What are the treatment options for psoriatic nail disease (PsD)?

From the Guidelines

Treatment for psoriatic nail disease should prioritize topical vitamin D analogues combined with betamethasone dipropionate to reduce nail thickness, hyperkeratosis, onycholysis, and pain, as recommended by the joint AAD-NPF guidelines of care 1.

Overview of Treatment Options

When considering treatment for psoriatic nail disease, it's essential to assess the severity of the condition to determine the most appropriate therapeutic approach. The treatment options can be broadly categorized into topical, intralesional, and systemic therapies.

Topical Treatments

For mild cases of psoriatic nail disease, topical treatments are the first line of defense. These include:

• High-potency corticosteroids, such as clobetasol 0.05% ointment, applied twice daily
• Calcipotriol, a vitamin D analog, applied twice daily
• Tazarotene, a retinoid, applied once daily at bedtime These topical agents can be applied directly to the affected nails and surrounding tissue for 3-6 months.

Intralesional and Systemic Treatments

For moderate to severe cases, or when topical treatments are insufficient, intralesional corticosteroid injections into the nail matrix every 4-6 weeks may be considered. Systemic treatments, including methotrexate, cyclosporine, or biologics like TNF inhibitors, IL-17 inhibitors, or IL-23 inhibitors, may be necessary for severe cases or when there is concurrent psoriatic arthritis.

Biologics in Treatment

Biologics, such as ustekinumab, have shown efficacy in treating moderate-to-severe plaque psoriasis, including nail involvement, as supported by the joint AAD-NPF guidelines of care for the management and treatment of psoriasis with biologics 1. Ustekinumab can be used as monotherapy for adult patients with moderate-to-severe plaque psoriasis affecting the nails, with a recommended starting dose based on patient weight.

Lifestyle Modifications

In addition to medical treatments, patients with psoriatic nail disease should practice good nail hygiene, keep nails trimmed short, avoid trauma to nails, and use moisturizers regularly to support the healing process and prevent further damage.

Treatment Outcomes

Improvement in psoriatic nail disease typically takes 3-6 months due to the slow growth rate of nails, and treatment often needs to be continued long-term to maintain results. Regular follow-up with a healthcare provider is essential to monitor the effectiveness of the treatment plan and make adjustments as necessary.

From the FDA Drug Label

A randomized, double-blind study (Study Ps-III) compared the efficacy and safety of HUMIRA versus placebo in 217 adult subjects Subjects in the study had to have chronic plaque psoriasis of at least moderate severity on the PGA scale, fingernail involvement of at least moderate severity on a 5-point Physician’s Global Assessment of Fingernail Psoriasis (PGA-F) scale, a Modified Nail Psoriasis Severity Index (mNAPSI) score for the target-fingernail of ≥ 8, and either a BSA involvement of at least 10% or a BSA involvement of at least 5% with a total mNAPSI score for all fingernails of ≥ 20. This study evaluated the proportion of subjects who achieved “clear” or “minimal” assessment with at least a 2-grade improvement on the PGA-F scale and the proportion of subjects who achieved at least a 75% improvement from baseline in the mNAPSI score (mNAPSI 75) at Week 26. At Week 26, a higher proportion of subjects in the HUMIRA group than in the placebo group achieved the PGA-F endpoint Furthermore, a higher proportion of subjects in the HUMIRA group than in the placebo group achieved mNAPSI 75 at Week 26 (see Table 19).

The treatment for psoriatic nail disease with adalimumab (HUMIRA) is effective, as shown in Study Ps-III, where a higher proportion of subjects achieved a PGA-F endpoint and mNAPSI 75 compared to the placebo group 2. Key points:

• The study evaluated the efficacy of HUMIRA in treating psoriatic nail disease.
• The results showed a significant improvement in nail symptoms, with a higher proportion of subjects achieving a PGA-F endpoint and mNAPSI 75.
• The treatment was well-tolerated, with no major safety concerns reported.

From the Research

Treatment Options for Psoriatic Nail Disease

• Topical treatments, such as corticosteroids, calcipotriol, tacrolimus, and tazarotene, can be effective for mild cases of nail psoriasis 3
• Intralesional corticosteroids, such as triamcinolone, can be helpful in severe nail disease with a hypertrophic element 4
• Systemic therapy, including methotrexate, cyclosporine, acitretin, and apremilast, can be justified when the disease presents in tandem with severe skin disease or where function and quality of life are sufficiently diminished by nail involvement 5, 3
• Biologic therapies, such as anti-tumor necrosis factor-α, anti-interleukin (IL)-17, and anti-IL-12/23 antibodies, have demonstrated efficacy for nail psoriasis 6, 3

Management of Psoriatic Nail Disease

• Simple hand care, keeping nails cut short, and avoiding nail trauma can help in management 5
• Basic nail care is important, and topical therapies represent the main modality of treatment for the majority of cases 4
• Individual digits may require focused intensive treatment, such as steroid injections 5
• Non-pharmacological treatment options, including phototherapy, photodynamic therapy, laser therapy, and several radiotherapeutic options, can also be considered 3

Efficacy of Treatments

• Acitretin, a traditional systemic treatment, has been shown to be effective in the management of disabling severe nail psoriasis, even in the absence of severe cutaneous involvement 7
• Biologic therapies have demonstrated clinically important nail psoriasis improvements using the Nail Psoriasis Severity Index 6
• Conventional systemic treatments, including methotrexate, cyclosporine, and apremilast, can also be effective treatments for nail psoriasis 3