Optimal diagnosis and management of common nail disorders

Nails in older adults

As the world's population of adults greater than 60 years old continues to increase, it is important to manage nail disorders that may impact their daily lives. Nail disorders may have significant impact on quality of life due to decreased functionality, extreme pain, or social embarrassment. In this review, we discuss nail disorders affecting older patients, including physiologic, traumatic, drug-induced, infectious, environmental, inflammatory, and neoplastic conditions. Diagnosis of these conditions involves a detailed history, physical examination of all 20 nails, and depending on the condition, a nail clipping or biopsy and/or diagnostic imaging. Nails grow even more slowly in older adults compared to younger individuals, and therefore it is important for accurate diagnosis, and avoidance of inappropriate management and delay of treatment. Increased awareness of nail pathologies may help recognition and management of nail conditions in older adults.

Dermoscopic features of nail psoriasis: a systematic review

INTRODUCTION

Nail psoriasis is common in psoriasis vulgaris and even more prevalent in psoriatic arthritis. Dermatoscopy of the nail proves helpful in enhancing the visualization of psoriatic nail lesions.

OBJECTIVE

This systematic review aimed to summarize the existing studies published in the literature that reported the various dermoscopic features of nail psoriasis.

MATERIALS AND METHODS

A systematic search of two medical databases, PubMed and Scopus, was conducted in April 2023. In total, 11 records were included. The number of reported cases in the included studies was 723.

RESULTS

The average age was 42.39 years. Sixty percent of patients were males, and 40% were females. Pitting constituted the most common onychoscopic feature indicating nail matrix involvement, followed by various other features such as leukonychia, nail plate thickening, transverse and longitudinal ridges, and different lunula abnormalities. The predominant onychoscopic feature indicating nail bed involvement was onycholysis, followed by splinter hemorrhages, oil drop sign, subungual hyperkeratosis, dilated capillaries, agminated capillary dots, erythematous border, and pustules. Vascular abnormalities observed in all locations were present in 52% of patients.

CONCLUSIONS

The clinical signs of nail psoriasis are diverse, and for the majority, they are nonspecific. Nail dermoscopy is a noninvasive tool that enhances the visualization of the nail manifestations of psoriasis. It may facilitate the establishment of diagnostic criteria for this pathology without resorting to more invasive procedures, such as nail biopsy.

Treatment of Nail Psoriasis

Nail psoriasis is associated with significant disease burden, negative impact on quality of life, and potential progression to psoriatic arthritis. Initiating timely and appropriate treatment is of the utmost importance, especially because nail disease may be more resistant to therapies than cutaneous psoriasis. This article reviews available intralesional, topical, and systemic treatment options for nail psoriasis, and discusses efficacy and safety of studied agents. Also reviewed are consensus treatment guideline recommendations. An updated algorithm to aid physicians in selection of specific treatment options is provided.

Fungal Melanonychia: A Systematic Review

Fungal melanonychia is an uncommon condition, most typically caused by opportunistic melanin-producing pigmented filamentous fungi in the nail plate. In the present study, the clinical characteristics of patients diagnosed with fungal melanonychia were analyzed through a systematic review of cases reported in the literature. The MESH terms used for the search were "melanonychia" AND "fungal" OR "fungi" through four databases: PubMed, SciELO, Google scholar and SCOPUS. After discarding inadequate articles using the exclusion criteria, 33 articles with 133 cases were analyzed, of which 44% were women, 56% were men and the age range was between 9 and 87 years. The majority of cases were reported in Turkey followed by Korea and Italy. Frequent causal agents detected were Trichophyton rubrum as non-dematiaceous in 55% and Neoscytalidium dimidiatum as dematiaceous in 8%. Predisposing factors included nail trauma, migration history, employment and/or outdoor activities. Involvement in a single nail was presented in 45% of the cases, while more than one affected nail was identified in 21%, with a range of 2 to 10 nails. Regarding the clinical classification, 41% evidenced more than one type of melanonychia, 21% corresponded to the longitudinal pattern and 13% was of total diffuse type. Likewise, the usual dermoscopic pattern was multicolor pigmentation. It is concluded that fungal melanonychia is an uncommon variant of onychomycosis and the differential diagnosis is broad, which highlights the complexity of this disease.

Examination of the nails: Main signs

Understanding the anatomy of the nail apparatus is a prerequisite for diagnosing and managing various nail disorders. The latter may be associated with systemic pathologies, or accompany infectious, inflammatory, tumoral, toxic or traumatic dermatoses. Before attempting to identify the cause, a rigorous clinical examination should be conducted to screen for elementary lesions that may affect general nail shape, nail surface, subungual attachments, periungual soft tissue or nail color. All of these guide differential diagnosis.

Natural Treatment Options for Nail Disorders

The growing demand for natural treatments has raised concerns among clinicians due to limited scientific evidence supporting their use. This review article addresses the issue by assisting dermatologists and general practitioners in recommending natural treatments for the following common nail disorders: nail brittleness, onychomycosis, periungual verrucae, paronychia, chloronychia, nail psoriasis, nail lichen planus, onychocryptosis, onycholysis, and congenital malalignment of the great toenail. One limitation is the scarcity of existing reviews on natural treatment options for nail disorders in the literature. Through a comprehensive review of existing literature, this article consolidates the available evidence on natural treatment options for these conditions. Although some natural treatments for nail disorders are supported by scientific evidence, the indiscriminate use of such remedies may lead to severe poisoning and health problems. Given the widespread and increasing use of natural treatments, clinicians play a pivotal role in educating patients about evidence-based remedies and debunking misleading claims. By doing so, clinicians can enhance patient safety and improve treatment outcomes. It is essential for healthcare professionals to be well-informed and equipped with the knowledge to differentiate between effective natural treatments and unverified claims, ensuring that patients receive appropriate care.

Nail disorders to be kept in mind

Recognizing and diagnosing the most common nail diseases is essential, to be able to guide patients and provide appropriate treatment. However, uncommon nail disorders should not be neglected, in order to avoid inadequate treatment and above all to ensure that no severe underlying disorder, with severe prognosis, is overlooked.

Gout Affecting the Nail Unit: Report of Two Cases and Literature Review

Background

Gout is a depositional, inflammatory disorder that is rarely reported to affect the nail unit. Cases of gout involving the nail unit are likely under-recognized and therefore underreported. We present two cases of tophaceous gout affecting the nail unit and a literature review of the various presentations.

Summary

Five cases of gout were identified to affect the nail unit. In all cases, these presented as white hyperkeratotic papulonodules with associated nail dystrophy. Chalky discharge was seen in three of the five cases. Nine cases were identified to have demonstrated pseudocarcinomatous changes that histopathologically mimic squamous cell carcinoma (SCC). Literature review highlights a range of findings including subclinical deposits of uric acid in the nail, onychoschizia, onychorrhexis, and Beau's line.

Key Messages

Physicians should be aware of the subtle and nonspecific clinical findings of gout, which may be easily misconstrued for other pathological entities.

Line-field confocal optical coherence tomography, a novel non-invasive tool for the diagnosis of onychomycosis

BACKGROUND AND OBJECTIVES

Onychomycosis is common and important to distinguish from other nail diseases. Rapid and accurate diagnosis is necessary for optimal patient treatment and outcome. Non-invasive diagnostic tools have increasing potential for nail diseases including onychomycosis. This study evaluated line-field confocal optical coherence tomography (LC-OCT) as a rapid non-invasive tool for diagnosing onychomycosis as compared to confocal laser scanning microscopy (CLSM), optical coherence tomography (OCT), and conventional methods.

PATIENTS AND METHODS

In this prospective study 86 patients with clinically suspected onychomycosis and 14 controls were examined using LC-OCT, OCT, and CLSM. KOH-preparation, fungal culture, PCR, and histopathology were used as comparative conventional methods.

RESULTS

LC-OCT had the highest sensitivity and negative predictive value of all methods used, closely followed by PCR and OCT. Specificity and positive predictive value of LC-OCT were as high as with CLSM, while OCT scored much lower. The gold standard technique, fungal culture, showed the lowest sensitivity and negative predictive value. Only PCR and culture allowed species differentiation.

CONCLUSIONS

LC-OCT enables quick and non-invasive detection of onychomycosis, with advantages over CLSM and OCT, and similar diagnostic accuracy to PCR but lacking species differentiation. For accurate nail examination, LC-OCT requires well-trained and experienced operators.

Nail psoriasis and nail lichen planus: Updates on diagnosis and management

BACKGROUND

Inflammatory diseases of the nail, including nail psoriasis and nail lichen planus, are associated with significant disease burden and have a negative impact on quality of life. Diagnosis is often delayed, especially when patients present without cutaneous findings. Therefore, recognizing clinical signs and symptoms of inflammatory nail diseases, and initiating timely and appropriate treatment, is of utmost importance.

OBJECTIVE

We review recent studies on diagnostic techniques, discuss severity grading and scoring systems, and describe consensus treatment recommendations for nail psoriasis and nail lichen planus.

METHODS

An updated literature review was performed using the PubMed database on studies assessing diagnostic techniques or treatment modalities for nail psoriasis and nail lichen planus.

RESULTS

Recent studies on diagnostic techniques for inflammatory nail disease have focused on use of dermoscopy, capillaroscopy, and ultrasound modalities. Treatment of these conditions is dichotomized into involvement of few (≤3) or many (>3) nails. Recent psoriatic therapeutics studied for nail outcomes include brodalumab, tildrakizumab, risankizumab, deucravacitinib, and bimekizumab, while emerging treatments for nail lichen planus include JAK inhibitors and intralesional platelet rich plasma injections.

CONCLUSIONS

We emphasize the need for increased awareness and expanded management strategies for inflammatory nail diseases to improve patient outcomes.

Konfokale Line-Field optische Kohärenztomographie, ein innovatives nichtinvasives Instrument zur Diagnose der Onychomykose: Line-field confocal optical coherence tomography, a novel non-invasive tool for the diagnosis of onychomycosis

Hintergrund und Ziele

Onychomykose ist weit verbreitet und sollte von anderen Nagelerkrankungen unterschieden werden. Eine rasche und genaue Diagnostik ist für die optimale Behandlung des Patienten und ein bestmögliches Ergebnis erforderlich. Nichtinvasive Techniken haben ein wachsendes Potenzial bei der Diagnose von Nagelerkrankungen, einschließlich Onychomykose. In dieser Studie wurde die konfokale Line‐Field optische Kohärenztomographie (LC‐OCT) als schnelle nichtinvasive Methode zur Diagnose von Onychomykose im Vergleich zur konfokalen Laserscanmikroskopie (KLM), optischen Kohärenztomographie (OCT) und konventionellen Methoden bewertet.

Patienten und Methodik

In dieser prospektiven Studie wurden 86 Patienten mit klinischem Verdacht auf Onychomykose und 14 Kontrollen mittels LC‐OCT, OCT und KLM untersucht. KOH‐Präparation, Pilzkultur, PCR und Histopathologie wurden als vergleichende konventionelle Methoden eingesetzt.

Ergebnisse

LC‐OCT hatte die höchste Sensitivität und den höchsten negativen Vorhersagewert aller verwendeten Methoden, dicht gefolgt von PCR und OCT. Die Spezifität und der positive Vorhersagewert der LC‐OCT waren genauso hoch wie bei der KLM, während OCT deutlich schlechter abschnitt. Das Goldstandardverfahren Pilzkultur zeigte die geringste Sensitivität und den niedrigsten negativen Vorhersagewert. Nur PCR und Kultur ermöglichten eine Differenzierung der Pilzspezies.

Schlussfolgerungen

LC‐OCT ermöglicht eine schnelle und nichtinvasive Diagnostik von Onychomykose, mit Vorteilen gegenüber KLM und OCT und ähnlicher diagnostischer Genauigkeit wie die PCR, aber ohne Differenzierung der Pilzarten. Für eine genaue Nageluntersuchung erfordert die LC‐OCT gut geschulte und erfahrene Anwender.

Clinical value of dermoscopy in psoriasis

BACKGROUND

Dermoscopy is a noninvasive technique that has attracted increasing attention in the field of inflammatory skin diseases (such as psoriasis) in recent years.

OBJECTIVE

This study aimed to provide an up-to-date overview of the role of dermoscopy in the diagnosis and extra-diagnosis of psoriasis.

METHODS

This study sought to review the published literature regarding use of dermoscopy in the evaluation of psoriasis.

RESULTS

The diagnostic value of dermoscopy in psoriasis vulgaris, nail psoriasis, and other types of psoriasis was summarized from the aspects of vascular pattern, scale pattern, and other features. Meanwhile, the application value of dermoscopy in the differential diagnosis, efficacy and severity assessment, prediction and monitoring of psoriasis was discussed.

CONCLUSION

Dermoscopy has good clinical value in the diagnosis and differential diagnosis of psoriasis and shows great prospects for severity assessment and efficacy prediction monitoring.

A focused review on laser- and energy-assisted drug delivery for nail disorders

The purpose of this review is to consolidate and summarize laser-assisted drug delivery (LADD) for nail diseases, particularly onychomycosis and psoriasis. A PubMed search was conducted in June 2023 using search terms (1) "laser assisted drug delivery" AND "nail," (2) "laser" AND "nail," and (3) "nail disorder" AND "laser treatment." References of papers were also reviewed, yielding 15 papers for this review. Fractional ablative CO2 laser (FACL) and Er:YAG laser can be used for LADD of topical medications such as amorolfine, terbinafine, and tioconazole to treat onychomycosis. A fungal culture should be performed to determine the type of dermatophyte, which will help determine which topical will be most effective. Laser settings varied between studies, but overall LADD tended to be more effective than topical treatments alone. Laser-assisted photodynamic therapy (PDT) was also found to be effective in treating onychomycosis. For psoriatic nails, LADD was used to deliver calcipotriol-betamethasone dipropionate foam, tazarotene, triamcinolone, or methotrexate into the nail. Again, LADD was found to be significantly more effective than topical treatment alone. FACL was the only laser noted for use for LADD in both diseases. Laser-assisted drug delivery for nail disease is a newer approach for onychomycosis and nail psoriasis with several benefits and drawbacks. Dermatologists should discuss the option of LADD with their patients who have recalcitrant onychomycosis or nail psoriasis.

Infrequent Pediatric Subungual Injury Diagnosed by Intraoperative Anatomopathological Material: A Case Report

Subungual lesions are very common in clinical practice. We present the clinical case of a 10-year-old female patient who presented with progressive nail deformity. The onset of the condition was approximately five years prior to presentation with an injury in the left hallux, according to the mother. She denied pain or change in the color of the area from the onset of the injury to the day of consultation. There was no previous trauma. Examination revealed subungual bone injury to the distal extremity (distal phalanx of the left hallux), and imaging tests (X-ray and soft tissue ultrasound) found bone injury. Subungual exostosis was considered as a possible diagnosis, thus prompting the indication for exeresis of the tumoral process. After surgical removal, the resected specimen was sent for pathological assessment, which found that an intraosseous hemangiolymphangioma was the origin of the tumor. A subungual exostosis is a slow-growth benign osseous tumor mainly located in the distal phalanx of the hallux that especially affects young adults, being less frequent in children. This condition results from a process of bone neoformation involving different stages, the clinical symptoms of which depend on its size and associated processes. Hemangiolymphangiomas are angiomatous lesions of the blood and lymphatic vessels that have a controversial etiology and present slow, painless, and progressive growth; these lesions are mostly benign. It is worth emphasizing that subungual injuries are not always caused by an underlying bone; therefore, potential differential diagnoses, both benign and malignant, should be considered, based on the location of the injury.

A Comprehensive Review of Ixekizumab Efficacy in Nail Psoriasis from Clinical Trials for Moderate-to-Severe Psoriasis and Psoriatic Arthritis

Nail psoriasis is a difficult-to-treat manifestation of psoriatic disease affecting up to 80% of patients with psoriatic arthritis (PsA) and 40-60% of patients with plaque psoriasis (PsO). Ixekizumab (IXE), a high-affinity monoclonal antibody that selectively targets interleukin-17A, is approved for the treatment of patients with PsA and patients with moderate-to-severe PsO. This narrative review aims to summarize nail psoriasis data generated from IXE clinical trials in patients with PsA (SPIRIT-P1, SPIRIT-P2, and SPIRIT-H2H) and/or moderate-to-severe PsO (UNCOVER-1, -2, -3, IXORA-R, IXORA-S, and IXORA-PEDS) with an emphasis on head-to-head clinical trial data. Across numerous trials explored, IXE treatment was associated with greater improvement in resolution of nail disease versus comparators at week 24, results which were maintained up to and beyond week 52. Additionally, patients experienced higher rates of resolution of nail disease versus comparators at week 24 and maintained high levels of resolution up to week 52 and beyond. In both PsA and PsO, IXE demonstrated efficacy in treating nail psoriasis, and therefore may be an effective therapy option. Trial Registration: ClinicalTrials.gov identifier UNCOVER-1 (NCT01474512), UNCOVER-2 (NCT01597245), UNCOVER-3 (NCT01646177), IXORA-PEDS (NCT03073200), IXORA-S (NCT02561806), IXORA-R (NCT03573323), SPIRIT-P1 (NCT01695239), SPIRIT-P2 (NCT02349295), SPIRIT-H2H (NCT03151551).

Retrospective Analysis of Liver Enzyme Abnormalities in Patients Prescribed Terbinafine and Itraconazole for Onychomycosis

Introduction Onychomycosis (OM) is defined as a nail fungal infection. Its prevalence increases with advancing age. Human-to-human transmission makes it a serious public health risk. Although OM is not a life-threatening disease, it has a detrimental effect on patients' quality of life. Due to the long therapy duration and potential side effects of systemic antifungal medicines, physicians may be reluctant to treat OM orally. In this study, we aimed to evaluate the effect of terbinafine and itraconazole on liver transaminases, the side effects of these treatments, and patients' adherence to systemic treatment of OM. Methods This is a retrospective study conducted in our dermatology department (Ordu University, Ordu) between June 2020 and October 2021. Hospital records were analyzed, and patients with the diagnosis of tinea unguium (ICD code B35.1) were investigated. Patients who were prescribed terbinafine or itraconazole were included in the study. Following a clinical diagnosis of OM, the researchers first tried to confirm it through direct microscopic examination with potassium hydroxide (KOH). If the direct microscopic examination was negative but the suspicion about OM continued, confirmation was done through a fungal culture. Results This study included 735 patients, of whom 409 (55.6%) were female and 326 (44.4%) were male. The research covered all of the patients who were given one of these two medications. To find patients who could apply to other hospitals, the Turkish National Healthcare System was checked in addition to hospital information. To identify patients who could apply to other healthcare institutions, all hospitals share their data with this national healthcare system. Terbinafine was used by 433 patients (76.4%), 75 patients (13.2%), and 37 patients (6.5%), respectively, for one, two, and three months. A total of 119 patients (70.8%) took itraconazole for a month, 32 patients (19%) took it for two months, and four patients (2.33%) took it for three months. At the end of the first month, the proportion of the patients with elevated aspartate transaminase (AST) levels was 5.2% for terbinafine and 0% for itraconazole. Eighteen (8.4%) patients with terbinafine had elevated alanine aminotransferase (ALT) levels, and four patients (7.5%) who were on itraconazole treatment had high ALT levels. None of the patients reported cutaneous adverse drug reactions, gastrointestinal disturbances, or headaches due to OM treatment. Also, no patients discontinued treatment because of hepatotoxicity. Conclusion In this study, none of the patients discontinued the treatment because of hepatotoxicity. According to the results of this study, oral terbinafine and itraconazole can be used with close follow-up. Baseline and regular laboratory monitoring for AST and ALT should be done to monitor liver toxicity with terbinafine and itraconazole. Besides, we did not observe other side effects like cutaneous or cardiac side effects or drug-drug interactions.

Onychogryphosis Is Associated with Dermatologic and Vascular Disease: A Case-Control Study of the All of Us Research Program

Introduction

Onychogryphosis is a nail condition characterized clinically by a thickened, curved, yellow-brown, and opaque nail plate and may result in pain, paronychia, and onychogryphosis.

Methods

We performed a nested case-control study of 1,114 onychogryphosis patients and 3,423 matched controls to quantify the association between onychogryphosis and self-care limitations, chronic foot injury, dermatologic conditions, and vascular disease.

Results and Conclusion

Onychogryphosis was positively associated with increased age, activity limitations (difficulty running errands alone, bathing, and concentrating), psoriasis, onychomycosis, hallux malleus, hallux valgus, peripheral vascular disease, lower extremity ulcers, venous varices, and type II diabetes mellitus. Therefore, physicians should screen patients presenting with onychogryphosis for these conditions.

[Successful therapy of retronychia]

ANAMNESIS

We report on a 66-year-old patient who had had painful swelling of his left big toe for about 9 months with subjectively stopped growth.

EXAMINATION

Previously, bacteriological, and mycological smears and an MRI examination had not provided any groundbreaking findings, and previous antibiotic, antiseptic and anti-inflammatory therapies had not contributed to alleviating the symptoms.

DIAGNOSIS AND THERAPY

Based on the clinical findings with a reddened, piston-like distended distal phalanx with a raised proximal nail wall, we made the diagnosis of retronychia and performed a nail plate extraction.

CLINICAL COURSE

In the follow-up checks, which lasted more than two years, the patient was symptom-free with recovered nail growth.

CONCLUSION

As in the case presented, retronychia is often misdiagnosed. The knowledge of groundbreaking clinical and anamnestic parameters and the correct therapy options allows a quick, inexpensive, and long-term successful treatment.

LIFEHOUSE’s Functional Nutrition Examination (Physical Exam, Anthropometrics, and Selected Biomarkers) Informs Personalized Wellness Interventions

Each individual has a unique and interacting set of genetic, lifestyle, and environmental factors that are reflected in their physical exam and laboratory biomarkers and significantly impact their experience of health. Patterns of nutrient deficiency signs and biomarker levels below health-promoting thresholds have been identified in national nutrition surveys. However, identifying these patterns remains a challenge in clinical medicine for many reasons, including clinician training and education, clinical time restraints, and the belief that these signs are both rare and recognizable only in cases of severe nutritional deficiencies. With an increased interest in prevention and limited resources for comprehensive diagnostic evaluations, a functional nutrition evaluation may augment patient-centered screening evaluations and personalized wellness programs. During LIFEHOUSE, we have documented physical exam, anthropometric, and biomarker findings that may increase the recognition of these wellness-challenging patterns in a population of 369 adult employees working in two occupational areas: administrative/sales and manufacturing/warehouse. Distinct and significant physical exam differences and constellations of biomarker abnormalities were identified. We present these patterns of physical exam findings, anthropometrics, and advanced biomarkers to assist clinicians in diagnostic and therapeutic interventions that may stem the loss of function that precedes the development of the non-communicable chronic diseases of aging.

Adult and Pediatric Nail Unit Melanoma: Epidemiology, Diagnosis, and Treatment

Nail unit melanoma (NUM) is an uncommon form of melanoma and is often diagnosed at later stages. Approximately two-thirds of NUMs are present clinically as longitudinal melanonychia, but longitudinal melanonychia has a broad differential diagnosis. Clinical examination and dermoscopy are valuable for identifying nail findings concerning malignancy, but a biopsy with histopathology is necessary to confirm a diagnosis of NUM. Surgical treatment options for NUM include en bloc excision, digit amputation, and Mohs micrographic surgery. Newer treatments for advanced NUM include targeted and immune systemic therapies. NUM in pediatric patients is extremely rare and diagnosis is challenging since both qualitative and quantitative parameters have only been studied in adults. There is currently no consensus on management in children; for less concerning melanonychia, some physicians recommend close follow-up. However, some dermatologists argue that the "wait and see" approach can cause delayed diagnosis. This article serves to enhance the familiarity of NUM by highlighting its etiology, clinical presentations, diagnosis, and treatment options in both adults and children.

Safety of current systemic therapies for nail psoriasis

INTRODUCTION

A discussion of safety of systemic treatments for nail psoriasis is lacking, particularly in reference to approval of new therapies assessed for nail outcomes. A review of safety profiles for agents commonly utilized for treatment of nail psoriasis is warranted to help inform treatment choices. The PubMed database was searched on 5 April 20235 April 2023, with articles discussing safety of nail psoriasis systemic therapies identified and reviewed.

AREAS COVERED

Systemic treatments for nail psoriasis include biologic therapies (tumor necrosis factor-alpha inhibitors, interleukin-17 inhibitors, interleukin-23 inhibitors, interleukin-12/23 inhibitors), small molecule inhibitors (apremilast, tofacitinib), and oral systemic immunomodulators (methotrexate, cyclosporine, acitretin), each with unique safety profiles and considerations. Herein, we discuss adverse events, contraindications, drug-drug interactions, screening/monitoring guidelines, as well as utilization for special populations, including pregnant, older, and pediatric patients.

EXPERT OPINION

The advent of targeted therapies, including biologic treatments and small molecule inhibitors, has revolutionized outcomes for nail psoriasis patients, but warrant review and monitoring for potential adverse events. Oral systemic immunomodulators have demonstrated moderate efficacy for nail psoriasis treatment, but are notable for frequent contraindications and drug-drug interactions. Further study of these agents and their use in special populations is needed to elucidate safety profiles for long-term use.