A pilot study of intralesional methotrexate injections versus triamcinolone acetonide in patients affected by nail matrix psoriasis

Abstract

Summary Nail disorders in general are difficult to treat and often frustrating, and this is also the case with nail psoriasis, especially when it is limited to the nails, and not affecting joints. The quality of life of patients with nail psoriasis is negatively affected, owing to the chronic course of the disease and frequent relapses. The purpose of this study was to compare treatment response and maintenance of response during follow‐up of 12 patients with nail matrix psoriasis limited to a few nails, who were treated with intralesional injections of either methotrexate (MTX) 25 mg/mL or triamcinolone acetonide 10 mg/mL. Patients were treated every 6 weeks for 24 weeks and followed up for 6 months. Photographic documentation and assessment by Nail Psoriasis Severity Index were performed during each treatment session and at each follow‐up visit. At the end of the four treatment sessions, all patients had improvement of their disease, which continued during follow‐up, especially for the MTX‐treated group.

The Anti-Psoriatic Efficacy and Safety Profile of Topical and Intralesional Methotrexate: A Literature Review

“…Nevertheless, its side effects—especially pain, subungual hematoma and transient post-injection numbness—may limit its usage. 44 , 46 , 48 , 53 …”

“… - Local AE: N/A - Systemic AE: No Duarte et al (2019) 45 Case report 2 (2) Nail matrix 0.1 ml of MTX 25 mg/ml - Every 30 days 3 months Improvement - Local AE: N/A - Systemic AE: N/A Jindal et al (2020) 47 Case report 1 (1) ACH Nail matrix 0.2 ml of MTX 5 mg/ml - Monthly 4 months Completely disappear of lesion - Local AE: N/A - Systemic AE: N/A Choudhary et al (2021) 44 Prospective study 20 (89) Nail matrix 2.5 mg - Weekly 6 weeks NAPSI score decrease significantly from 3.70 (baseline) to 0.67 at 12 weeks. - Local AE: Pain at injection site (10%), acute paronychia (5%) - Systemic AE: No Starace et al (2022) 53 Prospective study 12 (20) Nail matrix 0.1 ml of MTX 25 mg/ml 0.1 ml of 10 mg/ml triamcinolone acetonide 4 injections with an interval of 6 weeks. 24 weeks Nail psoriasis responded well to both treatment but more stability was noted at follow-up period in MTX group - Local AE: Subungual hematoma - Systemic AE: N/A Alakad et al (2022) 52 RCT 28 (123) Nail matrix and nail bed 0.02 ml of MTX 25 mg/ml Fractional CO 2 laser followed by topical application of 0.1 mL of MTX 25 mg/mL Biweeky for 6 treatment sessions …”

“…Eleven studies examined the use of intralesional MTX for psoriasis (Table 4). 15,[44][45][46][47][48][49][50][51][52][53] One study of its efficacy for psoriasis skin lesions found no significant improvements. By contrast, all 10 studies investigating its efficacy for nail psoriasis demonstrated significant improvements in the nail matrix and nail bed.…”

“…Nevertheless, its side effects-especially pain, subungual hematoma and transient post-injection numbness-may limit its usage. 44,46,48,53 There were 3 studies comparing the efficacy of intralesional MTX (25 mg/mL) for nail psoriasis with intralesional triamcinolone acetonide (10 mg/mL). 48,51,53 Two studies reported the good and comparable efficacy of intralesional methotrexate and triamcinolone acetonide with more stability of the result from MTX group in one study.…”

“…44,46,48,53 There were 3 studies comparing the efficacy of intralesional MTX (25 mg/mL) for nail psoriasis with intralesional triamcinolone acetonide (10 mg/mL). 48,51,53 Two studies reported the good and comparable efficacy of intralesional methotrexate and triamcinolone acetonide with more stability of the result from MTX group in one study. 48,53 While Abdelmeniem et al reported that the mean Nail Psoriasis Severity Index (NAPSI) score improvement of intralesional MTX was less than intralesional triamcinolone acetonide and topical 0.005% calcipotriol cream plus 20% urea under occlusion at psoriatic nail.…”