From the Guidelines
Treatment of nail dystrophy in psoriasis should prioritize biologic DMARDs, such as TNF inhibitors, IL-17 inhibitors, IL-12/23 inhibitors, and IL-23 inhibitors, due to their strong evidence base and recommendation by recent guidelines 1. When considering treatment options for nail dystrophy in psoriasis, it's essential to weigh the benefits and risks of various approaches.
- Topical therapies, including calcipotriol and glucocorticoid preparations, can be considered for mild cases.
- Systemic medications like methotrexate, acitretin, and ciclosporin may be effective for more severe cases, but their use should be guided by the presence of comorbidities and activity in other psoriatic arthritis domains.
- Intralesional glucocorticoids and pulsed dye laser are also options, although evidence for their use in nail psoriasis is limited. The selection of a specific biologic DMARD should be informed by head-to-head studies in psoriasis, comorbidities, and activity in other PsA domains, as recommended by the GRAPPA guidelines 1. It's crucial to note that improvement in nail dystrophy 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. Patients should also practice gentle nail care, avoid trauma, keep nails trimmed short, and use moisturizers regularly to support treatment outcomes. Recent studies, such as those published in the Journal of the American Academy of Dermatology 1, support the use of biologics like ustekinumab for the treatment of moderate-to-severe plaque psoriasis, including cases with nail involvement. However, the most recent and highest-quality study, published in Nature Reviews Rheumatology 1, provides the strongest evidence base for the treatment of nail dystrophy in psoriasis, emphasizing the importance of biologic DMARDs.
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 options for nail dystrophy in psoriasis include HUMIRA (adalimumab), which has been shown to improve nail symptoms in patients with moderate to severe psoriasis.
- Key benefits of HUMIRA for nail dystrophy in psoriasis include:
- Improvement in PGA-F score
- Achievement of mNAPSI 75
- Reduction in nail pain 2
From the Research
Treatment Options for Nail Dystrophy in Psoriasis
- Topical treatments, including corticosteroids, calcipotriol, tacrolimus, and tazarotene, have been shown to be effective in treating nail psoriasis, particularly in mild cases 3
- Intralesional corticosteroids can also be used to treat nail psoriasis, especially for individual digits that require focused intensive treatment 4, 5
- Systemic treatments, such as methotrexate, cyclosporine, acitretin, and apremilast, can be effective in treating nail psoriasis, especially in patients with severe skin disease or significant impairment of quality of life 3, 4, 6
- Biologic agents, including anti-tumor necrosis factor-α, anti-interleukin (IL)-17, and anti-IL-12/23 antibodies, have been shown to be highly effective in treating nail psoriasis, especially in patients with severe disease or psoriatic arthritis 3, 4, 6
Specific Treatment Recommendations
- For disease limited to the nails, high-potency topical corticosteroids with or without calcipotriol are initial options 4
- For patients with significant nail disease for whom topical therapy has failed, treatment with adalimumab, etanercept, intralesional corticosteroids, ustekinumab, methotrexate sodium, and acitretin are recommended 4
- For patients with significant skin and nail disease, adalimumab, etanercept, and ustekinumab are strongly recommended, and methotrexate, acitretin, infliximab, and apremilast are recommended 4