What are the treatment options for psoriasis of the toenails (onychopsoriasis)?

From the Guidelines

Topical vitamin D analogues combined with betamethasone dipropionate are recommended for the treatment of nail psoriasis to reduce nail thickness, hyperkeratosis, onycholysis, and pain. Treating toenail psoriasis typically requires a combination of approaches, starting with topical treatments like corticosteroids, vitamin D analogs (calcipotriol), or tazarotene applied directly to affected nails and surrounding skin 1. For more severe cases, consider intralesional steroid injections where triamcinolone (2.5-10 mg/mL) is injected at the nail matrix.

Key Treatment Considerations

• Topical treatments: vitamin D analogs, corticosteroids, or tazarotene
• Intralesional steroid injections for severe cases
• Oral medications: methotrexate, cyclosporine, or biologics like adalimumab or secukinumab for widespread or resistant cases
• Maintain good nail hygiene: keep nails trimmed short, avoid trauma, and use moisturizers containing urea or salicylic acid to reduce thickness
• Phototherapy with UVB light can also help when administered by a dermatologist These treatments work by reducing inflammation, normalizing skin cell growth, and modulating the immune response that triggers psoriasis 1. Treatment typically requires patience, as nail growth is slow and visible improvement may take 3-6 months. Consult a dermatologist for proper diagnosis and personalized treatment, especially before starting systemic medications which require monitoring for potential side effects.

Important Considerations for Treatment

• Simultaneous use of salicylic acid with calcipotriene should be avoided because the acid pH of salicylic acid will inactivate calcipotriene and reduce its effectiveness 1
• Topical maxcalcitol (not available in the US) ointment can be considered as an initial treatment for palmoplantar psoriasis, including palmoplantar pustulosis 1
• Combination products with calcipotriene and topical nicotinamide are effective for the treatment of mild to moderate psoriasis 1

From the FDA Drug Label

To treat moderate to severe chronic (lasting a long time) plaque psoriasis (Ps) in adults who have the condition in many areas of their body and who may benefit from taking injections or pills (systemic therapy) or phototherapy (treatment using ultraviolet light alone or with pills). HUMIRA is used: To reduce the signs and symptoms of: psoriatic arthritis (PsA) in adults.

The treatment options for psoriasis of the toenails (onychopsoriasis) may include systemic therapy or phototherapy, as adalimumab (HUMIRA) is used to treat moderate to severe chronic plaque psoriasis in adults. However, the label does not explicitly mention onychopsoriasis. 2

From the Research

Treatment Options for Onychopsoriasis

The treatment options for onychopsoriasis, also known as nail psoriasis, include:

• Topical treatments, such as corticosteroids, calcipotriol, tacrolimus, and tazarotene, which have been shown to be effective in mild cases 3, 4, 5
• Intralesional corticosteroids, which can be effective in treating nail psoriasis 3, 6
• Conventional systemic treatments, including methotrexate, cyclosporine, acitretin, and apremilast, which can be effective in treating nail psoriasis 3, 4, 6, 7
• Biologic systemic treatments, such as anti-tumor necrosis factor-α, anti-interleukin (IL)-17, and anti-IL-12/23 antibodies, which have been shown to be highly effective in treating nail psoriasis 3
• Non-pharmacological treatment options, including phototherapy, photodynamic therapy, laser therapy, and radiotherapeutic options, which may be considered in some cases 3

Specific Treatment Recommendations

• For disease limited to the nails, high-potency topical corticosteroids with or without calcipotriol are initial options 6
• 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 6
• For patients with significant skin and nail disease, adalimumab, etanercept, and ustekinumab are strongly recommended, and methotrexate, acitretin, infliximab, and apremilast are recommended 6
• For a patient with significant nail, skin, and joint disease, adalimumab, etanercept, ustekinumab, infliximab, methotrexate, apremilast, and golimumab are recommended 6

Case Studies

• A study of 10 patients with nail psoriasis treated with 8% clobetasol nail lacquer showed positive results, with improvement in nail alterations and no local or systemic side effects 5
• A case study of a patient with severe 20-nail psoriasis successfully treated with low-dose methotrexate, with complete resolution of nail dystrophy after 9-13 months of therapy 7