Management of nail psoriasis

Abstract

Nail involvement is estimated to affect 80-90% of patients with psoriasis at some point in their lives and is often associated with severe disease. Patients with nail involvement experience pain, functional impairment and social stigma, with significant restriction of daily activities and quality of life. Nail psoriasis is also considered a risk factor for the development of psoriatic arthritis (PsA). Management of nail psoriasis is deemed challenging and as a result, it is often left untreated by physicians. Assessing the severity of nail disease can also be difficult in clinical practice. While the Nail Psoriasis Severity Index is used widely in trials, it is time-consuming and rarely used in the clinic, highlighting the need to develop a simplified disease severity score for nail psoriasis. All patients should be advised to keep their nails short, wear gloves for wet and dirty work, and regularly apply emollient to the nail folds and nail surface. Patients with mild nail psoriasis, without signs of severe cutaneous psoriasis or PsA, may benefit from topical treatment, while systemic treatment is indicated in patients with severe nail involvement. Evidence suggests that all antitumour necrosis factor (TNF)-a, anti-interleukin (IL)-17, and anti-IL-12/23 antibodies available for plaque psoriasis and PsA are highly effective treatments for nail psoriasis. This article aims to provide an up-to-date review of the therapeutic options currently available for the management of nail psoriasis in patients with or without skin psoriasis. Therapeutic options for the management of nail psoriasis in children will also be discussed.

Ultrasound Evaluation of the Effectiveness of the Use of Acitretin in the Treatment of Nail Psoriasis

“…In one study, intramatricial methotrexate administration was found to be more effective in treating nail psoriasis than administration of triamcinolone or cyclosporine, with fewer side effects [ 30 ]. Undoubtedly, a breakthrough in the treatment of nail psoriasis was the use of biological drugs [ 15 , 16 , 31 ]. Biologic therapy including anti-TNF-a, IL-17 and IL-12/23 antibodies used in the treatment of psoriasis and PsA appears to be highly effective in the treatment for nail psoriasis [ 15 , 16 , 31 ] as well as small molecule therapies [ 15 , 16 , 32 ].…”

“…Undoubtedly, a breakthrough in the treatment of nail psoriasis was the use of biological drugs [ 15 , 16 , 31 ]. Biologic therapy including anti-TNF-a, IL-17 and IL-12/23 antibodies used in the treatment of psoriasis and PsA appears to be highly effective in the treatment for nail psoriasis [ 15 , 16 , 31 ] as well as small molecule therapies [ 15 , 16 , 32 ]. In recent studies, also apremilast showed fast and sustained improvement of nail psoriasis [ 33 , 34 , 35 ].…”

“…In recent studies, also apremilast showed fast and sustained improvement of nail psoriasis [ 33 , 34 , 35 ]. Biological drugs exert a faster effect than conventional drugs in the treatment of nail psoriasis [ 16 ]. It seems, however, that due to the high incidence of nail changes in psoriasis and the costs of therapy, conventional treatment, including acitretin, remains a valuable therapeutic option in everyday clinical practice.…”

“…In our study, after six months of treatment with acitretin in the group of patients, ultrasound examination showed a reduction in the thickness of the nail bed and matrix ( p = 0.046 and p = 0.031, respectively). The thickness of the nail plates also decreased, although it was statistically insignificant ( p = 0.059), which may indicate the need for longer treatment as acitretin is a slow-acting drug with moderate potency and the use of 6 months may be too short to achieve a significant improvement [ 16 ]. Additionally, in the study, the thickness of the nail plates was still greater than in the control group ( p = 0.034).…”

“…Treatment of nail psoriasis, particularly in severe cases, can be difficult. Acitretin, methotrexate, cyclosporin, biological drugs and small molecules are recommended in the systemic treatment of psoriatic changes of the nails [ 15 , 16 ]. Due to the high incidence of nail changes in psoriasis and the high costs of biological and small-molecule therapy, conventional treatment, including acitretin is still widely used in everyday clinical practice.…”