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

Concepts, Role, and Advances on Nail Imaging

This review discusses, from a practical point of view, the most common imaging techniques and their applications in nail pathologies with some technical considerations. There are several imaging techniques for studying the nail, and all of them require proper devices and trained operators. The highest axial resolution and a more extensive range of applications are provided by ultrasound, which currently is the first-choice imaging technique for evaluating nail conditions. A correlation of state-of-the-art clinical and imaging figures supports the review of this topic.

Pulse-Dye Laser Followed by Betamethasone-Calcipotriol and Fractional Ablative CO2-Laser-Assisted Delivery for Nail Psoriasis

BACKGROUND

Nail psoriasis is a common and potentially debilitating condition for which no effective and safe nonsystemic therapy is currently available. Recently, laser-assisted drug delivery (LADD) is being increasingly used to facilitate transcutaneous penetration of topical treatments.

OBJECTIVES

We set to assess the efficacy and safety of combined pulse-dye laser and fractional CO2 laser-assisted betamethasonecalcipotriol gel delivery for the treatment of nail psoriasis.

MATERIAL AND METHODS

We conducted a prospective, intrapatient comparative study in a series of 22 patients with bilateral fingernail psoriasis. Nails on the randomized hand were treated with 3 monthly sessions of pulse-dye laser to the proximal and lateral nail folds followed by fractional ablative CO2 laser to the nail plate. Between treatments and one month following the last treatment, the participants applied betamethasone propionate-calcipotriol gel once daily to the nail plate. Clinical outcome was ascertained using nails photography, the Nail Psoriasis Severity Index (NAPSI) and patient satisfaction.

RESULTS

Seventeen completed the study. Three participants withdrew from the study because of treatment-associated pain. Treatment was associated with a statistically significant improvement of the NAPSI scale (p < .002). Patient satisfaction was high.

CONCLUSION

Combined PDL and fractional ablative CO2-LADD of betamethasone-calcipotriol gel should be considered for the treatment of nail psoriasis.

Topical calcipotriol plus betamethasone dipropionate for the treatment of plaque psoriasis: a drug evaluation

Introduction: Psoriasis is an inflammatory skin disease affecting approximately 3.2% of adults in the United States. The mainstay treatment for mild-to-moderate plaque psoriasis (the most common subtype and severity) is topical therapy.Areas covered:The fixed combination calcipotriol plus betamethasone dipropionate (BD) is an effective topical treatment for plaque psoriasis. Two therapies with separate actions - a Vitamin D analog and a high-potency topical corticosteroid - combined into a single medication allows for better efficacy and patient adherence. The treatment is available in ointment, gel, suspension, foam, and cream formulations. The authors elaborate on this and provide their expert perspectives.Expert opinion: Combination calcipotriol/BD offers several advantages over its separate product monotherapies, including better efficacy, safety, and ease of use. Newer calcipotriol/BD formulations include less messy vehicles, thus promoting improved adherence. Further data are needed on whether combination calcipotriol/BD will be cost-effective and whether insurers will place it in the treatment coverage algorithm. Due to its higher price, calcipotriol/BD will likely remain a second-line treatment option after generic topical corticosteroids.

Nail Psoriasis: Diagnosis, Assessment, Treatment Options, and Unmet Clinical Needs

OBJECTIVE

An estimated 40-50% of patients with psoriasis (PsO) have psoriatic nail disease, which is associated with and directly contributes to a greater clinical burden and worse quality of life in these patients. In this review, we examine how recent advances in the use of new diagnostic techniques have led to improved understanding of the link between nail and musculoskeletal manifestations of psoriatic disease (PsD; e.g., enthesitis, arthritis) and we review targeted therapies for nail PsO (NP).

METHODS

We performed a literature search to identify which systemic therapies approved for the treatment of PsO and/or psoriatic arthritis (PsA) have been evaluated for the treatment of NP, either as a primary or secondary outcome. A total of 1546 articles were identified on February18, 2019, and evaluated for relevance.

RESULTS

We included findings from 66 articles on systemic therapies for the treatment of NP in PsD. With several scoring systems available for the evaluation of psoriatic nail disease, including varied subtypes and application of the Nail Psoriasis Area Severity Index, there was a high level of methodological heterogeneity across studies.

CONCLUSION

NP is an important predictor of enthesitis, which is associated with the early stages of PsA; therefore, it is important for rheumatologists and dermatologists to accurately diagnose and treat NP to prevent nail damage and potentially delay the onset and progression of joint disease. Further research is needed to address the lack of both standardized NP scoring systems and well-defined treatment guidelines to improve management of PsD.

Nail Psoriasis in Older Adults: Epidemiology, Diagnosis, and Topical Therapy

Nail involvement is common in patients with cutaneous psoriasis, which is prevalent among older adults. Nail psoriasis greatly impacts patients' quality of life and self-esteem. Concomitant psoriatic arthritis is common. Treating nail psoriasis in the geriatric population may be challenging. General nail care measures may prevent exacerbations. Topical therapy is relatively effective, with a low rate of adverse events and little to no risk of systemic toxicity or drug interactions. However, application under occlusion may be cumbersome. There is a need for randomized controlled clinical trials in the elderly population to make more evidence-based treatment guidelines.

Management of Nail Psoriasis

Nail psoriasis is a chronic nail disorder that requires personalized treatment. General prophylactic measures are suggested for all patients. Topical treatment is considered when treating a few-nail disease, with involvement of 3 or fewer nails, without joint involvement and without (or with mild) skin psoriasis. The ideal formulation should be ointment, solution, or foam. When moderate to severe skin psoriasis or psoriatic arthritis coexists, systemic treatment is suggested. This also should be considered when more than 3 nails are affected or significant impairment of quality of life is present. Conventional systemic agents, biologics, and small molecules are highly efficacious.

Nail Psoriasis in Older Adults: Intralesional, Systemic, and Biological Therapy

Psoriasis may affect the skin, scalp, joints, and nails and is common in older adults. Intramatrical injections with triamcinolone acetonide are safe and effective in older individuals. Conventional systemic medications are relatively effective, but side effects, including laboratory abnormalities and drug interactions, are particularly common among older adults. Biologic medications have shown excellent efficacy in treating nail psoriasis. Their safety profile is favorable, but data assessing long-term safety are lacking. Randomized controlled trials in older adults exclusively are necessary to develop evidence-based treatment guidelines in this population.

The Impact of Nail Psoriasis and Treatment on Quality of Life: A Systematic Review

At least 80% of patients with psoriasis will have nail involvement during their lifetimes. Understanding quality of life (QoL) impact of this condition and associated treatments is of utmost importance. Study objectives were to review the available literature describing patient-reported QoL outcomes in nail psoriasis and relationship with disease severity and treatment. A literature search was performed for English-language articles published prior to August 1, 2020. Articles were included in the review if primary data and validated patient-reported outcome measures assessing QoL were presented, and nail involvement was specifically examined. Fifteen studies were included in the final analysis. Patients with nail psoriasis had higher Psoriasis Area Severity Index and Dermatology Life Quality Index scores than those with psoriasis without nail involvement. The largest percent improvement in QoL score was associated with adalimumab. Studies investigating topicals, intralesionals, and systemic treatments were excluded since only biologic studies utilized validated patient-reported outcome measures. This review affirms that nail psoriasis is physically and emotionally distressing, warranting prompt treatment. Increased efforts are needed to address the impact of treatment on patient QoL using validated outcome measures that assess cosmetic, physical, and social problems.

Association of Nail Psoriasis With Disease Activity Measures and Impact in Psoriatic Arthritis: Data From the Corrona Psoriatic Arthritis/Spondyloarthritis Registry

OBJECTIVE

To examine the association of nail psoriasis with disease activity, quality of life, and work productivity in patients with psoriatic arthritis (PsA).

METHODS

All patients with PsA who enrolled in the Corrona PsA/Spondyloarthritis Registry between March 2013 and October 2018 and had data on physician-reported nail psoriasis were included and stratified by presence vs absence of nail psoriasis at enrollment. Patient demographics, disease activity, quality of life (QOL), and work productivity at enrollment were compared between patients with vs without nail psoriasis using t-tests or Wilcoxon rank-sum tests for continuous variables and chi-square or Fisher exact tests for categorical variables.

RESULTS

Of the 2841 patients with PsA included, 1152 (40.5%) had nail psoriasis and 1689 (59.5%) did not. Higher proportions of patients with nail psoriasis were male (51.9% vs 44.1%) and disabled from working (12.3% vs 7.8%) compared with patients without nail psoriasis (all P < 0.05). Patients with nail psoriasis had higher disease activity than those without nail psoriasis, including higher tender and swollen joint counts, worse Disease Activity Index for Psoriatic Arthritis and Psoriatic Arthritis Disease Activity Score values, and increased likelihood of having enthesitis and dactylitis (all P < 0.05). Patients with nail psoriasis had worse pain, fatigue, and work and activity impairment than those without nail psoriasis (all P < 0.05).

CONCLUSION

Patients with PsA who have nail psoriasis had worse disease activity, QOL, and work productivity than those without nail involvement, emphasizing the importance of identification and management of nail disease in patients with PsA.

Intralesional steroid treatment for the intermediate stage of retronychia: A pilot study

Retronychia describes the proximal ingrowing of the nail plate. In the early stage, topical steroids are the gold standard therapy, while in the late stage surgical treatment is mandatory. We identified an intermediate severity stage of retronychia, where the topical treatment alone is ineffective and surgery is avoidable. Intralesional steroids turn the best treatment in these patients. A pilot study consisting of a 3-month treatment period and 9-month follow-up time was designed to evaluate the treatment outcome to intralesional steroid injections in patients affected by the intermediate-stage of toenail retronychia. The complete recovery of retronychia-associated nail abnormalities was observed in 27/28 recruited patients at the end of the treatment phase. Paronychia, nail plate discoloration, proximal nail fold (PNF) elevation, and discharge were reduced (P < .01) after one steroid administration, while nail regrowth became significant after two sessions. No significant difference in terms of clinical outcome was found, while pain VAS score and intra-operative pain evaluated with Wong-Baker faces scale were higher in the female group (P < .01). Limitation Lack of control group of patients. Despite its temporary effect, the intralesional triamcinolone injection is an effective, cheap, and safe treatment especially for the intermediate stage of retronychia.

Apremilast as a target therapy for nail psoriasis: a real-life observational study proving its efficacy in restoring the nail unit

PURPOSE

Psoriasis, Psoriatic Arthritis and Nail psoriasis are chronic diseases that share a common underlying etiology of immunity dysregulation, enhanced activation of inflammatory pathways and remitting-relapsing course. Although nails represent a small percentage of the body surface involvement of this site can lead to impaired quality of life, severe discomfort and even result in permanent disability. Current therapeutic options for nail psoriasis include a variety of topical and systemic treatments although they are often reported as unsatisfactory from patients either due to their poor effectiveness or disturbing side effects. Recently small molecule drugs such as the PDE4 inhibitors were introduced in clinical practice and specifically apremilast has shown to be an effective new treatment option for psoriasis and psoriatic arthritis. Considering either the specific mechanism of action of apremilast, we performed a real-life observational study of 24 weeks assessing apremilast role in nail psoriasis.

MATHERIALS AND METHODS

Patients received apremilast 30mg bid, orally. Safety and efficacy were assessed at weeks 0, 4, 8, 12 and 24 using Dermatologic Life Quality Index (DLQI) and Nail Area Psoriasis Severity Index (NAPSI). At T0 we took a nail sample to investigate the presence of onychomycosis. Culture tests were performed in all the patients to search for fungi.

RESULTS

We recruited a total of 15 patients with nail psoriasis. The analysis of variance (one-way ANOVA) showed the following results: DLQI (F.15.7; p-value < .00001) and NAPSI (F.9.4; p-value < .00001). Three patients (20%) presented also onychomycoses at the beginning of the treatment.

CONCLUSIONS

Apremilast showed fast and sustained improvement of nail psoriasis over time and a complete resolution of life quality impairment due to the disease.

Management of nail psoriasis

Nail involvement is estimated to affect 80-90% of patients with psoriasis at some point in their lives and is often associated with severe disease. Patients with nail involvement experience pain, functional impairment and social stigma, with significant restriction of daily activities and quality of life. Nail psoriasis is also considered a risk factor for the development of psoriatic arthritis (PsA). Management of nail psoriasis is deemed challenging and as a result, it is often left untreated by physicians. Assessing the severity of nail disease can also be difficult in clinical practice. While the Nail Psoriasis Severity Index is used widely in trials, it is time-consuming and rarely used in the clinic, highlighting the need to develop a simplified disease severity score for nail psoriasis. All patients should be advised to keep their nails short, wear gloves for wet and dirty work, and regularly apply emollient to the nail folds and nail surface. Patients with mild nail psoriasis, without signs of severe cutaneous psoriasis or PsA, may benefit from topical treatment, while systemic treatment is indicated in patients with severe nail involvement. Evidence suggests that all anti-tumour necrosis factor (TNF)-α, anti-interleukin (IL)-17, and anti-IL-12/23 antibodies available for plaque psoriasis and PsA are highly effective treatments for nail psoriasis. This article aims to provide an up-to-date review of the therapeutic options currently available for the management of nail psoriasis in patients with or without skin psoriasis. Therapeutic options for the management of nail psoriasis in children will also be discussed.

Inflammatory nail conditions. Part 1: nail changes in psoriasis

Nail changes are visible in a variety of inflammatory dermatoses. The commonest dermatological condition with nail manifestations is chronic plaque psoriasis. This two-part article reviews the nail signs in psoriasis in Part 1, and the nail changes in cutaneous lichen planus and alopecia areata in Part 2. It provides a brief summary of the salient points in the clinical features, management and prognosis of these entities, with practical recommendations that may be beneficial to all dermatologists.

Small Molecules and Biologics in the Treatment of Nail Psoriasis

Nail psoriasis (PsO) is a disorder with profound impact on patients' quality of life. Several challenges and unmet needs remain in the treatment of nail PsO. Introduction of biologics and small molecules in the treatment of nail PsO has allowed for rapid control of the disease and high efficacy. The aim of this review was to present the published studies on nail PsO therapy with biologics and small molecules and illuminate the results in the studies where the design and outcome evaluation had nail PsO in the forefront.

Ixekizumab and Ustekinumab Efficacy in Nail Psoriasis in Patients with Moderate-to-Severe Psoriasis: 52-Week Results from a Phase 3, Head-to-Head Study (IXORA-S)

Introduction

Patients with plaque psoriasis often have nail psoriasis, which is difficult to treat. Ixekizumab (IXE) and ustekinumab (UST) are biologics with established efficacy in nail psoriasis. We present post hoc data from a head-to-head trial of IXE and UST (IXORA-S) to examine the efficacy in nail psoriasis in patients with moderate-to-severe plaque psoriasis over 52 weeks.

Methods

In IXORA-S,  randomised patients received IXE (N = 136) or UST (N = 166) per label for 52 weeks. Eighty-four (61.8%) and 105 (63.3%) of the patients treated with IXE or UST, respectively, had baseline fingernail psoriasis (Nail Psoriasis Severity Index [NAPSI] > 0); of these, 54 (64.3%) and 63 (60.0%) patients, respectively, had significant baseline fingernail psoriasis (defined as NAPSI ≥ 16 with ≥ 4 fingernails involved). The proportion of patients achieving NAPSI = 0, a NAPSI score change from baseline and correlations in Psoriasis Area of Severity Index (PASI) and NAPSI improvement over 52 weeks were examined.

Results

Progressive improvement occurred in both treatment groups over 52 weeks. Statistically significantly more patients achieved NAPSI = 0 with IXE versus UST by week 16–20, and the proportions continued to increase through week 52 among patients with baseline nail psoriasis (61.9 vs. 28.6%, respectively; P < 0.001), including those with significant nail psoriasis (57.4 vs. 17.5%, respectively; P < 0.001). Similar results were observed for NAPSI score improvement from baseline to week 52. Interestingly, the presence of nail psoriasis was associated with lower skin response with UST but not with IXE.

Conclusions

Ixekizumab was superior to UST in the clearance of nail psoriasis, with earlier improvement continued through 52 weeks regardless of baseline nail severity.

Trial Registration

ClinicalTrials.gov identifier; NCT02561806.

Management of nail psoriasis by topical drug delivery: a pharmaceutical perspective

The management of nail psoriasis is an arduous task owing to the disease manifestations and anatomical structure of the nail plate. Although various treatment therapies are available for nail psoriasis, topical therapy is contemplated as one of the most favorable options as systemic therapies are accompanied by numerous side effects that result in patient incompliance. The topical formulations including creams, gels, ointments, and nail lacquers have been used as delivery systems for various antipsoriatic drugs. Among these, nail lacquers emerge to be promising and patient friendly formulations. However, the major defiance with topical delivery is inefficacious penetration of drug through impenetrable keratinized nail plate to reach the target sites: nail matrix and nail bed. Therefore, in order to obtain effectual drug delivery systems that can retain/remain on the nail plate for a prolonged period of time and deliver the drug across it, systematic approaches like quality by design (QbD) need to be followed so that the desired quality can be "built in" the system rather than to rely solely on retrograde evaluation. Furthermore, more advances in research are still required to develop a validated animal model so as to determine the efficacy of the formulation and to establish a mathematical model that can help in predicting the desirable attributes of the formulation and permeation of various molecules through the nail plate.

Isolated nail lichen planus: An expert consensus on treatment of the classical form

Lichen planus is a benign inflammatory disorder of unknown etiology that may affect the skin, mucosae, scalp, and nails. When the nails are affected, it may lead to permanent destruction with severe functional and psychosocial consequences. Therefore, prompt diagnosis and early treatment are essential, even in mild cases. There are currently no guidelines for the management of nail lichen planus and the published literature on treatment is limited. The aim of this review is to provide practical management recommendations for the classical form of nail lichen planus, especially when restricted to the nails. Topical treatment has poor short-term efficacy and may cause long-term side effects. Instead, intralesional and intramuscular triamcinolone acetonide should be considered first-line therapies. Oral retinoids are second-line choices, and immunosuppressive agents may also be considered.