What is the recommended treatment for a patient with nail psoriasis?

Treatment of Nail Psoriasis

For mild nail psoriasis (≤3 affected nails), start with topical calcipotriene/betamethasone dipropionate applied once daily to reduce nail thickness, hyperkeratosis, and onycholysis; for moderate-to-severe disease (>3 nails, functional impairment, or concurrent psoriatic arthritis), biologic DMARDs—particularly TNF inhibitors, IL-17 inhibitors, or IL-23 inhibitors—are the most effective treatment. 1

Severity-Based Treatment Algorithm

Mild Disease (≤3 Affected Nails)

First-Line Topical Options:

• Calcipotriene/betamethasone dipropionate combination applied once daily for 4-12 weeks is the preferred initial treatment, targeting nail thickness, hyperkeratosis, onycholysis, and pain 1, 2
• Tazarotene 0.1% cream applied under occlusion shows significant improvement in the Nail Psoriasis Severity Index, particularly for onycholysis and pitting 1, 3, 4
  • In one study, tazarotene 0.1% ointment under occlusion achieved 87.9% improvement in NAPSI scores at 6 months 4
  • Critical warning: Tazarotene is teratogenic and contraindicated in pregnancy; females of reproductive potential must use effective contraception 1, 5
• High-potency topical corticosteroids (clobetasol 0.05% cream) applied under occlusion for nail matrix involvement 1

Intralesional Therapy:

• Triamcinolone acetonide 5-10 mg/cc injections are highly effective for nail matrix involvement when fewer than 3 nails are affected 1
• This approach is more effective for nail matrix disease, while topical treatments work better for nail bed involvement 1

For Nail Fold Inflammation:

• Mid-to-high potency topical corticosteroid ointments (not creams) applied twice daily to periungual areas for edema and pain 6
• Topical calcineurin inhibitors (tacrolimus 0.1% or pimecrolimus) are well-tolerated alternatives that do not cause atrophy, making them ideal for nail folds 6

Moderate-to-Severe Disease (>3 Nails, Functional Impairment, or Concurrent Psoriatic Arthritis)

Biologic DMARDs (First-Line Systemic Therapy):

• TNF inhibitors, IL-17 inhibitors, IL-12/23 inhibitors, and IL-23 inhibitors are strongly recommended as the most effective treatment for moderate-to-severe nail psoriasis 1
• Specific agents include adalimumab, etanercept, infliximab, golimumab, secukinumab, ixekizumab, ustekinumab, guselkumab, and risankizumab 1
• Adalimumab demonstrated 47% mNAPSI 75 response at 26 weeks 1
• Infliximab 5 mg/kg showed 57.2% nail score improvement versus -4.1% for placebo (P < 0.001) 7
• Golimumab 50 mg and 100 mg showed 33% and 54% improvement, respectively, versus 0% for placebo (P < 0.001) 7
• IL-17 inhibitors may have superior short-term efficacy compared to IL-23 and TNF-alpha inhibitors, though long-term efficacy is similar 1

Second-Line Systemic Options:

• Acitretin 0.2-0.4 mg/kg/day for patients with more than 3 affected nails 1
  • One case report showed marked improvement after 2 months with progressive improvement at 6 months when combined with urea nail lacquer 8
• Methotrexate 15 mg/week, particularly when significant skin involvement is present 1
• Cyclosporine may be effective but should be limited to less than 12 consecutive months due to cumulative nephrotoxicity 1
• Apremilast is a second-line option 1

Critical Clinical Considerations

Important Precautions:

• Never combine calcipotriene with salicylic acid—the acidic pH inactivates calcipotriene and reduces effectiveness 1, 2, 6
• Never use systemic corticosteroid monotherapy for psoriasis, as skin disease can flare during or after taper, potentially triggering pustular or erythrodermic forms 1
• Apply calcipotriene after phototherapy sessions, as UVA radiation decreases calcipotriene concentration 2
• Warm, moist environments like nail folds increase medication penetration, raising the risk of irritation and atrophy with potent topical medications 6

Limitations of Topical Therapy:

• Topical treatments have significant limitations in treating severe nail disease due to poor penetration of the nail plate 1, 6
• This is why systemic therapy becomes necessary when topical treatments fail or when more than 3 nails are affected 1

Special Population Considerations:

• Nail psoriasis is considered a vulnerable area that may warrant systemic therapy even with limited body surface area involvement, due to the high risk of progressive psoriatic arthritis 1
• Etanercept may be less effective in patients with high BMI 1

Adjunctive Measures

• Emollients and moisturizers can be used as frequently as desired and should be applied at least 1 hour before tazarotene cream in psoriasis patients 2, 5
• Daily dilute vinegar soaks (10-15 minutes twice daily) can be beneficial for managing periungual inflammation 6
• Differentiate between nail fold inflammation and onychomycosis, which requires antifungal treatment 6