A pilot study of intralesional methotrexate injections versus triamcinolone acetonide in patients affected by nail matrix psoriasis

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.

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.

Triamcinolone Acetonide Injections in Nail Psoriasis: A Pragmatic Analysis

Introduction

Treatment of nail psoriasis is challenging. Systemic therapies may be difficult to justify, while topical therapies may be sup-optimal. Triamcinolone acetonide (TA) injections are recommended as first-line therapy in cases with less than 3 nails involved; however, limited studies are available. This study was conducted to evaluate the reduction in NAPSI (Nail Psoriasis Severity Index) with TA injections in patients with isolated nail psoriasis.

Methods

A retrospective case record analysis of efficacy and safety of TA (5 mg/mL) nail injections (4-weekly for fingernails, 8-weekly for toenails) was done in 10 patients. NAPSI was evaluated at each visit and treatment endpoint (75% reduction or 10 injections, whichever was earlier). Dropouts and adverse effects were recorded.

Results

Among 10 patients (94 involved nails, 61 fingernails, and 33 toenails), 3 patients (30%) dropped out (2, 4, and 5 sessions, respectively), citing procedural pain. Three patients achieved NAPSI-75 (3, 6, and 7 sessions, respectively). Baseline mean NAPSI of 5.03 (4.63 fingernails and 5.78 toenails) dropped to 3.67 (3.13 fingernails and 4.42 toenails) by the 5th injection; and 2.35 (2.13 fingernails and 2.59 toenails) by the 10th injection. Adverse effects included pain (30%), subungual haematoma (1.7%), and proximal nail fold hypopigmentation with mild atrophy (1.1%).

Conclusions

TA (5 mg/mL) injections are effective in nail psoriasis and associated with minimal adverse effects.

Updates in treatment and impact of nail psoriasis

INTRODUCTION

Nail psoriasis is an inflammatory disorder without a potential scarring outcome, but the nail signs, even the milder ones, can cause discomfort to patients and severely affect their quality of life. Nail psoriasis may be associated with psoriatic arthritis and when it starts during infancy, it may be a predictor of a more severe disease course in adulthood. All these issues contribute to the high economic burden of psoriasis.

AREAS COVERED

Nail psoriasis is notoriously difficult to treat, even though new treatments are in continuous development. This paper provides an update on new treatments and address the current gaps in care of nail psoriasis.

EXPERT OPINION

A better understanding of the disease pathogenesis and more 'real-life' studies will definitely be helpful to improve treatment results. A lower level of heterogeneity should be advisable among trials when evaluating nail psoriasis. Moreover, the relationship between nail psoriasis and psoriatic arthritis should be the focus of unbiased studies in order to better define the real risk that nail psoriasis patients have to develop arthritis.

The Anti-Psoriatic Efficacy and Safety Profile of Topical and Intralesional Methotrexate: A Literature Review

Methotrexate (MTX) has long been considered the first-line oral systemic pharmacotherapy for psoriasis. The drug has several well-known systemic side effects, such as bone marrow suppression and hepatotoxicity. To avoid them, the use of topical or intralesional administrations of MTX has become an interesting option. With the advent of novel drug delivery systems, especially nanocarriers, the usage of a high-efficacy and safe topical MTX for psoriasis has nearly been attained. This review examined the development, anti-psoriatic efficacy and adverse effects of topical forms of MTX (plain MTX; MTX with chemical enhancer; MTX using nanotechnology; MTX with protein transduction domains; MTX with liquid crystalline systems; and MTX with physical enhancer/laser) and intralesional MTX in psoriasis patients and psoriasis-induced animals. The efficacy of topical MTX varied with the drug delivery technology employed. Nevertheless, the overall safety profile of the topical forms was favourable. A 25 mg/mL MTX solution injected intralesionally at the nail matrix worked well for nail psoriasis recalcitrant to topical treatment. To improve the standard of care for patients with psoriasis, randomized controlled trials that establish the most effective MTX-delivery system are needed.