te s th is va lu e is a m ea n, - in di ca te s th is v al ue is a m ed ia n T ab le 1 . B as el in e C ha ra ct er is ti cs o f In cl ud ed S tu di es . ( co nt in ue d) Review | Dermatol Pract Concept. 2025;15(2):4793 9 30 mg twice daily and adalimumab 80 mg Q2W. This is con- sistent with previous head-to-head comparative studies [49]. These results, consistent with previous research, indicate that the use of newer biologics may be linked to better clinical performance and control of scalp psoriasis symptoms, thus improving quality of life [47]. Scalp psoriasis treatment is greatly expanding, includ- ing over 10 different biologic drugs and one small molecule. Scalp psoriatic plaques are particularly refractory to topical not used in real life. In the PSSI analysis, the biologic agents (secukinumab 300 mg Q4W, brodalumab 210 mg Q2W, and ixekizumab 150/160 mg Q2-4W) had a higher likelihood of being more effective than etanercept 50 twice weekly, which is consistent with previous studies [7, 16]. In the IGA re- sponse analysis, bimekizumab 320 mg Q4W, ustekinumab, secukinumab 300 mg Q4W, and the 100 mg dosing of gusel- kumab Q8W were deemed to be more effective than other biologic and small molecule therapies, including apremilast Figure 2. (A) Network plot of studies reporting the PSSI response. (B) Forest plot of network meta-analysis results for studies reporting the PSSI response. (PSSI = Psoriasis Scalp Severity Index.) Figure 3. (A) Network plot of studies reporting the IGA response. (B) Forest plot of network meta-analysis results for studies reporting the IGA response. (IGA = scalp-specific Investigator Global Assessment). 10 Review | Dermatol Pract Concept. 2025;15(2):4793 In summary, this systematic review and network meta- analysis offer new insights into the range of treatments for scalp psoriasis. There is a critical need for effective thera- pies for scalp psoriasis given its significant impact on pa- tients’ quality of life. The findings of this study highlight the efficacy of various treatments in improving symptoms, with secukinumab 300 mg Q4W and bimekizumab 320 mg Q4W deemed most effective in improving PSSI and IGA, re- spectively. These interventions were deemed most effective among biologic agents analyzed, indicating that they may be helpful among patients with moderate-to-severe scalp pso- riasis that is refractory to traditional first-line treatments. To address these limitations, future studies should conduct head-to-head trials comparing various treatments directly, using standardized outcome measures and consistent tim- ing of assessments. In this study, certain studies found in the systematic review could not be included as they did not use an outcome that was being assessed for the network meta-analysis. Thus, standardization is not only crucial for the generalizability of the results but also to facilitate evi- dence synthesis. Furthermore, there should be efforts to re- cruit a more diverse patient population for clinical trials to increase the generalizability of findings to underrepresented groups. Lastly, studies with long-term follow-up are needed to assess adverse events associated with prolonged therapy and the durability of treatment responses over time. References 1. van de Kerkhof PC, de Hoop D, de Korte J, Kuipers MV. Scalp psoriasis, clinical presentations and therapeutic management. Dermatology 1998;197(4):326-34. DOI: 10.1159/000018026. PMID: 9873169. 2. Crowley J. Scalp psoriasis: an overview of the disease and available therapies. J Drugs Dermatol 2010;9(8):912-8. PMID: 20684141. 3. Mrowietz U, Macheleidt O, Eicke C. Effective treatment and im- provement of quality of life in patients with scalp psoriasis by topical use of calcipotriol/betamethasone (Xamiol®-gel): results. J Dtsch Dermatol Ges 2011;9(10):825-31. DOI: 10.1111/j.1610 -0387.2011.07695.x [published Online First: 20110512]. PMID: 21564540. 4. Wang TS, Tsai TF. Managing Scalp Psoriasis: An Evidence-Based Review. Am J Clin Dermatol 2017;18(1):17-43. DOI: 10.1007 /s40257-016-0222-4. PMID: 27650520. 5. Blakely K, Gooderham M. Management of scalp psoriasis: cur- rent perspectives. Psoriasis (Auckl) 2016;6:33-40. DOI: 10.2147 /ptt.S85330 PMID: 29387592. 6. Chan CS, Van Voorhees AS, Lebwohl MG, et al. Treatment of severe scalp psoriasis: from the Medical Board of the National Psoriasis Foundation. J Am Acad Dermatol 2009;60(6):962-71. DOI: 10.1016/j.jaad.2008.11.890 PMID: 19375191. 7. Alsenaid A, Ezmerli M, Srour J, Heppt M, Illigens BM, Prinz JC. Biologics and small molecules in patients with scalp psoriasis: a systematic review. J Dermatolog Treat 2022;33(1):473-82. and phototherapeutic treatments due to the presence of hair, and patients often struggle with adherence due to poor cos- metic results [1, 7, 8]. However, current clinical decision- making tools still endorse topical corticosteroids as the first- line treatment for patients, and agents such as ciclosporin, methotrexate, fumaric esters, and acitretin as second-line agents for moderate-severe or treatment-resistant psoriasis [50]. Despite their clear advantages, the widespread adop- tion of biologics in psoriasis treatment is constrained by cost, administration challenges, and uncertainties surrounding long-term efficacy and safety. Foremost among these is the substantial cost associated with biologics, far exceeding that of traditional medications. Despite efforts such as patient assistance programs and savings coupons, cost-related barri- ers persist, leading to discontinuation of treatment and hin- dering cost-effective care. Moreover, the need for injections or infusions adds another layer of inconvenience, impacting adherence and posing logistical challenges particularly for travelers who must navigate storage and transportation re- quirements. Additionally, while biologics offer promise for long-term maintenance due to their lower toxicity compared to alternatives, uncertainties remain regarding their efficacy and safety over extended periods. Limited long-term clini- cal data and the potential for patients to develop anti-drug antibodies raise concerns about treatment durability and ef- fectiveness [51]. Limitations The strengths of this review include its comprehensive na- ture, encompassing a wide range of treatments and out- come measures for scalp psoriasis, the use of a network meta- analysis methodology to compare these simultane- ously, and a systematic approach enhancing the reliability and validity of the findings. However, this study was not without limitations. Due to the heterogeneity in the timing of outcome reporting, trials with durations between 8 and 12 weeks were pooled, and trials beyond 12 weeks were included, which may have favored treatments with longer trial durations and thus increased time to improve psoria- sis. Combining different dosing regimens of treatments to incorporate more information may also have introduced limitations due to heterogeneity and comparability issues across the different treatment groups. This analysis was further limited by differences in trial design and hetero- geneity in the populations involved. For example, though most studies that reported race-/ethnicity-based data had a majority of Caucasian populations, there were some stud- ies with only racial minorities and significant heterogeneity in the country of study completion. The generalizability of these results is also limited in populations underrepresented in the included clinical trials, such as racial minorities and older patients. Review | Dermatol Pract Concept. 2025;15(2):4793 11 controlled trial. Br J Dermatol 2022;186(1):30-39. DOI: 10.1111 /bjd.20481 PMID: 33991341. 21. Rattanakaemakorn P, Triyangkulsri K, Iamsumang W, Suchonwanit P. 308-nm Excimer Lamp vs. Combination of 308-nm Excimer Lamp and 10% Liquor Carbonis Detergens in Patients With Scalp Psoriasis: A Randomized, Single-Blinded, Controlled Trial. Front Med (Lausanne) 2021;8:677948. DOI: 10.3389/fmed .2021.677948 PMID: 34211988. 22. Zhou J, Yi X, Li Y, Ding Y. Efficacy assessment of UVA1 and nar- rowband UVB for treatment of scalp psoriasis. Lasers Med Sci 2018;33(9):1979-82. DOI: 10.1007/s10103-018-2564-z PMID: 29915975. 23. Buckley C, Hoffmann V, Shapiro J, Saari S, Cambazard F, Milsgaard M. Calcipotriol plus betamethasone dipropionate scalp formulation is effective and well tolerated in the treatment of scalp psoriasis: a phase II study. Dermatology 2008;217(2): 107-13. DOI: 10.1159/000130425 PMID: 18463448. 24. Jemec GBE, Ganslandt C, Ortonne J-P, et al. A new scalp for- mulation of calcipotriene plus betamethasone compared with its active ingredients and the vehicle in the treatment of scalp psoria- sis: A randomized, double-blind, controlled trial. J Am Acad Der- matol 2008;59(3):455-63. DOI: 10.1016/j.jaad.2008.04.027. PMID: 18694678. 25. Kragballe K, Hoffmann V, Ortonne JP, Tan J, Nordin P, Segaert S. Efficacy and safety of calcipotriol plus betamethasone dipro- pionate scalp formulation compared with calcipotriol scalp solution in the treatment of scalp psoriasis: a randomized con- trolled trial. Br J Dermatol 2009;161(1):159-66. DOI: 10.1111 /j.1365-2133.2009.09116.x PMID: 19416259. 26. Liu L, Zhang C, Wang J, et al. Comparison of safety and effi- cacy between calcipotriol plus betamethasone dipropionate gel and calcipotriol scalp solution as long-term treatment for scalp psoriasis in Chinese patients: a national, multicentre, prospec- tive, randomized, active-controlled phase 4 trial. Eur J Derma- tol 2020;30(5):580-90. DOI: 10.1684/ejd.2020.3876. PMID: 33052103. 27. Ma L, Yang Q, Yang H, et al. Calcipotriol plus betamethasone dipropionate gel compared with calcipotriol scalp solution in the treatment of scalp psoriasis: a randomized, controlled trial investi- gating efficacy and safety in a Chinese population. Int J Dermatol 2016;55(1):106-13. DOI: 10.1111/ijd.12788 PMID: 26094549. 28. van de Kerkhof PC, Hoffmann V, Anstey A, et al. A new scalp formulation of calcipotriol plus betamethasone dipropionate compared with each of its active ingredients in the same vehicle for the treatment of scalp psoriasis: a randomized, double-blind, controlled trial. Br J Dermatol 2009;160(1):170-6. DOI: 10.1111 /j.1365-2133.2008.08927.x PMID: 19067709. 29. Patel DS, Veverka KA, Hansen JB, Yamauchi PS, Alonso- Llamazares J, Lebwohl M. Efficacy of Fixed-combination Cal- cipotriene 0.005% and Betamethasone Dipropionate 0.064% Foam for Scalp Plaque Psoriasis: Additional Analysis of a Phase II, Randomized Clinical Study. J Clin Aesthet Dermatol 2020;13(5):12-18 PMID: 32802249. 30. Reygagne P, Mrowietz U, Decroix J, et al. Clobetasol propio- nate shampoo 0.05% and calcipotriol solution 0.005%: a ran- domized comparison of efficacy and safety in subjects with scalp psoriasis. J Dermatolog Treat 2005;16(1):31-6. DOI: 10.1080 /09546630410024853. 31. Saraceno R, Camplone G, D’Agostino M, et al. Efficacy and maintenance strategies of two-compound formulation DOI: 10.1080/09546634.2020.1770167 [published Online First: 20200619]. PMID: 32406275. 8. Schlager JG, Rosumeck S, Werner RN, et al. Topical treatments for scalp psoriasis. Cochrane Database Syst Rev 2016;2(2):Cd009687. DOI: 10.1002/14651858.CD009687.pub2. 9. Feldman SR, Ravis SM, Fleischer AB, Jr., et al. Betamethasone valerate in foam vehicle is effective with both daily and twice a day dosing: a single-blind, open-label study in the treat- ment of scalp psoriasis. J Cutan Med Surg 2001;5(5):386-9. DOI: 10.1007/s10227-001-0005-1. PMID: 11907847. 10. Aslam S, Emmanuel P. Formulating a researchable question: A critical step for facilitating good clinical research. Indian J Sex Transm Dis AIDS 2010;31(1):47-50. DOI: 10.4103/0253-7184 .69003. PMID: 21808439. 11. Page MJ, McKenzie JE, Bossuyt PM, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. Bmj 2021;372:n71. DOI: 10.1136/bmj.n71 PMID: 33782057. 12. Sterne JAC, Savović J, Page MJ, et al. RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ. 2019;366:l4898. DOI:10.1136/bmj.l4898. PMID: 31462531. 13. Bagel J, Duffin KC, Moore A, et al. The effect of secukinumab on moderate-to-severe scalp psoriasis: Results of a 24-week, random- ized, double-blind, placebo-controlled phase 3b study. J Am Acad Dermatol 2017;77(4):667-74. DOI: 10.1016/j.jaad.2017.05.033 [published Online First: 20170802]. PMID: 28780364. 14. Elewski B, Rich P, Lain E, Soung J, Lewitt GM, Jacobson A. Efficacy of brodalumab in the treatment of scalp and nail pso- riasis: results from three phase 3 trials. J Dermatolog Treat 2022;33(1):261-65. DOI: 10.1080/09546634.2020.1749546 PMID: 32250714. 15. Bagel J, Lynde C, Tyring S, Kricorian G, Shi Y, Klekotka P. Mod- erate to severe plaque psoriasis with scalp involvement: a ran- domized, double-blind, placebo-controlled study of etanercept. J Am Acad Dermatol 2012;67(1):86-92. DOI: 10.1016/j.jaad .2011.07.034 [published Online First: 20111020]. PMID: 22014541. 16. Reich K, Leonardi C, Lebwohl M, et al. Sustained response with ixekizumab treatment of moderate-to-severe psoria- sis with scalp involvement: results from three phase 3 trials (UNCOVER-1, UNCOVER-2, UNCOVER-3). J Dermatolog Treat 2017;28(4):282-87. DOI: 10.1080/09546634.2016.1249820 PMID: 27759463. 17. Seo SJ, Shin BS, Lee JH, Jeong H. Efficacy and safety of broda- lumab in the Korean population for the treatment of moderate to severe plaque psoriasis: A randomized, phase III, double-blind, placebo-controlled study. J Dermatol 2021;48(6):807-17. DOI: 10.1111/1346-8138.15733 PMID: 33373480. 18. Nakagawa H, Niiro H, Ootaki K. Brodalumab, a human anti-interleukin-17-receptor antibody in the treatment of Japanese patients with moderate-to-severe plaque psoriasis: Ef- ficacy and safety results from a phase II randomized controlled study. J Dermatol Sci 2016;81(1):44-52. DOI: 10.1016/j.jdermsci .2015.10.009 PMID: 26547109. 19. Langley RG, Rich P, Menter A, et al. Improvement of scalp and nail lesions with ixekizumab in a phase 2 trial in patients with chronic plaque psoriasis. J Eur Acad Dermatol Venereol 2015;29(9):1763-70. DOI: 10.1111/jdv.12996 PMID: 25693783. 20. Thaçi D, Eyerich K, Pinter A, et al. Direct comparison of ri- sankizumab and fumaric acid esters in systemic therapy-naïve patients with moderate-to-severe plaque psoriasis: a randomized 12 Review | Dermatol Pract Concept. 2025;15(2):4793 40. Okubo Y, Natsume S, Usui K, Muro M, Tsuboi R. Combina- tion therapy using maxacalcitol and corticosteroid lotions pre- liminary to monotherapy with maxacalcitol lotion for scalp psoriasis. J Dermatolog Treat 2014;25(1):34-7. DOI: 10.3109 /09546634.2012.687087 PMID: 22515652. 41. Bahraini P, Rajabi M, Mansouri P, Sarafian G, Chalangari R, Azizian Z. Turmeric tonic as a treatment in scalp psoriasis: A randomized placebo-control clinical trial. J Cosmet Dermatol 2018;17(3):461-66 DOI: 10.1111/jocd.12513 PMID: 22515652. 42. Jury CS, McHugh L, Shankland GS, Burden AD. A randomized, placebo-controlled trial of oral itraconazole in scalp psoriasis. J. Dermatol. Treat. 2000;11(2):85-89. DOI: 10.1080/095466 30050517469. 43. Rich P, Gooderham M, Bachelez H, et al. Apremilast, an oral phosphodiesterase 4 inhibitor, in patients with difficult-to-treat nail and scalp psoriasis: Results of 2 phase III randomized, con- trolled trials (ESTEEM 1 and ESTEEM 2). J Am Acad Dermatol 2016;74(1):134-42. DOI: 10.1016/j.jaad.2015.09.001. PMID: 26549249. 44. Blauvelt A, Papp KA, Griffiths CE, et al. Efficacy and safety of guselkumab, an anti-interleukin-23 monoclonal antibody, com- pared with adalimumab for the continuous treatment of patients with moderate to severe psoriasis: Results from the phase III, double-blinded, placebo- and active comparator-controlled VOY- AGE 1 trial. J Am Acad Dermatol 2017;76(3):405-17. DOI: 10.1016 /j.jaad.2016.11.041 PMID: 28057360. 45. Bergstrom KG, Arambula K, Kimball AB. Medication formula- tion affects quality of life: a randomized single-blind study of clobetasol propionate foam 0.05% compared with a combined program of clobetasol cream 0.05% and solution 0.05% for the treatment of psoriasis. Cutis 2003;72(5):407-11. PMID: 14655784. 46. Stein Gold L, Papp K, Pariser D, et al. Efficacy and safety of apremilast in patients with mild-to-moderate plaque psoriasis: Results of a phase 3, multicenter, randomized, double-blind, placebo-controlled trial. J Am Acad Dermatol 2022;86(1):77-85. DOI: 10.1016/j.jaad.2021.07.040 PMID: 34343599. 47. Camela E, Ocampo-Garza SS, Cinelli E, Villani A, Fabbrocini G, Megna M. Therapeutic update of biologics and small mole- cules for scalp psoriasis: a systematic review. Dermatol Ther 2021;34(2):e14857 DOI: 10.1111/dth.14857 PMID: 33559275. 48. Takeda K, Arase S, Takahashi S. Side effects of topical cortico- steroids and their prevention. Drugs 1988;36 Suppl 5:15-23. DOI: 10.2165/00003495-198800365-00005. PMID: 3076129. 49. Fotiadou C, Lazaridou E, Sotiriou E, Kyrgidis A, Apalla Z, Ioannides D. Scalp psoriasis and biologic agents: a retrospective, comparative study from a tertiary psoriasis referral centre. J Eur Acad Dermatol Venereol 2016;30(12):2091-96. DOI: 10.1111 /jdv.13780 PMID: 27406435. 50. Feldman SR. Treatment of psoriasis in adults. 2023. 51. Hoffman MB, Hill D, Feldman SR. Current challenges and emerg- ing drug delivery strategies for the treatment of psoriasis.  Expert Opin Drug Deliv. 2016;13(10):1461-1473. DOI:10.1080 /17425247.2016.1188801. calcipotriol and betamethasone dipropionate gel (Xamiol® gel) in the treatment of scalp psoriasis: results from a study in 885 patients. J Dermatolog Treat 2014;25(1):30-3. DOI: 10.3109 /09546634.2013.800182 PMID: 23621170. 32. Tyring S, Mendoza N, Appell M, et al. A calcipotriene/ betamethasone dipropionate two-compound scalp formula- tion in the treatment of scalp psoriasis in Hispanic/Latino and Black/African American patients: results of the randomized, 8-week, double-blind phase of a clinical trial. Int J Dermatol 2010;49(11):1328-33. DOI: 10.1111/j.1365-4632.2010.04598.x. PMID: 20964660. 33. Van Voorhees AS, Stein Gold L, Lebwohl M, et al. Efficacy and safety of apremilast in patients with moderate to severe plaque psoriasis of the scalp: Results of a phase 3b, multicenter, random- ized, placebo-controlled, double-blind study. J Am Acad Derma- tol 2020;83(1):96-103. DOI: 10.1016/j.jaad.2020.01.072 34. Reich K, Armstrong AW, Foley P, et al. Efficacy and safety of guselkumab, an anti-interleukin-23 monoclonal antibody, compared with adalimumab for the treatment of patients with moderate to severe psoriasis with randomized withdrawal and retreatment: Results from the phase III, double-blind, placebo- and active comparator-controlled VOYAGE 2 trial. J Am Acad Dermatol 2017;76(3):418-31. DOI: 10.1016/j.jaad.2016.11.042 PMID: 28057361. 35. Ohtsuki M, Kubo H, Morishima H, Goto R, Zheng R, Nakagawa H. Guselkumab, an anti-interleukin-23 monoclonal antibody, for the treatment of moderate to severe plaque-type psoriasis in Japanese patients: Efficacy and safety results from a phase 3, randomized, double-blind, placebo-controlled study. J Dermatol 2018;45(9):1053-62. DOI: 10.1111/1346-8138 .14504 PMID: 29905383. 36. Thaçi D, Pinter A, Sebastian M, et al. Guselkumab is superior to fumaric acid esters in patients with moderate-to-severe plaque psoriasis who are naive to systemic treatment: results from a randomized, active-comparator-controlled phase IIIb trial (POLARIS). Br J Dermatol 2020;183(2):265-75. DOI: 10.1111 /bjd.18696 PMID: 31705526. 37. Reich K, Papp KA, Blauvelt A, et al. Bimekizumab versus ustekinumab for the treatment of moderate to severe plaque psoriasis (BE VIVID): efficacy and safety from a 52-week, multi- centre, double-blind, active comparator and placebo controlled phase 3 trial. Lancet 2021;397(10273):487-98. DOI: 10.1016 /s0140-6736(21)00125-2. 38. Gordon KB, Foley P, Krueger JG, et al. Bimekizumab efficacy and safety in moderate to severe plaque psoriasis (BE READY): a multicentre, double-blind, placebo-controlled, randomised withdrawal phase 3 trial. Lancet 2021;397(10273):475-86. DOI: 10.1016/s0140-6736(21)00126-4. PMID: 33549192. 39. Lebwohl M, Tyring S, Bukhalo M, et al. Fixed Combination Aerosol Foam Calcipotriene 0.005% (Cal) Plus Betamethasone Dipropionate 0.064% (BD) is More Efficacious than Cal or BD Aerosol Foam Alone for Psoriasis Vulgaris: A Randomized, Dou- ble-blind, Multicenter, Three-arm, Phase 2 Study. J Clin Aesthet Dermatol 2016;9(2):34-41 PMID: 27313822.