What are the treatment options for nail psoriasis?

Treatment Options for Nail Psoriasis

For mild nail psoriasis limited to the nails, start with topical combination therapy using calcipotriene/betamethasone dipropionate applied to the nail plate, while for moderate to severe disease or when topical therapy fails, biologic DMARDs (particularly TNF inhibitors, IL-17 inhibitors, or IL-23 inhibitors) are the most effective treatment options. 1, 2, 3

Disease Severity Assessment and Treatment Selection

Nail psoriasis should be considered a "vulnerable area" that warrants systemic therapy consideration even with limited body surface area involvement, particularly when symptomatic (pain, bleeding) or causing more than minimal impact on quality of life. 4

Criteria for Topical Therapy Alone:

• Generally asymptomatic nail disease 4
• Minimal impact on quality of life 4
• Amenable and responsive to localized therapy 4
• No concurrent psoriatic arthritis or extensive skin involvement 3

Criteria for Systemic Therapy:

• Symptomatic nail disease (pain, bleeding, itching) 4
• More than minimal impact on quality of life 4
• Inadequate response to topical therapy 4
• Concurrent psoriatic arthritis or extensive skin disease 3

First-Line Topical Treatment for Mild Nail Psoriasis

Apply calcipotriene/betamethasone dipropionate combination product once daily to the nail plate for 4-8 weeks to reduce nail thickness, hyperkeratosis, onycholysis, and pain. 1, 2

Alternative Topical Options:

• High-potency topical corticosteroids (clobetasol 0.05% cream) under occlusion for nail plate disease 1
• Tazarotene 0.1% cream under occlusion shows comparable efficacy to clobetasol when applied for 12 weeks 1, 2
• Mid to high-potency corticosteroid ointments (not creams) applied twice daily to nail folds for periungual inflammation 5

Critical Topical Therapy Pitfalls:

• Never combine salicylic acid with calcipotriene simultaneously—the acidic pH inactivates calcipotriene completely 1, 2
• Topical treatments have significant limitations for severe nail disease due to poor penetration of the nail plate and matrix 1, 5
• Tazarotene is contraindicated during pregnancy 1
• Warm, moist nail fold environments increase medication penetration and risk of irritation/atrophy with potent topicals 5

Nail Fold-Specific Management

For periungual inflammation and nail fold psoriasis:

• First-line: Mid-potency topical corticosteroid ointment twice daily for 2-4 weeks, then taper to twice weekly maintenance 5
• Second-line: Topical calcineurin inhibitors (tacrolimus 0.1% ointment) twice daily for persistent inflammation, as they do not cause atrophy 1, 5
• Adjunctive therapy: Daily dilute vinegar soaks (10-15 minutes twice daily) for periungual inflammation 5

Systemic Biologic Therapy for Moderate to Severe Nail Psoriasis

Biologic DMARDs are strongly recommended as the most effective treatment for moderate to severe nail psoriasis, particularly with concurrent psoriatic arthritis. 1, 3

First-Line Biologic Options (in order of evidence strength):

TNF Inhibitors:

• Adalimumab: 80 mg initial dose, then 40 mg every other week starting Week 1—achieves 47% mNAPSI 75 response at 26 weeks versus 3% for placebo (P<0.001) 6, 3
• Infliximab: 5 mg/kg shows 57.2% nail score improvement versus -4.1% for placebo (P<0.001) after medium-term treatment 7
• Golimumab: 50 mg shows 33% improvement, 100 mg shows 54% improvement versus 0% for placebo (P<0.001) 7
• Etanercept: Recommended for significant nail disease, though may be less effective in patients with high BMI 4, 3

IL-17 Inhibitors:

• Secukinumab and ixekizumab are strongly recommended as first-line options 1

IL-12/23 and IL-23 Inhibitors:

• Ustekinumab, guselkumab, and risankizumab are strongly recommended as first-line options 1, 3

When to Choose Biologics:

• Significant nail disease with failed topical therapy 3
• Concurrent moderate to severe skin psoriasis 3
• Concurrent psoriatic arthritis 1, 3
• Major impact on quality of life despite topical treatment 3

Conventional Systemic Therapy Options

For patients where biologics are not appropriate or accessible:

• Methotrexate: Recommended for significant nail disease with skin and/or joint involvement 3
• Acitretin: Recommended option, though evidence is limited 3
• Cyclosporine: Can be effective but evidence is limited 8
• Apremilast: Recommended for patients with nail, skin, and joint disease 3

Important caveat: Systemic corticosteroids should be avoided in psoriasis as monotherapy because skin disease can flare during or after taper. 4

Intralesional Corticosteroid Therapy

Intralesional triamcinolone acetonide (10 mg/ml) injected into the nail bed and matrix following ring block anesthesia is recommended for significant nail disease when topical therapy has failed. 3, 9

Technique and Efficacy:

• Inject into nail bed and matrix with ring block anesthesia 9
• Repeat injection after 2 months if warranted by poor response 9
• Shows improvement in pitting (57.7%), onycholysis (40.5%), and subungual hyperkeratosis (100%) 9
• Side effects are minimal (painless subungual hematoma) 9

Treatment Algorithm by Clinical Scenario

Scenario 1: Disease Limited to Nails

• Start with high-potency topical corticosteroids with or without calcipotriol 3
• If failed: Consider adalimumab, etanercept, intralesional corticosteroids, ustekinumab, methotrexate, or acitretin 3

Scenario 2: Significant Nail and Skin Disease

• Strongly recommended: Adalimumab, etanercept, ustekinumab 3
• Recommended: Methotrexate, acitretin, infliximab, apremilast 3

Scenario 3: Significant Nail, Skin, and Joint Disease

• Recommended: Adalimumab, etanercept, ustekinumab, infliximab, methotrexate, apremilast, golimumab 3

Essential Clinical Considerations

Always evaluate for onychomycosis before treating nail psoriasis, as fungal infection may complicate psoriatic nail disease and requires antifungal treatment. 5, 3

Monitoring and Maintenance:

• Treatment response should be assessed using validated nail scores (NAPSI, mNAPSI) 6, 7
• Complete remissions are uncommon; nail psoriasis typically has a chronic course 10
• Sun exposure does not usually improve and may worsen nail psoriasis 10

Quality of Life Impact:

• Nail psoriasis causes significant psychosocial, aesthetic, and functional problems 10
• Treatment decisions should balance extent of disease with quality of life impairment 3
• Nail pain improvement should be monitored as a treatment outcome 6