What are the treatment options for psoriasis nail?

Treatment of Nail Psoriasis

For mild nail psoriasis affecting fewer than 3 nails, start with high-potency topical corticosteroids (clobetasol 0.05%) combined with vitamin D analogues (calcipotriol), and for moderate-to-severe disease or when more than 3 nails are affected, biologic DMARDs—particularly IL-17 inhibitors, TNF inhibitors, or IL-23 inhibitors—are the most effective treatment options. 1, 2

Initial Assessment and Disease Stratification

Before initiating treatment, evaluate for onychomycosis as this commonly complicates psoriatic nail disease and requires antifungal therapy 2. Determine whether nail involvement is primarily nail matrix disease (pitting, leukonychia) versus nail bed disease (onycholysis, subungual hyperkeratosis) as this guides treatment selection 1.

Mild disease is defined as fewer than 3 affected nails with minimal functional impairment and quality of life impact 1. Moderate-to-severe disease includes more than 3 affected nails, significant functional impairment, or concurrent psoriatic arthritis 3, 1.

Treatment Algorithm for Mild Nail Psoriasis (≤3 nails)

First-Line Topical Therapy

• Apply combination therapy with topical vitamin D analogues (calcipotriol) and betamethasone dipropionate to reduce nail thickness, hyperkeratosis, onycholysis, and pain 1
• High-potency topical corticosteroids such as clobetasol 0.05% cream applied under occlusion are highly effective 1
• Tazarotene 0.1% cream under occlusion shows significant improvement in Nail Psoriasis Severity Index scores 1

Critical caveat: Never use salicylic acid simultaneously with calcipotriene—the acidic pH inactivates calcipotriene and eliminates its effectiveness 1, 4. Tazarotene is absolutely contraindicated in pregnancy and must be discontinued if pregnancy is recognized 1.

Alternative Topical Options

• Topical tacrolimus and topical ciclosporin are conditionally recommended, particularly for nail fold involvement where they avoid corticosteroid-induced atrophy 1, 4
• For nail fold inflammation specifically, mid-to-high potency corticosteroid ointments (not creams) applied twice daily are preferred 4

Intralesional Therapy for Nail Matrix Disease

• Intralesional triamcinolone acetonide 5-10 mg/cc is highly effective for nail matrix involvement when fewer than 3 nails are affected 1
• This approach is more effective for nail matrix disease (pitting) than nail bed disease 1

Important limitation: Topical treatments have poor penetration through the nail plate, limiting efficacy in severe disease 1, 4.

Treatment Algorithm for Moderate-to-Severe Nail Psoriasis (>3 nails)

First-Line Systemic Therapy: Biologic DMARDs

Biologic DMARDs are strongly recommended as the most effective treatment for moderate-to-severe nail psoriasis, particularly when concurrent psoriatic arthritis or extensive skin disease is present 1, 2.

Specific Biologic Recommendations by Clinical Scenario:

For nail disease with concurrent psoriatic arthritis:

• Adalimumab, etanercept, infliximab, golimumab, secukinumab, ixekizumab, ustekinumab, guselkumab, and risankizumab are all first-line options 1, 2
• All three TNF inhibitors have shown efficacy in phase 3 trials, though etanercept may be less effective in patients with high BMI 3
• Adalimumab demonstrated 47% mNAPSI 75 response at 26 weeks in a controlled trial specifically for nail psoriasis 5

For nail disease with significant skin involvement:

• Adalimumab, etanercept, and ustekinumab are strongly recommended 2
• Methotrexate, acitretin, infliximab, and apremilast are also recommended 2

Comparative efficacy note: IL-17 inhibitors may have superior short-term efficacy compared to IL-23 and TNF-alpha inhibitors, though long-term efficacy is similar to TNF-alpha inhibitors 6. IL-23 inhibitors and TNF-alpha inhibitors have comparable efficacy for nail psoriasis 6.

Second-Line Systemic Options

When biologics are not accessible or appropriate:

• Acitretin 0.2-0.4 mg/kg/day is recommended for patients with more than 3 affected nails 1
• Methotrexate 15 mg/week is particularly effective with significant skin involvement 1, 2
• Cyclosporine may be effective but must be limited to less than 12 consecutive months due to cumulative nephrotoxicity 1
• Apremilast is a second-line option 1, 2

Critical Clinical Pitfalls to Avoid

• Never use systemic corticosteroid monotherapy for psoriasis—skin disease can flare during or after taper, potentially triggering pustular or erythrodermic forms 3
• Do not overlook onychomycosis evaluation, as fungal infection commonly coexists and requires separate antifungal treatment 2
• Avoid prolonged high-potency topical steroids on nail folds due to increased absorption in warm, moist environments and risk of atrophy 4
• The efficacy of therapies for psoriatic nail disease is not well studied in older literature; specific recommendations were limited due to small study sizes and lack of appropriate controls 3

Special Considerations

• Nail psoriasis is considered a vulnerable area that may warrant systemic therapy even with limited body surface area involvement 3
• Patients with nail psoriasis have higher rates of progressive psoriatic arthritis and should be monitored accordingly 7, 8
• Daily dilute vinegar soaks (10-15 minutes twice daily) can be beneficial adjunctive therapy for periungual inflammation 4
• All patients should keep nails short, wear gloves for wet work, and regularly apply emollients to nail folds and surfaces 8, 9