Nail psoriasis is common in psoriatic patients, particularly in patients with joint involvement. It has a significant impact on their quality of life, affecting physical activities as well as causing emotional and social impairement. The disease is often refractory to treatment, and available therapeutic agents affect the matrix or the nail-bed features with variable success. The recent design of the Nail Psoriasis Severity Index allows a more standarized approach regarding outcome assessment.
Nail Psoriasis Severity Index (NAPSI). The nail is divided into quadrants, each of which is rated with a 0 or 1, based on the absence or presence of pathological signs resulting from involvement of both the nail matrix and the nail bed. NAPSI has significantly helped in a more standardized approach to outcome assessment of therapeutic studies.
Nail involvement is common in psoriatic patients, affecting up to 80% of patients at some point in their lives. It has been suggested that nail disease is more common in psoriatic arthritis (PsA) than cutaneous psoriasis. This link highlights the importance of diagnosis of PsA through initial nail manifestations in the absence of cutaneous involvement, since if left untreated, PsA can lead to destructive permanent changes. Nail involvement without cutaneous disease affects 5-10% of patients.
Nail psoriasis has significant adverse influence on the quality of life of many patients. psoriatic patients with nail disease considered their condition a significant cosmetic handicap, interfered with their job and described pain as a symptom.
Typical complaints concerned the ability to grab small objects, tie shoe laces and button clothes; an altered sense of touch was also reported. Despite significant impairment on daily activities, nail disease remains occasionally untreated. Patients are often fatigued, as a result of poor efficacy of various treatment modalities and failure to comply to long-term treatments with topical agents. Owing to great difficulty in drug delivery to the site of action and significant toxicities of most conventional systemic therapies, treatment of nail psoriasis remains a challenge.
In a small number of patients, the diagnosis may be unclear because nail features might be inconclusive. In such situations, onychomycosis should be excluded through direct microscopy and culture of nail clippings and subungual debris. Presence of fungus does not exclude psoriasis as onychomycosis has been reported to have a higher prevalence in psoriatics. Nail-plate histology might be helpful in differential diagnosis, but it might cause permanent dystrophy if nail matrix tissue is included. When the patient presents with pustular nail psoriasis, it is important to rule out both bacterial and fungal infection. Negative results help to establish the diagnosis.
For patients :
Patients should protect their hands and nails by wearing gloves when in contact with water and irritants. This is of particular importance in patients presenting with onycholysis and paronychia. Application of emollient cream in the dry psoriatic skin of the hands and nail folds could also be helpful. The need for injury avoidance, which could aggravate the nail disease, should be stressed. Nails should be cut short to avoid increased risk of injury and onycholysis. Patients who are obsessed with removing debris from beneath the nail with various manicure instruments should be discouraged, since this will only exacerbate onycholysis. Colored nail lacquer is safe to use and can hide discoloration and partially fill surface irregularities. The result is good enough to prevent proper assessment by a dermatologist, consequently it should be removed by the patient before follow-up visits. Prosthetic nails can make onycholysis worse.
Treatment options :
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Onychomycosis (if present) requires antifungal therapy for improvement. The treatment options for nail psoriasis include topical corticosteroids, intralesional corticosteroids, psoralen plus ultraviolet light A (PUVA), topical fluorouracil, topical calcipotriol, topical anthralin, topical tazarotene, topical cyclosporin, avulsion therapy, and systemic therapy for severe cases.
Topical Corticosteroids. Potent and very potent topical steroids have been attempted once or twice daily for 3-9 months under occlusion with cellophane wrap at bedtime can improve nail psoriasis.. Patients should be advised to clip the detached nail plate and apply topical steroids to the nail bed, hyponychium and paronychial area. Improvement has been reported on both the nail bed and the nail matrix features. Side effects of topical steroids after long-term use include telangiectasias and atrophy of the paronychial area . he only study utilizing NAPSI, by Rigopoulos et al., reports an effectiveness for clobetasol propionate 0.05% cream comparable to tazarotene after 12 weeks. New formulations, such as the clobetasol 8% nail lacquer, allow for intermittent application and have demonstrated encouraging results . Avoid long, continuous therapy with corticosteroids to avoid tachyphylaxis. Also, avoid prolonged occlusion. A topical preparation of a combination of high-potency corticosteroid and calcipotriol may benefit some patients .
Intralesional Steroids. Triamcinolone acetonide 10 mg/ml is the mainstay intralesional agent used bimonthly. The procedure should be preceded by ring block or distal block anesthesia if the injection ( injection is given with a 30-gauge needle ) is likely to enter the matrix as this is a very sensitive site. Use of dermojet can offer an alternative application technique with considerably decreased pain. However, even with dermojet, adverse events such as inclusion cysts have been reported. Injection sites should be the proximal paronychial area for nail matrix features treatment and the lateral paronychial area for nail-bed feature treatment. The dose should be 0.05-0.1 ml of triamcinolone acetonide 2.5-10 mg/ml at up to four injection sites, depending on the lesions, used bimonthly for 5-6 months. Side effects include Beau's lines nail atrophy and subungual hemorrhage. Efficacy is high, mainly for nail matrix lesions, but available studies were published before NAPSI design and utilize different doses and outcome assessments, lacking therefore sufficient power to extrapolate a standardized therapeutic regimen. In these studies, 70-90% of psoriatic patients with both nail matrix and nail-bed lesions responded to intralesional steroids. However, onycholysis proved more difficult to treat than the remaining psoriatic lesions, with only 20-55% of patients responding.
Vitamin D Analogues. Calcipotriol twice daily for 3-6 months has been evaluated in the treatment of nail psoriasis in several studies. It presents significant efficacy regarding hyperkeratosis resolution. Tosti et al. reported a 49% reduction of subungual hyperkeratosis after 5 months application in a randomized double-blind study. An open-label study by Rigopoulos et al. reported a decrease of hyperkeratosis up to 70% after 6 months of application for both fingernails and toenails. There are no studies utilizing NAPSI. Side effects were minimal and self-limiting.
Tazarotene. Tazarotene 0.1% gel or cream applied once daily for 12-24 weeks has been documented to improve psoriatic nail features resulting from both nail matrix and nail-bed involvement. Scher et al. reported significant improvement, mainly of onycholysis with tazarotene 0.1% gel in a randomized, vehicle-controlled, double-blind study. Results were visible from week 4 for patients using the agent under occlusion, compared with week 24 for those using it without occlusion. Subsequent studies reported improvement for onycholysis, hyperkeratosis, pitting and salmon patches on both fingernails and toenails Tazarotene application may cause mild skin irritation and a sense of burning or desquamation of the paronychial area.
5-fluorouracil. 5-fluorouracil (5-FU) has been used in the treatment of nail psoriasis in several studies with mixed results. Fredriksson reported improvement in onycholysis and pittings in 17 out of 20 patients after 4 months of 5-FU application once daily. Fritz reported improvement of oil spots and subungual hyperkeratosis in 59 patients applying 5-FU cream and urea 20% twice daily and poor results on a group applying a monotherapy of 5-FU solution.
Anthralin. Anthralin 0.4-2% in petrolatum applied once daily for 5 months has been evaluated by Yamamoto et al. in the treatment of nail psoriasis. Improvement was seen in 60% of the patients regarding pachyonychia, pitting and onycholysis. Despite the use of triethanolamine 10% cream, patients exhibited undesired but reversible pigmentation of the nail plate .
Topical Ciclosporin Solution. Application of ciclosporin maize oil-dissolved oral solution with a final 70% ciclosporin concentration twice daily for 3-4 months has been reported to improve subungual hyperkeratosis and onycholysis in a randomized, placebo-controlled study of 16 patients. Three out of eight patients in the ciclosporin group presented complete resolution, with the remaining five exhibiting improvement. There were no reported adverse events.
Systemic therapies have been used in patients with severe cutaneous psoriasis. Few studies have shown significant improvement in nail psoriasis with long-term results. At present, 3 systemic medications are most commonly used for psoriasis and nail psoriasis: methotrexate, retinoids and cyclosporin. All 3 agents have potential serious adverse effects and toxicities. Carefully weigh the risk-to-benefit ratio in the treatment of nail psoriasis. Systemic therapies are seldom a first-line therapy for nail psoriasis. Topical treatment with calcipotriol can be used as adjunctive therapy and maintenance therapy with systemic treatment. Biological therapy for psoriasis and psoriatic arthritis may have a significant benefit for some patients with psoriatic nail disease .
Retinoids. Etretinate and acitretin have been evaluated for pustular nail psoriasis and nail lesions in patients with extensive cutaneous and/or joint involvement. Mahrle et al. reported improvement of nail lesions in 47 out of 60 patients receiving etretinate for cutaneous psoriasis in a multicenter study. Piraccini et al. reviewed treatment outcomes in 46 patients with pustular psoriasis. Patients with severe disease received oral retinoids and six out of 12 patients had improvement of their nail lesions. Mild-severity patients received calcipotriol, topical steroids or oral nimesulide with only calcipotriol presenting efficacy comparable to retinoids. Acitretin in a dose of 0.25-0.5 mg/kg/day for 3 months exhibits satisfactory efficacy in the management of pustular psoriasis, dystrophy, pittings and subungual hyperkeratosis. Acitretin may cause leukonychia, pseudopyogenic granuloma, brittle nails and lesions, such as paronychia. In addition, even though retinoid dose for nail psoriasis is considerably lower than the dose administered for the treatment of cutaneous lesions, liver function should be regularly monitored.
Ciclosporin. Data regarding the efficacy of ciclosporin in the treatment of nail psoriasis are conflicting. Mahrle et al. reported mild improvement of 17.5%, using a four-point scale score, in the nail lesions of 90 out of 137 patients receiving ciclosporin 2.5-5.0 mg/kg for 10 weeks in a multicenter study. Feliciani et al. reported improvement in 47% of 21 patients treated with ciclosporin 3.5 mg/kg for 3 months compared with an improvement of 79% of 33 patients similarly matched treated with the same ciclosporin dosage plus topical calcipotriol. Patients treated with ciclosporin should be monitored for renal function and blood pressure since prolonged treatment duration may result in well-documented adverse events. systemic ciclosporin should be considered a second-line treatment for nail psoriasis.
Photochemotherapy & Psoralen & UVA Bath. Psoralen and UVA (PUVA) has been reported to improve onycholysis, salmon patches, subungual hyperkeratosis, proximal paronychia and onychorrhexis in a small series of patients with nail psoriasis. It has no effect on pitting. Both oral and topical PUVA therapies have improved nail psoriasis in 3-6 months. A possible adverse effect of PUVA may be nail discoloration.
Superficial X-ray Therapy. Superficial x-rays are still being in use in Germany and Switzerland for the treatment of psoriatic nails. Yu et al. used superficial radiotherapy (SRT) for psoriatic fingernails as three fractionated doses of 150 cGy (90 kV, 5 mA, 1.00 mm aluminium filter). The treated nails demonstrated a significant fall in scoring on a clinical rating scale at 10 and 15 weeks after therapy (mean scores = 4.4 and 4.6, respectively) when compared with a mean pretreatment score of 5.5 at week 0 (p < 0.0001 and p < 0.05, respectively); the treated nails also showed significant clinical improvement when compared with the sham-treated nails at weeks 10 and 15 (p < 0.05). Mean nail thickness in treated nails 15 weeks after therapy was significantly thinner (mean thickness = 0.75 mm) than that of sham-treated nails (0.88 mm; p = 0.005), but the difference was not significant at week 20. The rate of linear nail growth was unaffected. The authors concluded that SRT appears to confer a definite albeit temporary benefit on psoriasis of the nails at this dosage.
Biologicals. There are presently few available studies on biological therapy for nail psoriasis, but there are many in progress .
Alefacept has been evaluated in a limited number of patients with nail psoriasis. Cassety et al. reported improvement of NAPSI by 30% in three out of six patients receiving alefacept intramuscularly for 12 weeks. Korver et al. reported improvement of NAPSI in two out of five patients with moderate nail psoriasis NAPSI greater than 15, while patients with milder severity displayed variable results. No adverse events were reported.
Infliximab has shown extremely beneficial results in the treatment of nail psoriasis. Reich et al. reported significant improvement from as early as week 10 of therapy with infliximab 5 mg/kg in 240 patients with a mean NAPSI of 4.6 Improvement of NAPSI at week 22 reached 56.3% in this vehicle-controlled, randomized, double-blind study. Bianchi et al. reported even more impressive results in severe nail involvement. Nine patients with plaque psoriasis and a mean NAPSI of 28.3 and 16 patients with PsA and a mean NAPSI of 33.3 received infliximab and were without nail lesions (NAPSI: 0) at week 22. Although no adverse effects were reported, infusion reactions with infliximab are not uncommon. Reactions range in severity from mild fever and chill to anaphylactic reactions and acute coronary artery syndrome .
Avulsion therapy with chemical or surgical means can be used as an alternative therapy for psoriatic nail disease. Chemical avulsion therapy includes the use of urea ointment in a special compound to the affected nail under occlusion for 7 days, and the nail is removed atraumatically. Chemical avulsion therapy is painless, involves no blood loss, and is less expensive than surgical avulsion.
Surgical Care Surgical avulsion therapy can be performed for psoriatic nail disease when other treatments have failed. During surgery, the matrix can be electively ablated to prevent regrowth of the nail. This procedure is performed under local anesthesia. Inform patients of postoperative discomfort, limitations, and possible physical nail disfigurement.
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