What are the treatment options for nail psoriasis?

Treatment Options for Nail Psoriasis

Biologic DMARDs (TNF inhibitors, IL-17 inhibitors, IL-12/23 inhibitors, and IL-23 inhibitors) are strongly recommended as the most effective treatment for nail psoriasis, particularly for patients with moderate to severe disease or those with concurrent psoriatic arthritis. 1

Topical Treatments for Mild Nail Psoriasis

• Topical vitamin D analogues (calcipotriol) combined with betamethasone dipropionate can reduce nail thickness, hyperkeratosis, onycholysis, and pain, though they have limitations in treating severe nail disease due to poor penetration, particularly of the nail matrix 1
• Topical tazarotene 0.1% cream can be used for nail psoriasis, with studies showing significant improvement in the Nail Psoriasis Severity Index with respect to onycholysis, pitting, hyperkeratosis, and oil spots when applied under occlusion 1
• Topical corticosteroids, particularly high-potency formulations like clobetasol 0.05% cream, have shown efficacy for nail psoriasis when applied under occlusion 1
• Topical tacrolimus and topical ciclosporin are conditionally recommended options for nail psoriasis 1
• Intralesional glucocorticoids can be considered for focal nail disease 1, 2

Systemic Treatments for Moderate to Severe Nail Psoriasis

First-Line Systemic Options

• Biologic DMARDs have the strongest evidence for nail psoriasis treatment 1:

  • TNF inhibitors (adalimumab, etanercept, infliximab)
  • IL-17 inhibitors (secukinumab, ixekizumab)
  • IL-12/23 inhibitors (ustekinumab)
  • IL-23 inhibitors (guselkumab, risankizumab)

• Adalimumab has demonstrated significant efficacy for nail psoriasis in controlled trials, with 49% of patients achieving clear or minimal disease compared to 7% with placebo 3, 2

Second-Line Systemic Options

• Conventional systemic medications with conditional recommendations include 1, 4:
  • Ciclosporin
  • Methotrexate
  • Acitretin
  • JAK inhibitors
  • PDE4 inhibitors (apremilast)

Treatment Algorithm Based on Disease Severity

For Isolated Nail Psoriasis (Limited to Nails)

1. Start with topical therapies:

   • Vitamin D analogues combined with betamethasone dipropionate 1
   • Tazarotene 0.1% cream under occlusion 1
   • High-potency topical corticosteroids 1

2. If inadequate response after 3-6 months, consider:

   • Intralesional corticosteroid injections 1, 2
   • Systemic treatments if quality of life is significantly impacted 2, 5

For Nail Psoriasis with Concurrent Moderate-Severe Skin Disease

1. Biologic DMARDs are strongly recommended as first-line therapy 1:

   • TNF inhibitors (adalimumab, etanercept)
   • IL-17 inhibitors
   • IL-12/23 inhibitors
   • IL-23 inhibitors

2. Alternative systemic options include methotrexate, acitretin, ciclosporin, JAK inhibitors, and PDE4 inhibitors 1, 4

For Nail Psoriasis with Concurrent Psoriatic Arthritis

1. Biologic DMARDs are strongly recommended as first-line therapy 1:

   • TNF inhibitors (adalimumab, etanercept, infliximab, golimumab)
   • IL-17 inhibitors
   • IL-12/23 inhibitors
   • IL-23 inhibitors

2. Alternative systemic options include methotrexate, JAK inhibitors, and PDE4 inhibitors 1, 2

Important Clinical Considerations

• Always evaluate for concurrent onychomycosis, which may complicate psoriatic nail disease 2, 5
• Keep nails short, wear gloves for wet and dirty work, and regularly apply emollient to the nail folds and nail surface 5
• Topical treatments have limitations in treating severe nail disease due to poor penetration of the nail plate 1, 4
• Avoid simultaneous use of salicylic acid with calcipotriene as the acid pH will inactivate calcipotriene and reduce its effectiveness 1
• Tazarotene is contraindicated during pregnancy and should be discontinued if pregnancy is recognized 1
• Pulsed dye laser therapy can be considered for resistant cases, though evidence is limited 1, 6
• Agents with limited evidence that are not recommended include topical tazarotene (as monotherapy), dimethyl fumarates/fumaric acid esters, phototherapy, and alitretinoin 1

Treatment Duration and Monitoring

• Topical treatments typically require 3-6 months for significant improvement 2, 6
• Biologic treatments show more rapid improvement, often within 2-3 months 3, 2
• Regular monitoring of nail improvement using standardized scoring systems (NAPSI) is recommended to assess treatment efficacy 4, 6
• Patients should be counseled that nail psoriasis may be more resistant to treatment than skin psoriasis, and longer treatment durations may be necessary 4, 5