Treatment Options for Nail Psoriasis
With plaque psoriasis or psoriatic arthritis, there is a risk of developing nail psoriasis. This risk is so large in fact, that it is estimated that 80-90% of individuals with plaque psoriasis, and an even greater percentage of those with psoriatic arthritis, will develop nail bed or nail matrix symptoms. These symptoms are often hard to predict and can vary greatly from person to person. Because of this, past studies have lacked common standards for comparing the response of nail psoriasis to certain treatment options, and have made it very difficult to determine which treatments are “the best.” However, the answer to this question may be much more challenging that previously thought, as nail psoriasis can present in many different ways and individuals can respond completely different to identical treatments.
Right now, the common therapies for nail psoriasis include topical methods, intralesional methods, conventional systemic methods, biologic systemic methods, and non-pharmalogical treatment options. We rallied up information on all of these types of treatments, to help you figure out what methods may be best for you. Of course, no treatment option will be perfect, and it is important to discuss these with your healthcare provider. Additionally, nail growth is slow, as is response to treatments, so symptoms may not alleviate in any of these methods for 12 weeks to a year after starting.
Topical treatments are generally recommended for nail psoriasis that is fairly mild and without signs of severe PsA or plaque psoriasis accompanying symptoms. The most effective way to utilize topical treatments is to determine where the nail psoriasis is located, as some treatments work better for nail bed versus nail matrix psoriasis. Topical treatments include topical corticosteroids, corticosteroids combined with other modalities such as vitamin D3 analogs, and topical calcineurin inhibitors, among others. Additionally, corticosteroids can go beyond the topical level, and can be injected intralesionally, if the nail psoriasis is more severe. Topical methods are generally applied one to two times a day, and have relatively mild side effects.
Systemic treatments take measures a step further and get the whole body involved. This paves the way for additional side effects, that can often be severe, such as renal dysfunctions, hypertension, paresthesia, gastrointestinal disorders or fatigue. Systemics have often showed a moderate improvement in nail psoriasis, but are reserved for more severe cases, or cases in which there is significant PsA or plaque psoriasis accompanying the nail symptoms. Systemic treatments include methotrexate, cyclosporine, and retinoids, and often cannot be used for prolonged periods of time.
Biologic treatments are very similar to systemic treatments, both in usage and side effects, however, biologic treatments are newer, and thus, more expensive and less researched. Many biologics target the immune response and include anti-tumor necrosis factor alpha (infliximab, adalimumab, etanercept, and golimumab), inhibit interleukin (IL)-17 (secukinumab, ixekizumab), or inhibit IL-12/23 (ustekinumab). Biolsimilars to these medications are currently being developed, increasing the prevalence of biologics, as well as decreasing their cost.
Non-pharmalogical treatments are the least researched of all treatments, and have shown the least amount of promise. It is for this reason that they are not recommended as a first-line treatment modality for nail psoriasis, and are only recommended in cases where other treatment options have failed. Treatments in this category include laser treatment, phototherapy, and radiotherapy.
As always, it is crucial to keep an open line of communication with your healthcare provider to determine what treatment plan is right for you. Much more research is on the rise for the treatment of PsA, plaque psoriasis, and nail psoriasis, which will hopefully shed more light on the complex issue of management.