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Nail psoriasis
Evidence Levels: A Double-blind study B Clinical trial ≥ 20 subjects C Clinical trial < 20 subjects D Series ≥ 5 subjects E Anecdotal case reports
Nail changes are reported in up to 50%–60% of psoriatic patients; among patients with psoriatic arthritis, the prevalence is even higher (80%). Isolated nail psoriasis is present instead in 5%–10% of psoriatic patients. Depending on the anatomic area affected, the disease presents with different clinical signs: irregular pitting, leukonychia, red spots in the lunula, nail plate thickening and crumbling (typical of nail matrix inflammation); salmon patches, onycholysis, splinter hemorrhages and subungual hyperkeratosis (typical of nail bed inflammation); and paronychia (typical of nailfold inflammation). All these signs could present together in the same patient and even in the same nail.
Management Strategy
When dealing with possible nail psoriasis, it is very helpful to look for specific clinical signs with the aid of a dermatoscope. A biopsy is rarely necessary, but if it has to be performed, it is important to choose the right anatomical area based on nail changes, selecting the nail bed as the biopsy site when possible.
Due to the association with psoriatic arthritis, it is mandatory to ask about pain and swelling, referring the patient to a rheumatologist, if necessary. Associated conditions like onychomycosis should be always ruled out and treated first.
Nail disorders in general are difficult and frustrating to treat – nail psoriasis is no exception.
Due to the slow growth rate of the nail plate and the difficulty for drugs to penetrate the nail tissues, it is usually necessary to wait several months before seeing improvement. Clinicians are often reluctant to prescribe systemic treatment when the disease is localized only to the nails. Treatment should be selected according to the types and severity of clinical signs, number of affected nails, the extent of psoriasis on the skin/joints, comorbidities, considering previous successful/unsuccessful treatments, patient age, and, above all, QoL.
For mild-to-moderate cases, a cream containing calcipotriol and betamethasone dipropionate is useful, in particular for nail bed disease. Effectiveness can be improved with an overnight occlusion, after trimming the onycholytic plate. Application of topical tazarotene 0.1% , with or without occlusion, is another good option, but irritation of the nailfolds occurs frequently. Both calcipotriol and tazarotene are unable to reach the nail matrix if applied on the proximal nailfold. In case of nail matrix psoriasis, a high potency steroid (clobetasol propionate 0.05%) is a better option, but it has been proven that if applied for a long time, it may cause bone atrophy. Intralesional monthly injections of triamcinolone acetonide 5–10 mg/mL are then more appropriate, but feasible only for matrix psoriasis, as it is too painful in the nail bed. In severe cases systemic treatment should be considered. Oral acitretin at low dosage is a good option both for matrix and bed psoriasis. Subungual hyperkeratosis and thickening improve more than onycholysis and pitting, but when the nail plate is thin and fragile acitretin is not recommended because it could worsen the condition. Methotrexate and oral ciclosporin are therefore better options, with methotrexate seeming to give better results for matrix psoriasis and oral ciclosporin for bed psoriasis. The presence of psoriasis in other body areas is also very important in the choice of the drug, since acitretin and ciclosporin are much more effective on skin than joints psoriasis.
Apremilas t, a small-molecule inhibitor of PDE 4, is not approved yet for nail psoriasis alone, but both matrix and bed psoriasis improved significantly in clinical studies on psoriasis. The same has been for tofacitinib , an oral Janus kinase (JAK) 1/3 inhibitor.
The higher success rate in clinical studies has been, however, achieved by biologicals. They act very fast compared with conventional drugs with the exception of ciclosporin. Adalimumab is the only biological approved for nail psoriasis (US Food and Drug Administration [FDA] only). Others should be used off-label. They include brodalumab , certolizumab pegol , etanercept , golimumab , guselkumab , infliximab , ixekizumab , risankizumab , secukinumab , tildrakizumab , and ustekinumab . Research is, however, very active in this field and many new drugs are currently on trial.
Recommendations for the definition, evaluation, and treatment of nail psoriasis in adult patients with no or mild skin psoriasis: a dermatologist and nail expert group consensus
Rigopoulos D, Baran R, Chiheb S, et al. J Am Acad Dermatol 2019; 81: 228–40.
A consensus group, made up of a panel of dermatologists with special expertise in nail disorders, established an agreement regarding the definition, severity, and treatment response of nail psoriasis. In the case of matrix involvement only, intralesional steroid injections were considered the treatment of choice. Topical steroids alone or in combination with topical vitamin D analogs were suggested for nail psoriasis limited to the nail bed. For the systemic treatment of nail psoriasis, acitretin, methotrexate, ciclosporin, small molecules, and biologics are all recommended.
Specific Investigations
The availability of sensitive, responsive, specific, and validated scoring is essential for drug research and comparison of clinical trials. This kind of evaluation is still missing in nail psoriasis. NAPSI is the tool most commonly used, followed by target-NAPSI, where only the most seriously affected nail is taken into account, remaining always the same even if it is no longer the most affected.
Dermoscopy can be a valid aid to distinguish clinically between nail psoriasis and traumatic onycholysis (homogeneous background with a linear line of detachment of the plate from the bed). Additionally, it can identify the presence of fungi (white–yellow longitudinal indentations). When applied to the hyponychium, it diagnoses nail psoriasis through the presence of dilated, tortuous, elongated, and irregularly distributed capillaries. Dermoscopy can be used also to monitor treatment outcomes.
Ultrasound imaging (HFUS), reflectance confocal microscopy (RCM), and optical coherence tomography (OCT) have been recently recognized as adjunct tools in the early diagnosis and monitoring of nail psoriasis. They recognize submillimeter lesions and the nail unit blood flow in real time. Each of these modalities varies in depth of penetration, resolution, and visual representation. HFUS provides the deepest penetration depth and RCM has the best resolution. OCT has the advantage of capturing images in both the horizontal and vertical planes, but the main advantage is the capability of producing 3-D images of dynamic blood perfusion within the microcirculatory tissue beds without the use of any contrast agent.
Comparison of nail lacquer clobetasol efficacy at 0.05%, 1% and 8% in nail psoriasis treatment: prospective, controlled and randomized pilot study
Nakamura RC, Abreu L, Duque-Estrada B, et al. Ann Bras Dermatol 2012; 87: 203–11.
A split-hand study of 15 patients was performed with application of 0.05%, 1%, or 8% clobetasol nail lacquer on the left hand and a placebo lacquer on the right hand 2/week for 16 weeks. The treated group showed 51% improvement in modified NAPSI compared with baseline.
No difference was observed across different concentrations of lacquers. Improvements were observed more on nail bed signs.
Treatment of nail psoriasis with topical application of clobetasol propionate 0.05% solution: a pilot study
Brandi N, Starace M, Alessandrini A, et al. Eur J Dermatol 2018; 28: 111–2.
Topical application of clobetasol propionate 0.05% solution once daily for 4–6 months on the periungual tissues and nail bed was studied in mild nail psoriasis: 10/15 patients showed marked improvement of the nail lesions and 5/15 achieved complete resolution.
Nail bed signs responded more, but matrix signs also improved.
Calcipotriol ointment in nail psoriasis: a controlled double-blind comparison with betamethasone dipropionate and salicylic acid
Tosti A, Piraccini BM, Cameli N, et al. Br J Dermatol 1998; 139: 655–9.
This study compared twice-daily application of calcipotriol ointment (50 mcg/g) to betamethasone dipropionate (64 mg/g) plus salicylic acid (0.03 g/g) ointment to the nails of 58 patients for 3–5 months. There was 49.2% and 51.7% reduction in fingernail subungual hyperkeratosis and 20.1% and 22.9% reduction in the toenails in the calcipotriol and betamethasone dipropionate plus salicylic acid groups, respectively; however, the difference between the two treatment groups was not statistically significant.
Even severe nail bed psoriasis can be improved, with results being seen in 3 months.
Nail psoriasis: a combined treatment using calcipotriol cream and clobetasol propionate cream
Rigopoulos D, Ioannides D, Prastitis N, et al. Acta Derm Venereol 2002; 82: 140.
Calcipotriol cream is used overnight for five times a week and clobetasol cream overnight twice a week. This combination produced a greater improvement of subungual hyperkeratosis (77%), maintained with the steroid cream only, used overnight twice a week.
This is an option to minimize the side effects related to superpotent topical steroids, but the greatest effects are obtained on nail bed psoriasis.
Treatment of nail psoriasis with a two-compound formulation of calcipotriol plus betamethasone dipropionate ointment
Rigopoulos D, Gregoriou S, Daniel CR, et al. Dermatology 2009; 218: 338–41.
Calcipotriol-betamethasone valerate ointment was applied once a day for 12 weeks: significant improvement was recorded for hyperkeratosis and onycholysis, moderate improvement for oil drops, and slight improvement for pitting.
NAPSI at baseline was 5.8 ± 1.7, meaning an extremely mild nail psoriasis and, again, greater improvement achieved for bed psoriasis.
Nail psoriasis: treatment with tazarotene 0.1% hydrophilic ointment
Fischer-Levancini C, Sánchez-Regaña M, Llambí F, et al. Actas Dermosifiliogr 2012; 103: 725–8.
Six patients applied tazarotene 0.1% ointment under occlusion every night for 6 months. A statistically significant improvement was observed in all patients. Percentage improvement at the end of treatment was 87.9%.
This study, like all the studies on topical steroids (alone or in combination), showed a better response for nail bed signs of psoriasis. However, tazarotene is irritating and not well tolerated even if not under occlusion.
Treatment of psoriatic nails with tazarotene 0.1% cream vs. clobetasol propionate 0.05% cream: a double-blind study
Rigopoulos D, Gregoriou S, Katsambas A. Acta Derm Venereol 2007; 87: 167–8.
A group of patients was instructed to apply tazarotene 0.1% cream to nail plates, nailfolds, and periungual skin under occlusion overnight for 12 weeks. The second group was instructed to apply clobetasol propionate 0.05% cream in the same way. Patients showed a significant improvement of pitting, onycholysis, hyperkeratosis, and salmon patches with both agents.
Discontinuation of therapy resulted in regression of the signs for both groups, with the exception of hyperkeratosis, which seemed to retain significant improvement 12 weeks after the end of treatment for the patients applying tazarotene.
Tacrolimus 0.1% ointment in nail psoriasis: a randomized controlled open-label study
De Simone C, Maiorino A, Tassone F, et al. J Eur Acad Dermatol Venereol 2013; 27: 1003–6.
A single-blind, split-hand study of 21 patients treated with tacrolimus 0.1% ointment nightly for 12 weeks showed a significant 13-point reduction in NAPSI in the treated hands and a 3-point reduction in the untreated hands compared with baseline.
In our experience, topical tacrolimus is well tolerated by patients with nail psoriasis.
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