How can you treat nail psoriasis naturally at home. What are the most effective home remedies for managing nail psoriasis symptoms. Which lifestyle changes can help prevent and control nail psoriasis. Why is proper nail care essential for individuals with psoriasis.

Understanding Nail Psoriasis: Causes and Symptoms

Nail psoriasis is a manifestation of the autoimmune condition psoriasis, which affects not only the skin but also the nails. This condition occurs when the body’s immune system mistakenly accelerates the production of skin cells, leading to their accumulation in various areas, including the nail bed and matrix.

The primary symptoms of nail psoriasis include:

• Thickening of the nails
• Pitting or small depressions on the nail surface
• Discoloration, often appearing as yellowish-brown
• Separation of the nail from the nail bed (onycholysis)
• Tenderness and pain in the affected nails

These symptoms can significantly impact daily activities and quality of life, making effective treatment crucial for those affected by nail psoriasis.

Tea Tree Oil: A Natural Antifungal and Anti-inflammatory Agent

One of the most potent natural remedies for nail psoriasis is tea tree oil. This essential oil boasts a trifecta of beneficial properties: antibacterial, antifungal, and antiseptic. These characteristics make it particularly effective in combating fungal and bacterial infections that can exacerbate nail psoriasis symptoms.

How Does Tea Tree Oil Work for Nail Psoriasis?

Tea tree oil’s efficacy in treating nail psoriasis can be attributed to its high content of terpinen-4-ol, a compound known for its powerful anti-inflammatory properties. This component helps alleviate pain and reduce inflammation associated with nail psoriasis.

To harness the benefits of tea tree oil:

1. Mix 5-6 drops of tea tree oil with lukewarm water in a small bowl.
2. Soak affected nails in this solution for 15 minutes.
3. Pat dry and repeat twice daily until improvement is observed.

Aloe Vera: Nature’s Moisturizer for Brittle Nails

Aloe vera gel is renowned for its moisturizing and healing properties, making it an excellent natural treatment for nail psoriasis. Its ability to strengthen and hydrate dry, brittle nails can significantly improve the condition of psoriasis-affected nails.

Benefits of Aloe Vera for Nail Psoriasis

• Prevents nail reddening and cracking by moisturizing the nail bed
• Possesses anti-inflammatory properties to control swelling
• Boosts the immune system, potentially helping to manage the autoimmune aspect of psoriasis

For optimal results, apply fresh aloe vera gel to the nails and surrounding skin before bedtime, allowing it to absorb overnight.

Glycerin: A Hydration Powerhouse for Nail Health

Glycerin stands out as an exceptional hydrating agent in the treatment of nail psoriasis. Its ability to maintain optimal moisture levels in the skin for extended periods makes it particularly beneficial for preventing nail brittleness and cracking, common issues in nail psoriasis.

How to Use Glycerin for Nail Psoriasis

Create a simple yet effective treatment by mixing equal parts water and glycerin. Apply this mixture to the affected nails and surrounding skin, leave it on for an hour, then rinse with lukewarm water. This treatment can help restore moisture to dry, psoriasis-affected nails.

Coconut Oil: Nature’s Antifungal Moisturizer

Coconut oil is a versatile natural remedy that offers multiple benefits for those suffering from nail psoriasis. Its moisturizing properties help combat dryness, while its medium-chain fatty acids act as natural antifungal agents, providing protection against secondary fungal infections that can complicate nail psoriasis.

Maximizing Coconut Oil’s Benefits for Nail Psoriasis

For best results, massage coconut oil into the nails and cuticles several times a day. Alternatively, create a more potent treatment by mixing melted coconut oil with a few drops of oregano oil, known for its strong antifungal properties. Apply this blend to the affected nails, leave for 10 minutes, then wash off and pat dry.

Shea Butter: A Nutrient-Rich Solution for Nail Repair

Shea butter is a natural moisturizer packed with fatty acids and vitamins A and E, making it an excellent choice for strengthening and nourishing psoriasis-affected nails. Its rich composition helps hydrate the nail bed and surrounding skin, promoting healing and preventing further damage.

Incorporating Shea Butter into Your Nail Care Routine

Apply raw shea butter to your nails before bedtime, allowing it to work overnight. This simple treatment can significantly improve the condition of damaged, brittle nails associated with psoriasis.

Lifestyle Modifications to Manage and Prevent Nail Psoriasis

While natural remedies can be highly effective, incorporating certain lifestyle changes can enhance their efficacy and help manage nail psoriasis more comprehensively:

• Daily moisturizing: Apply a moisturizer to hands and nails after each wash. Opt for tube-squeezed ointments over lotions for better efficacy.
• Proper nail drying: Always pat nails dry after washing to prevent moisture accumulation that can lead to infections.
• Protective gear: Use gloves during household chores involving water exposure. Layer cotton gloves under vinyl or nitrile gloves for best protection.
• Sunlight exposure: Spend 15-20 minutes in morning sunlight daily to boost immunity and vitamin D production, beneficial for nail health.
• Dietary improvements: Increase intake of foods rich in fatty acids (e.g., flaxseeds, walnuts, sardines) and zinc (e.g., oysters, pumpkin seeds) to support nail health and prevent infections.

The Role of Nail Polish in Managing Nail Psoriasis Appearance

While nail polish doesn’t treat nail psoriasis directly, it can play a significant role in managing the cosmetic aspects of the condition. Clear or colored nail polish can help conceal discoloration and roughness, making nails appear smoother and more uniform.

Choosing the Right Nail Polish for Psoriasis-Affected Nails

When selecting nail polish for psoriasis-affected nails, consider the following:

• Opt for breathable formulas that allow moisture and air to reach the nail
• Choose polishes free from harsh chemicals that could irritate sensitive skin
• Consider using a base coat to protect the nail from staining and provide a smoother surface

Remember, while nail polish can improve appearance, it’s essential to remove it regularly and allow nails to breathe to prevent trapping moisture that could exacerbate psoriasis symptoms.

Complementary Therapies for Comprehensive Nail Psoriasis Management

In addition to natural remedies and lifestyle changes, several complementary therapies can enhance the management of nail psoriasis:

Stress Reduction Techniques

Stress is known to trigger or worsen psoriasis flares, including nail psoriasis. Incorporating stress-reduction techniques into your daily routine can help manage symptoms:

• Meditation and mindfulness practices
• Regular exercise, such as yoga or tai chi
• Deep breathing exercises
• Adequate sleep and rest

Proper Nail Care Routine

Establishing a consistent nail care routine is crucial for managing nail psoriasis:

1. Keep nails short to prevent injury and reduce the accumulation of debris
2. Use a soft nail file to smooth rough edges and prevent snagging
3. Avoid aggressive manicures or pedicures that could damage the nail or surrounding skin
4. Use lukewarm water for nail cleaning, as hot water can irritate psoriasis-affected skin

Nutritional Support

A balanced diet rich in certain nutrients can support overall skin and nail health:

• Omega-3 fatty acids: Found in fish oil, flaxseed, and chia seeds, these can help reduce inflammation
• Vitamin D: Either through sunlight exposure or supplements, vitamin D plays a role in skin cell growth and immune function
• Antioxidants: Colorful fruits and vegetables provide antioxidants that support overall skin health
• Probiotics: Found in fermented foods or supplements, probiotics may help modulate the immune system

When to Seek Professional Medical Advice

While natural remedies and lifestyle changes can be effective for many individuals with nail psoriasis, it’s important to recognize when professional medical intervention may be necessary:

Signs That Warrant a Visit to a Dermatologist

• Severe pain or discomfort in the nails that interferes with daily activities
• Signs of infection, such as increased redness, warmth, or pus
• Significant nail deformity or separation from the nail bed
• Lack of improvement after several weeks of consistent home treatment
• Development of new or worsening symptoms

A dermatologist can provide additional treatment options, including topical medications, oral treatments, or light therapy, depending on the severity of your nail psoriasis.

Innovative Technologies in Nail Psoriasis Treatment

As research in psoriasis treatment advances, new technologies are emerging that show promise for managing nail psoriasis:

Phototherapy for Nail Psoriasis

Targeted phototherapy using specific wavelengths of light has shown potential in treating nail psoriasis. This treatment can be administered in a clinical setting or, in some cases, using at-home devices under medical supervision.

Nail Lacquers with Active Ingredients

Medicated nail lacquers containing ingredients such as corticosteroids or vitamin D analogues are being developed to deliver treatment directly to the affected nails. These formulations aim to improve absorption and efficacy compared to traditional topical treatments.

Biologic Therapies

For severe cases of nail psoriasis that don’t respond to other treatments, biologic medications that target specific components of the immune system may be recommended. While not typically first-line treatments for nail psoriasis alone, they can be highly effective for individuals with widespread psoriasis affecting both skin and nails.

Long-Term Management and Prognosis of Nail Psoriasis

Managing nail psoriasis is often a long-term commitment that requires patience and consistency. While complete cure may not always be possible, many individuals can achieve significant improvement and control of their symptoms with proper care and treatment.

Factors Affecting Nail Psoriasis Prognosis

• Early intervention and consistent treatment
• Overall psoriasis severity and distribution
• Adherence to treatment plans and lifestyle modifications
• Individual response to various therapies
• Presence of other health conditions that may affect treatment options

It’s important to work closely with healthcare providers to develop a personalized treatment plan that addresses both immediate symptoms and long-term management of nail psoriasis. Regular follow-ups and adjustments to the treatment regimen may be necessary to maintain optimal nail health and prevent complications.

By combining natural remedies, lifestyle modifications, and professional medical care when needed, individuals with nail psoriasis can effectively manage their condition and maintain healthy, functional nails. Remember that what works best can vary from person to person, so don’t be discouraged if it takes some time to find the most effective combination of treatments for your specific case of nail psoriasis.

How to Treat & Prevent Nail Psoriasis at Home

Psoriasis is an autoimmune condition that boosts the generation of skin cells, causing their accumulation. As a result, skin thickening and deformation occur.

Since the protein of skin cells and nails is the same, psoriasis can also affect the nails by increasing cell production and accumulation in the nail bed or nail matrix.

Nail psoriasis is characterized by thickening, pitting, and discoloration of the nails. It can cause tenderness and pain in the nails, often interfering with daily activities. It is vital to treat nail psoriasis to prevent complications.

Most cases can be managed with proper care and home remedies, which will be discussed in this article.

Home Remedies for Nail Psoriasis

The following at-home treatments can help manage the signs and symptoms of nail psoriasis and prevent the condition from worsening:

1. Dab some tea tree oil

Tea tree essential oil has antibacterial, antifungal, and antiseptic properties that can fight fungal and bacterial infections of the nails. This essential oil is also rich in terpinen-4-ol, which is an anti-inflammatory agent (1) and helps reduce the pain.

How to use:

1. Add 5–6 drops of tea tree oil in a small bowl of lukewarm water.
2. Soak your nails in the water for 15 minutes and then pat them dry.
3. Repeat this remedy two times daily until you see improvement.

2. Apply aloe vera gel

Aloe vera gel can help strengthen and moisturize the dry, brittle nails associated with nail psoriasis. It helps prevent nail reddening and cracking by moisturizing and nourishing the skin and nail bed.

In addition, aloe vera possesses anti-inflammatory properties that help control swelling and boost the immune system. (2)

How to use:

1. Extract some fresh aloe vera gel.
2. Apply the gel to the nails and nail bed.
3. Leave it on overnight to be completely absorbed.

3. Use glycerin

Glycerin is an excellent hydrating agent that can help maintain optimum moisture levels in the skin for several hours. (3) This effect is beneficial in preventing nail brittleness and cracking.

How to use:

1. Mix water and glycerin.
2. Apply the mixture to the nails and surrounding skin.
3. Leave it on for an hour, and then rinse it off with lukewarm water.

4. Massage with coconut oil

Coconut oil is another effective moisturizing agent that can be useful in managing nail psoriasis. It contains medium-chain fatty acids that act as antifungal agents, helping prevent fungal nail infections. (4)

How to use:

• Apply coconut oil to your nails and cuticles, and massage it in for a few minutes. Do this multiple times a day.
• Alternatively, you can mix melted coconut oil with a few drops of oregano oil. Use this oil blend to massage your nails. Wash off the oil after 10 minutes of application, and pat your nails dry.

5. Moisturize with shea butter

Shea butter is a natural moisturizer that helps improve damaged, brittle nails. It contains fatty acids and vitamins A and E that strengthen, hydrate, and nourish the nail bed and surrounding skin.

How to use:

1. Apply raw shea butter to your nails before bedtime.
2. Wash it off in the morning.

Lifestyle Changes to Manage Nail Psoriasis

Implement these changes to better manage nail psoriasis and promote faster recovery:

• Moisturize daily: Make sure to apply a moisturizer to your hands and nails after washing your hands. Tube-squeezed ointments are more effective than lotion bottles.
• Dry your nails properly: Pat your nails dry every time you wash your hands. Avoid rubbing them or leaving them wet as the latter can increase the risk of infections.
• Use gloves: Wear gloves when you are doing any household chore that involves putting your hands in the water, such as washing the dishes. It is recommended to wear a cotton glove and layer it with a vinyl or nitrile glove rather than using a latex glove.
• Get some sunlight: Daily sun exposure for 15–20 minutes can boost your immunity, prevent infection, and stimulate vitamin D production. Thus, it is suggested to expose your nails to the morning sun every day. However, avoid the sun during the afternoon as there is a risk of sunburn and skin cancer during the peak hours.
• Improve your diet: It is seen that fatty acid consumption can help prevent fungal infections. Hence, consuming flaxseeds, walnuts, sardines, salmon, and mackerel may be helpful in managing nail infections. In addition, increase your intake of foods high in zinc, such as oysters, pumpkin seeds, and liver.
• Apply nail polish: While nail polishes cannot aid in the treatment of nail psoriasis, they can cover up any discoloration and roughness and can make your nails look smoother, especially if you use clear polish. This simple trick may help in reducing cosmetic concerns.
• Turn on the humidifier: Using an indoor humidifier helps maintain optimum moisture levels in your surroundings and therefore prevents dryness in the skin and nails.

Measures to Prevent Nail Psoriasis

It is vital to take good care of your nails to prevent nail psoriasis from developing or worsening. Prevention is also important to avoid the complications associated with nail psoriasis until treatment is complete.

Here’s what you can do:

1. Trim your nails: Keep your nails short; long nails are prone to breakage. This is more so important if you have nail psoriasis as the nails are already weak and any uneven cracking can result in excessive pain.
2. Avoid biting your nails: Never pick or bite your nails and the surrounding skin. These habits can compromise the protective skin barrier by causing skin injury, which then acts as an entry point for infections that can trigger or worsen nail psoriasis.
3. Refrain from using nail tools: Using harsh tools such as a nail brush to clean the nails can increase the risk of nail separation and therefore infection. Thus, avoid putting any pressure on your nails. Instead, get your monthly manicures and pedicures from professionals who are trained to take care of the nails. Just make sure they are using clean, sterile equipment to avoid the risk of infections.
4. Do not push back the cuticles: Pushing back your cuticles or cutting them can expose the nail bed to infections – refrain from these practices.
5. Avoid artificial nails: The glue used for artificial nails can be a potential irritant and may harm the nail bed in the long run. Avoid using these products.
6. Protect your nails: It is a must to protect your nails from any trauma or injury as this can trigger or worsen nail psoriasis.

Final Word

Nail psoriasis is a discomforting condition that makes your nails weak, brittle, and prone to damage and infections. It can often change the appearance of the nails, causing cosmetic problems.

However, the condition can be managed with proper treatment. You may try home remedies and self-care to manage the symptoms. If the condition doesn’t improve, make sure to consult your doctor for medical treatment to avoid complications.

Continue ReadingNail Psoriasis: Symptoms, Diagnosis, and Treatment

References

1. R; PNY. Tea tree oil as a novel antipsoriasis weapon. Skin pharmacology and physiology. https://pubmed.ncbi.nlm.nih.gov/22473218/.
2. Rahmani AH, Aldebasi YH, Srikar S, Khan AA, Aly SM. Aloe vera: Potential candidate in health management via modulation of biological activities. Pharmacognosy reviews. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4557234/. Published 2015.
3. Milani M, Sparavigna A. The 24-hour skin hydration and barrier Function effects of a Hyaluronic 1%, Glycerin 5%, And Centella asiatica stem cells EXTRACT moisturizing Fluid: AN Intra-subject, randomized, assessor-blinded study. Clinical, cosmetic and investigational dermatology. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5560567/. Published August 11, 2017.
4. Khoramnia A, Ebrahimpour A, Ghanbari R, Ajdari Z, Lai O-M. Improvement of medium chain fatty acid content and antimicrobial activity of coconut oil Via SOLID-STATE fermentation using a Malaysian Geotrichum candidum. BioMed research international. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3732585/. Published 2013.

5 Tips to Improve Nail Psoriasis at Home

Newswise — ROSEMONT, Ill. (June 11, 2020) — Approximately 7.5 million people in the U.S.[1] have psoriasis, a chronic inflammatory disease that mostly affects the skin and joints but could also affect the nails. According to dermatologists from the American Academy of Dermatology, most people who have plaque psoriasis — the most common form of psoriasis — also develop nail psoriasis at some point. This is why dermatologists say it’s important for psoriasis patients to check their nails — both their fingernails and toenails — for signs of nail psoriasis, which can include nail dents, lifting, discoloration, thickening and crumbling. However, it’s also possible for patients to experience nail psoriasis without having psoriasis on other parts of their body.

The good news, say dermatologists, is that the right treatment and at-home care can help reduce pain, allow you to perform your daily activities and make your nails look normal.

“There are many treatment options available for nail psoriasis, including topical and oral medications, corticosteroid injections, and biologics,” says board-certified dermatologist Richard K. Scher, MD, FAAD. “However, nail psoriasis can be challenging to treat. To get results, it’s important to treat your nails as directed and for as long as directed by your dermatologist. The right nail care at home can also help you get the best results from treatment. ”

To help improve nail psoriasis at home, Dr. Scher recommends the following tips:

1. Keep your nails trimmed short. This helps prevent your nails from lifting off of your fingers and toes. It can also help prevent buildup under the nails — a common issue associated with nail psoriasis. If you have a hangnail, clip it off immediately.

2. Avoid biting or picking your nails, the area under your nails and your cuticles. Injuring your skin increases your risk of infection, which could worsen your psoriasis. To kick this bad habit, try applying bitter-tasting nail polish, or replacing this habit with a better one, such as playing with a stress ball.

3. Moisturize your hands and nails. Apply moisturizer immediately after bathing or washing your hands to lock in moisture. Use ointments or creams you squeeze out of a tube, as these are more effective than products you pump out of a bottle.

4. Protect your nails. Any time you irritate your skin or nails, psoriasis can flare. To prevent this, always wear gloves when doing housework, yard work or other labor-intensive work to prevent your psoriasis from flaring. When doing wet work like washing dishes, it’s best to wear a cotton glove and then place a vinyl or nitrile glove over the cotton glove. Latex gloves cannot give your nails enough protection.

5. Consider nail polish: If you are concerned about the appearance of your nails, consider gently buffing them to help smooth the surface or wearing nail polish, which is a great way to hide nail issues, such as dents or discoloration. Artificial nails should be avoided, as they may contribute to your nails separating and lifting from your fingers.

“Nail psoriasis can be stubborn, however, the combination of treatment and the recommended at-home care can help clear nail psoriasis and reduce pain,” says Dr. Scher. “Nail psoriasis may also be a sign of psoriatic arthritis, a type of arthritis that can occur in psoriasis patients. If you notice any changes to your fingernails and toenails or nail changes coupled with swollen, stiff and sometimes painful joints when waking up, see a board-certified dermatologist, as the sooner your issue is addressed, the better your results.”

These tips are demonstrated in “How to Improve Nail Psoriasis,” a video posted to the AAD website and YouTube channel. This video is part of the AAD’s “Video of the Month” series, which offers tips people can use to properly care for their skin, hair and nails.

To find a board-certified dermatologist in your area, visit aad.org/findaderm.

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More Information

What Is Nail Psoriasis, and How Can I Treat It?

How to Stop Biting Your Nails

Psoriasis Resource Center

About the AAD

Headquartered in Rosemont, Ill. , the American Academy of Dermatology, founded in 1938, is the largest, most influential, and most representative of all dermatologic associations. With a membership of more than 20,000 physicians worldwide, the AAD is committed to: advancing the diagnosis and medical, surgical and cosmetic treatment of the skin, hair and nails; advocating high standards in clinical practice, education, and research in dermatology; and supporting and enhancing patient care for a lifetime of healthier skin, hair and nails. For more information, contact the AAD at (888) 462-DERM (3376) or aad.org. Follow the AAD on Facebook (American Academy of Dermatology), Twitter (@AADskin), Instagram (@AADskin1), or YouTube (AcademyofDermatology).

[1]Menter A, Gottlieb A, Feldman SR, Van Voorhees AS et al. Guidelines of care for the management of psoriasis and psoriatic arthritis: Section 1. Overview of psoriasis and guidelines of care for the treatment of psoriasis with biologics. J Am Acad Dermatol 2008 May;58(5):826-50.

Common Concepts and New Trends

Dermatol Res Pract. 2013; 2013: 180496.

Yasemin Oram

Department of Dermatology, V.K. Foundation American Hospital of Istanbul, Turkey

A. Deniz Akkaya

Department of Dermatology, V.K. Foundation American Hospital of Istanbul, Turkey

Department of Dermatology, V.K. Foundation American Hospital of Istanbul, Turkey

Academic Editor: Pablo Coto-Segura

Received 2013 Mar 5; Revised 2013 Apr 19; Accepted 2013 Apr 22.

This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

The lifetime incidence of nail involvement in psoriatic patients is estimated to be 80–90%, and the nails can be affected in 10% to 55% of psoriatic patients. Psoriasis may also solely involve the nails, without any other skin findings, in which the treatment can be more challenging. Nail psoriasis may lead to considerable impairment in quality of life due to aesthetic concerns and more importantly limitations in daily activities resulting from the associated pain, which may be overlooked by the physicians. Several topical and systemic treatment modalities, as well as radiation and light systems, have been used in the treatment of nail psoriasis. In the last decade, the introduction of biologic agents and the utilization of laser systems have brought a new insight into the treatment of nail psoriasis. This paper focuses on the recent advances, as well as the conventional methods, in treating nail psoriasis in adults and children, in reference to an extensive literature search.

1. Introduction

Psoriasis is a chronic skin disease that causes significant distress and morbidity. Although the skin manifestations are more characteristic, the lifetime incidence of nail involvement in psoriatic patients is estimated to be 80–90%, and the nails can be affected in 10% to 55% of psoriatic patients [1–3]. Moreover, psoriasis may involve the nails only, without any other signs of skin findings [1, 4]. Nail psoriasis has been shown to be associated with longer duration of skin lesions. There is an association between the duration of psoriasis and the severity of nail involvement [2, 3, 5]. Nail psoriasis is also associated with higher disease severity [3, 6]. However, it may also occur in 40% of patients with mild psoriasis [2]. It is slightly more common in male patients than females [3, 6]. Nail psoriasis leads to considerable impairment in quality of life due to aesthetic concerns and more importantly limitations in daily activities resulting from the associated pain [2, 7].

Nail psoriasis may show different clinical presentations according to the structure that is involved within the nail unit. Nail matrix involvement leads to irregular nail pitting (the most common finding of nail psoriasis), dystrophy, and leukonychia; nail bed involvement causes onycholysis, subungual hyperkeratosis, splinter hemorrhages, oil drop patches, and nail thickening, whereas nail fold involvement may result in paronychia [1, 8, 9]. In cases of very severe inflammation, combined nail matrix and nail bed psoriasis may develop, forming “psoriatic crumbly nail.” Psoriatic nail constitutes a risk factor for secondary mycotic infections, which can occur in up to 27% of the cases. This coexistence should be excluded by mycologic examination before treatment [10].

There is striking association between nail psoriasis and a high risk of psoriatic arthritis, a chronic inflammatory arthropathy, with a prevalence of nail involvement among patients with psoriatic arthritis as high as 70%. Nail involvement may precede arthritis or may be considered as a predictor of future psoriatic joint damage [3, 11]. Nail bed involvement prevalence has been found higher in patients with psoriatic arthritis [11]. Psoriatic arthritis mainly involves distal interphalangeal joints and is characterized by dactylitis, enthesitis, osteolysis, and periarticular new bone formation [12]. A possible explanation for this association might be the close anatomical link between the nail unit and the distal interphalangeal joint. Inflammation of the extensor tendon enthesis, which are the attachment points of ligaments, tendons, and joint capsules to bone, can extend to the nail unit and result in psoriatic nail changes [8].

The Nail Psoriasis Severity Index (NAPSI) has been developed as an objective and reproducible tool, which helps to estimate the nail involvement and therefore to standardize the treatment outcome assessments. The nail is divided into quadrants, based on the signs of involvement of the nail matrix and the nail bed, rated with 0 or 1 [13]. NAPSI scoring system has some limitations, as it does not specifically consider the severity of nail matrix or nail bed involvement. In a recent report by Mukai et al. [14], NAPSI scores were evaluated in psoriatic patients using acitretin, and it was concluded that the method was easy and rapid in measuring the improvement of the treatment; however, it did not quantify the existing lesions and might not detect small changes. In 2007, a modified NAPSI (mNAPSI) was proposed by Cassell et al. [15] in order to increase the sensitivity of NAPSI, using a qualitative gradation of severity for each parameter from 0 to 3 in each quadrant. Although it can be time consuming and impractical for the clinicians in an outpatient clinic, mNAPSI demonstrates excellent interrater reliability and validity in the assessment of psoriatic nail disease [8, 15]. Digital photography might be an easy and convenient method for monitoring the progression of the nail involvement during the treatment [8].

Although there exist several treatment options for psoriasis, there are no existing guidelines or consistent treatment algorithms for the treatment of nail psoriasis, as the amount of published evidence available is limited. Recently, a systematic review evaluating the randomized controlled trials has provided some evidence concerning the management of nail psoriasis [16]. The management of nail psoriasis has been challenging particularly when the nail involvement is the only manifestation of the disease. Low penetration of the topical medications and slow growth rate of the nails are the main factors for this difficulty. Moreover, most of the therapies require prolonged treatment and continuity, sometimes with side effects and/or disappointing results. Obviously, it may have a negative impact on patient’s compliance, motivation, and quality of life [4].

2. General Nail Care

The Koebner, or isomorphic response, which is the formation of new psoriatic lesions at sites of physical injury to the skin, is a well-known phenomenon. Psoriatic changes of the nail unit can also be triggered by minor traumas such as manicure, biting the nails, picking or trimming the cuticle, clearing subungual debris, or wearing tight-fitting shoes. An important part of the treatment is to ensure that the patient is avoiding all the factors that may exacerbate the disease. The physical trauma should be discouraged, the hands and feet should be thoroughly wiped dry, and the nails must be kept short [8, 9].

3. Topical Therapy

There is limited evidence for the efficacy of topical therapies in nail psoriasis. Various topical treatment modalities have been used in nail psoriasis including corticosteroids, dithranol, fluorouracil, vitamin D₃ analogues, tacrolimus, cyclosporine, and tazarotene [1, 4, 7, 8] ().

Table 1

Topical therapies for treatment of nail psoriasis.

Author	Year	n	Intervention	Comparison	Treatment protocol	Results	LoE [16]
Nakamura et al. [17]	2012	15	Clobetasol propionate at concentrations 0. 05%, 1%, and 8%	Placebo (coat nail lacquer)	Twice weekly, for 4 mos	51% improvement in treatment group (8% clobetasol more efficient)	N/A
Fischer-Levanchini et al. [18]	2012	6	0.1% tazarotene ointment	—	Once daily, under occlusion, for 6 mos	88% improvement in NAPSI scores at 6th mo	N/A
De Simone et al. [19]	2012	21	0.1% tazarotene ointment	No treatment to the other hand	Once daily, to the affected nails of a randomly selected hand, for 3 mos	Statistically significant improvements in the treated hands at week 12	N/A
Tzung et al. [20]	2008	40	0.005% calcipotriol + 0.05% betamethasone dipropionate	0.005% calcipotriol	Calcipotriol twice daily and calcipotriol + betamethasone once daily for 3 mos	Similar efficacy in both groups, significant reduction of NAPSI scores	B
Sánchez-Regaña et al. [21]	2008	15	8% clobetasol in nail lacquer and tacalcitol	—	Clobetasol once daily at weekends and tacalcitol at weekdays under occlusion, for 6 mos	78% reduction in NAPSI at 6 mos	N/A
Rigopoulos et al. [22]	2007	46	0.1% tazarotene cream	0.05% clobetasol propionate	Once daily under occlusion, for 3 mos	Similar efficacy in both groups, significant reduction of NAPSI scores	A2
Regaña et al. [23]	2005	10	8% clobetasol in nail lacquer	—	Once daily, for 3 weeks and twice weekly, for 9 mos	Reduction of all nail alterations within 1 mo	N/A
Cannavò et al. [24]	2003	16	70% CsA oral solution in maize oil	Maize oil	For 3 mos	Complete resolution or substantial improvement in CsA group	A2
Bianchi et al. [25]	2003	25	0.1% tazarotene gel	—	Once daily, for 3 mos	19/25 good clinical response	N/A
Rigopoulos et al. [26]	2002	62	Calcipotriol cream + clobetasol propionate	—	Calcipotriol once daily every weeknight and clobetasol once daily every weekend, for the first 6 mos and twice weekly clobetasol for the 2nd 6 mos	Reduction at subungual hyperkeratosis: 72. 3% at 6 mos and 81.2% at 12 mos	N/A
Scher et al. [27]	2001	31	0.1% tazarotene gel	Vehicle gel	Once daily, for 6 mos	Significant improvement of onycholysis and pitting in tazarotene group	A2/B
de Jong et al. [28]	1999	57	1% 5-FU in permeation enhancer lotion (Belanyx)	Belanyx (urea and propylene glycol)	Once daily, for 3 mos	Significant improvements with both preparations	A2
Baran and Tosti [29]	1999	18	8% clobetasol nail lacquer	Placebo	Once daily in the first week, from 2nd week onwards 2-3 times weekly, for up to 9 mos	Clear improvement in 80%, complete resolution in 22% of patients in the treatment arm	B
Tosti et al. [30]	1998	58	Calcipotriol ointment	Betamethasone propionate + salicylic acid	Twice daily, for up to 5 months	Calcipotriol as effective as the combination of topical steroid and salicylic acid (49% versus 51% reduction of subungual hyperkeratosis in fingernails at 6 mos)	B
Yamamoto et al. [31]	1998	20	0.4–2% anthralin in petrolatum	—	Once daily, for 5 mos	Effective in 12/20 patients, particularly in onycholysis and subungual hyperkeratosis	N/A
Fredriksson [32]	1974	20	1% 5-FU solution	—	Twice daily, for up to 6 mos	Considerable improvement in 17/20 patients, 75% reduction of symptoms compared to baseline	N/A

The main topical treatments for nail psoriasis have traditionally comprised potent corticosteroids applied under occlusion. The clobetasol propionate at a concentration of 0.05% in cream or gel vehicle has been the most recommended topical treatment. However, they may cause atrophy, depigmentation, telangiectasia, and bone reabsorption. In 1999, Baran and Tosti [29] first described the use of 8% clobetasol propionate in nail lacquer vehicle in the treatment of 45 patients with nail psoriasis. The nail lacquer is a solution that helps to prevent the adverse effects caused by the use of intralesional corticosteroids or corticosteroids in cream or gel applied to the skin. Consequently favorable results have been observed with 8% clobetasol propionate lacquer that has effective transungual penetration and therapeutic effect both on nail bed and matrix lesions, while lacking side effects [17, 23].

Dithranol is an anthracene derivative with antiinflammatory and antiproliferative actions [8]. In a prospective study, dithranol (anthralin) ointment with a 0.4–2% concentration has been shown to be effective in 60% of 20 patients particularly in the treatment of onycholysis and subungual hyperkeratosis using daily short-contact therapy. The ointment was applied for 30 minutes daily for 5 months. Side effects included local irritation and temporary staining of the nail [31].

Fluorouracil is a pyrimidine analog, which inhibits the thymidylate synthase. Topical 5-fluorouracil (5-FU) in 1% or 5% concentrations in different vehicles has been used in nail psoriasis with unpredictable results. In a prospective study, the application of 1% fluorouracil solution twice daily for 6 months demonstrated marked improvement in nail pitting and hyperkeratosis in 85% of patients [32]. However, another small double-blinded study failed to show any benefits from topical 5-FU lotion 1%, combined with urea and propylene glycol. Besides, onycholysis was aggravated with the treatment [28]. The reported side effects such as pain, infection, nail loss, hyperpigmentation, onycholysis, and skin irritation, in the small number of studies conducted, are the reasons to limit its use.

Vitamin D₃ analogues of calcipotriol, calcitriol, and tacalcitol have been used in the treatment of nail psoriasis by inhibiting keratinocyte growth and differentiation and suppressing T-cell activity and cytokine production [1, 7, 21, 33]. In a double-blind study involving 58 patients with nail bed psoriasis, topical application of calcipotriol ointment twice daily was found to be as effective as twice daily application of betamethasone dipropionate in reducing subungual hyperkeratosis after 3–9 months [30]. Side effects include periungual irritation, erythema, and burning [7]. Combination therapy of topical corticosteroids with vitamin D₃ analogues including calcipotriol and tacalcitol has been shown to be effective, although there is no standard therapeutic regimen. The antiinflammatory effect of corticosteroids together with the antiproliferative and immunomodulatory effects of vitamin D₃ not only enhances the outcome of the treatment but also reduces the risk of adverse effects [8]. Rigopoulos et al. [26] demonstrated that the combined treatment with calcipotriol cream (once daily, 5 days a week) and clobetasol propionate cream (once daily, 2 days a week) for 6 months resulted in a 72% reduction at subungual hyperkeratosis. The synergistic effect of topical vitamin D₃, which mainly affects the nail bed, togetherwith topical corticosteroid that is more effective on nail matrix, may provide safer and better treatment for nail psoriasis [20, 21, 30].

Tazarotene is a synthetic retinoid derived from vitamin A that downmodulates keratinocyte hyperproliferation, differentiation, and inflammation. Studies using tazarotene gel 0.1% have been conducted with successful results in nail psoriasis [25, 27]. Rigopoulos et al. [22] reported that tazarotene 0.1% cream was as effective as clobetasol propionate 0.05% cream in improving onycholysis, discoloration, pitting, and hyperkeratosis after 12 weeks in a double-blind study of 46 patients. In a small study, the efficacy and safety profile of tazarotene 0.1% hydrophilic ointment under occlusion was evaluated in the treatment of nail psoriasis of 6 patients. Clinically significant improvement in nail involvement, especially the subungual hyperkeratosis and onycholysis, was observed after 6 months of treatment [18]. Topical tazarotene has been generally well tolerated with mild erythema, local irritation, desquamation, and burning [25]. The combination of tazarotene with a topical corticosteroid might be helpful in decreasing the irritation caused by tazarotene while achieving an enhanced effect with two different molecules [7].

Several studies have shown that a topical calcineurin inhibitor, tacrolimus ointment, may penetrate the periungual skin and can be used to treat nail dystrophy caused by lichen planus or chronic paronychia [7, 34]. Tacrolimus in 0.1% and 0.03% ointment was found to be effective in psoriasis due to its immunosuppressive property. De Simone et al. [19] have reported good clinical results in nail psoriasis with topical tacrolimus 0.1% ointment application after 12 weeks. It seemed to be equally effective on nail bed and matrix lesions without having severe side effects.

Topical cyclosporine preparation showed to improve pitting and onycholysis in a small, placebo-controlled study. Oil-dissolved 70% solution of cyclosporine has been used in 8 patients for 12 weeks, and complete resolution or substantial improvement has been reported in all patients [24]. However, topical cyclosporine is not as effective as the systemic form in nail psoriasis, and further studies are necessary to optimize the vehicle and stability of the topical administration [35].

4. Intralesional Therapy

Despite a relative paucity of controlled studies, intralesional injections with corticosteroids are considered to be a standard treatment for nail psoriasis [1]. Triamcinolone acetonide is the most widely used agent in doses of 2.5–10 mg/mL at up to four injection sites (two into the proximal nail fold and two in the lateral nail fold), used bimonthly for 5-6 months. Injections to the proximal nail fold with 28- and 29-gauge needle syringes or with needle-less injectors are very effective in treating nail matrix disease such as pitting or ridging [1, 9, 36]. Up to 70–90% of psoriatic patients with both nail matrix and nail bed lesions respond to intralesional steroids, except for onycholysis, which shows a less pronounced response. Corticosteroid injections can cause considerable pain, atrophy, despigmentation, secondary infection, inclusion cysts, subungual hemorrhage, and tendon rupture [9, 36]. This treatment requires repeated injections.

Saricaoglu et al. [37] reported a case of severe psoriatic nail disease successfully treated with intralesional methotrexate at a dose of 2.5 mg of weekly injections for 6 weeks. The significant improvement in subungual hyperkeratosis and pitting was maintained after 2 years of treatment. The most important limitation of the therapy was the severe pain during injections.

5. Phototherapy, Radiation Therapy, and Laser Therapy

Although phototherapy with narrow-band UVB and photochemotherapy with UVA, in addition to oral psoralen (PUVA), have been successfully used in psoriasis, there is not enough evidence to support their beneficial effects in nail psoriasis. Several small studies have shown that PUVA can help psoriatic nails with variable results. The pitting and onycholysis have demonstrated poor response to PUVA treatment [38]. A recent study on the penetration of UV lights in normal human cadaveric fingernail plate showed that the nail plate completely blocks UVB light but only a minimal amount of UVA penetrates the nail [39]. This may explain the limited effect of PUVA in nail psoriasis.

Superficial radiotherapy, electron beam therapy, and Grenz rays have been infrequently used in the treatment of nail psoriasis with temporary benefits. The possibility of localized fibrosis and carcinogenesis should be considered in radiation therapy [7, 8]. Soft X-rays have been used for very thick psoriatic nails in one case, in fractionated doses of 1.5 Gy for a total of 13.5 Gy (43 kV, 25 mA, 0.6 mm aluminum filter) at 1- and 2-week intervals. The nail plates became normal after 12 months of therapy [40].

In recent years photodynamic therapy (PDT) and pulsed dye laser (PDL) have been described for the treatment of nail psoriasis regarding their proven effects on plaque type psoriasis. We have used 595 nm PDL (7 mm spot size, 1,5 ms pulse duration, 8–10 j/cm² energy) in nail psoriasis of 5 patients, once monthly for 3 months, with significant improvement, particularly of nail bed lesions [41]. Mean NAPSI scores declined from 21.2 at baseline to 3 at 1 month after 3 sessions. Treewittayapoom et al. [42] found PDL to be effective in both nail bed and matrix lesions, in a left-to-right comparison study of 20 patients, evaluating the effect of two different pulse durations (6 ms, 9 j/cm² versus 0.45 ms, 6 j/cm² both with 7 mm spot size). A significant reduction in NAPSI scores from baseline was observed in both groups after 6 months of the first treatment, while no significant difference was found between the longer and the shorter pulse duration groups. Fernández-Guarino et al. [43] evaluated the efficacy of PDT and PDL in the treatment of nail psoriasis in a left-to-right comparison study of 14 patients. Both hands were treated with 595 nm PDL (7 mm, 6 ms, 9 j/cm²), following 3 hours occlusion of methyl-aminolaevulinic acid (MAL) to one hand, once a month for 6 months. After 3 hours occlusion of methyl-aminolaevulinic acid (MAL) to one hand, both hands were treated with 595 nm PDL (7 mm, 6 ms, 9 j/cm²), once a month for 6 months. They showed that both treatments were equally effective in nail bed and nail matrix lesions; hence MAL did not play any role in the improvement of nail psoriasis.

6. Systemic Therapy

Systemic treatment can be recommended in severe localized nail psoriasis when topical or intralesional therapy has failed or in the treatment of moderate-to-severe psoriasis vulgaris accompanied with nail involvement [4, 7, 9] ().

Table 2

Systemic therapies for treatment of nail psoriasis.

Author	Year	n	Intervention	Comparison	Treatment protocol	Results	LoE [16]
Sánchez-Regaña et al. [44]	2011	84	Classical treatment	Biological treatment	Classical: acitretin, MTX, CsA, PUVA, NUVB, REPUVA, RENUVB Biological: infliximab, efalizumab, etanercept, adalimumab, for up to 8 mos	Significant reductions in NAPSI scores with all antipsoriatics, except for NUVB; significantly greater with CsA and biological as infliximab and adalimumab at 3 and 6 mos	N/A
Gümüşel et al. [45]	2011	37	MTX 15 mg/week, sc	CsA 5 mg/kg, po	MTX decreased to 10 mg/week after 3 months, for total 6 mos; CsA decreased to 2. 5–3.5 mg/kg/day after 3 mos, for total 6 mos	Similar efficacy in both groups: reduction in NAPSI scores: 43% in MTX group, 37% in CsA group	A2
Tosti et al. [46]	2009	36	Acitretin	—	0.2–0.3 mg/kg/day, for 6 mos	41% reduction in NAPSI scores	N/A
Syuto et al. [47]	2007	16	CsA-MEPC	—	3 mg/kg/day and reduced to 1. 5 mg/kg/day in responders	Improvement in over 90% of patients	N/A
Feliciani et al. [48]	2004	54	CsA	CsA + calcipotriol cream	CsA 3.5 mg/kg/day, in both groups; calcipotriol cream twice daily, for 3 mos	79% improvement in combination group and 47% improvement in CsA alone	N/A
Mahrle et al. [49]	1995	210	CsA	Etretinate	Phase 1: randomly assigned for CsA (2. 5–5 mg/kg/day) or etretinate (0.5–0.75 mg/kg/day) for 10 weeks Phase 2: etretinate group discontinued treatment and continued with topical dithranol; CsA group either tapered or discontinued and replaced with topical dithranol for 12 weeks	After phase 1: significant alleviation of nail involvement in both groups and after phase 2: statistically significant decrease in nail involvement for tapered cyclosporine group	B

Retinoids are vitamin A analogues that influence epidermal differentiation, proliferation, and immunomodulation. Etretinate and its active metabolite acitretin have been used in psoriasis. Tosti et al. [46] showed a 41% mean improvement in NAPSI scores after 6 months of treatment of low-dose acitretin (0.2–0.3 mg/kg/day) in nail psoriasis. Ricceri et al. [50] reported a case with severe nail psoriasis that showed marked improvement in 2 months of therapy of acitretin at a dose of 0. 5 mg/kg, combined with urea nail lacquer. Acitretin may decrease the thickness of the nail resulting in nail atrophy and fragility. Therefore patients with thickened nails and severe subungual hyperkeratosis are better candidates for acitretin treatment [8]. As retinoids are teratogenic and have been associated with significant hepatotoxicity and hypertriglyceridemia, they should be reserved for very resistant and severe nail involvement [7].

Although the efficacy of methotrexate and cyclosporine on plaque type psoriasis has been reported previously, the literature consists of few publications regarding the efficacy of the two treatment agents in the nail involvement. Syuto et al. [47] have reported that low-dose systemic cyclosporine successfully treats nail psoriasis with an improvement rate of over 90% of the patients. The initial dose was 3 mg/kg/day twice a day and was reduced to 1.5 mg/kg/day in a single administration when the improvement was observed. Oral cyclosporine (3. 5–4.5 mg/kg/day) in combination with topical calcipotriol cream (50 μg/kg/day) has been shown to be more effective with a low risk of relapse in nail psoriasis when compared to the results of the patients receiving cyclosporine alone [48]. In a study by Mahrle et al. [49], 210 patients were randomly assigned for oral cyclosporine (2.5–5 mg/kg/day) or etretinate (0.5–0.75 mg/kg/day) for 10 weeks, and a significant alleviation of nail involvement was shown in both groups. At the second phase of this study, either systemic therapies were discontinued and were switched to topical dithranol or cyclosporine was tapered for 12 weeks. The tapered cyclosporine group was reported to show a significant improvement in nail involvement.

Gümüşel et al. [45] compared the efficacy and safety of methotrexate and cyclosporine in psoriatic nails of 34 patients in a randomized blinded study using NAPSI scores as an objective evaluation of the treatment outcomes. Initial methotrexate dose was 15 mg/week subcutaneously and was decreased after 3 months of treatment. The initial dose of cyclosporine was 5 mg/kg/day and was tapered to 2.5–3.5 mg/kg/day. After 6 months of treatment, they concluded that the two medications were similarly and moderately effective in nail psoriasis. Methotrexate was found to be more effective on nail matrix lesions, whereas cyclosporine was more effective in nail bed involvement.

In the retrospective study of Sánchez-Regeña et al. [44] comparing the classical and biological therapies in the treatment of nail psoriasis, all the classical and biological systemic treatments including cyclosporine, acitretin, methotrexate, and PUVA were shown to significantly reduce the severity of nail psoriasis, with the exception of narrow-band UVB (NUVB). Among the classical treatments, the improvement of nail psoriasis was more prominent in patients who had received cyclosporine. However, the percentage of change in the NAPSI score was significantly greater with biological treatments.

7. Biologic Treatments

In the last decade, the introduction of biological agents used for the treatment of plaque psoriasis and psoriatic arthritis has brought a safe and highly effective treatment option for severe nail bed and matrix disease as well. Both antitumor necrosis-α (TNF-α) and T-cell-targeted therapies have been useful for refractory severe nail psoriasis [8]. While biological therapies have been shown to be effective in nail psoriasis, infliximab appears to be the most effective option with the strongest evidence [7, 51–54] ().

Table 3

Biologic therapies for treatment of nail psoriasis.

Author	Year	n	Intervention	Comparison	Protocol	Results	LoE [16]
Fabroni et al. [55]	2011	48	Infliximab	—	5 mg/kg, iv infusion at weeks 0, 2, 6 and every 8 weeks through week 38	NAPSI-50 is achieved in 85% of patients at week 14, 96% at week 22, 98% at week 38; NAPSI-75 is achieved in 23% of patients at week 14, 65% at week 22, 81% at week 38; NAPSI-90 is achieved in 29% of patients at week 38	N/A
Rich et al. [54]	2008	305	Infliximab	Placebo	5 mg/kg, iv infusion at weeks 0, 2, 6 and every 8 weeks through week 46	26% and 57% improvements in NAPSI scores at weeks 10 and 24 and complete clearance of target nail in 45% of patients at 1 year	A2
Rigopoulos et al. [56]	2008	18	Infliximab	—	5 mg/kg iv infusion at weeks 0, 2, 6 and every 8 weeks through week 38	Significant decrease in NAPSI scores (56 at baseline to 30 at week 14, 16 at week 22, 7 at week 30, and 3. 3 at week 38)	N/A
Bianchi et al. [53]	2005	25	Infliximab	—	5 mg/kg, iv, at weeks 0, 2, 6, 14, 22	NAPSI-50 is achieved in all patients at week 14; NAPSI-75 is achieved in all patients at week 22	N/A
Leonardi et al. [57]	2011	36	Adalimumab	Placebo	80 mg, sc at week 0, 40 mg every other week starting at week 1, through week 16; patients in the placebo group were started to receive active treatment starting at week 16, through week 28	Significantly higher improvement in NAPSI scores in the treatment arm (50% versus 8%) at week 16; once switched to adalimumab, patients in the initial placebo group improved 38% at week 28, while patients who began the study with adalimumab continued to improve to 54%	N/A
Van den Bosch et al. [58]	2010	259	Adalimumab	—	40 mg, sc, at every other week through week 12	Mean NAPSI scores are reduced by 44% at week 12	N/A
Rigopoulos et al. [59]	2010	21	Adalimumab	—	80 mg, sc at week 0, 40 mg every other week starting at week 1, through week 24	Significant improvement in all patients after 8th injection; fingernail NAPSI decreased from 11 at baseline to 4 at week 24 in patients with just cutaneous psoriasis and from 24 to 10 in patients with psoriatic arthritis	N/A
Ortonne et al. [60]	2012	69	Etanercept	Etanercept	1st group 50 mg weekly for 24 weeks and 2nd group 50 mg twice weekly for the first 12 weeks, 50 mg weekly for the other 12 weeks, sc	Both dose regimens are effective for nail psoriasis and significant improvement in NAPSI scores in both groups at week 24	N/A
Luger et al. [61]	2009	564	Etanercept	—	25 mg twice weekly for 54 weeks or 50 mg twice weekly for 12 weeks, continued with 25 mg twice weekly in case of relapse, sc	NAPSI scores improved by 29% at week 12, by 51% at week 54, complete resolution in 30% of patients	N/A
Kavanaugh et al. [62]	2009	287	Golimumab	Placebo	50 or 100 mg, sc, every 4 weeks through week 24	Significant improvements started as early as at week 14: 25% reduction in NAPSI scores in 50 mg group, 43% reduction in 100 mg group at week 14, 33% reduction in 50 mg, and 54% reduction in 100 mg group at week 24	B
Körver et al. [63]	2006	8	Alefacept	—	15 mg weekly, im, for 12 weeks	3 patients showed significant improvement, 3 patients unchanged, and 2 patients worsened	N/A
Parrish et al. [64]	2006	15	Alefacept	—	15 mg weekly, im, for 12 weeks	39% reduction in NAPSI scores at week 24	N/A
Cassetty et al. [65]	2005	6	Alefacept	—	15 mg weekly, im, for 12 weeks	3 patients showed ≥30% improvement in NAPSI scores, 1 unchanged, and 2 worsened	N/A
Patsatsi et al. [66]	2013	27	Ustekinumab	—	45 mg, sc, at weeks 0, 4 and every 12 weeks thereafter (90 mg if patient weight > 100 kg)	Significant improvements in NAPSI scores (43% at week 16, 86% at week 28, and 100% at week 40)	N/A
Vitiello et al. [67]	2013	13	Ustekinumab	—	90 mg (n = 5, patients weight > 100 kg), sc, at weeks 0, 4 and every 12 weeks thereafter or 45 mg in combination with MTX (n = 6) or CsA (n = 2)	38% reduction in NAPSI scores in monotherapy group, 27% reduction in MTX combination, complete resolution in CsA combination group, at week 12	N/A
Igarashi et al. [68]	2012	102	Ustekinumab	Placebo	45 or 90 mg, sc, at weeks 0, 4 and every 12 weeks through 72 weeks, placebo group with crossover to ustekinumab at week 12	Improvement in NAPSI scores: 57% in 45 mg group, 68% in 90 mg group at week 64	A2
Reich et al. [69]	2011	317	Briakinumab	MTX	Briakinumab 200 mg at weeks 0 and 4, 100 mg every 4 weeks through week 48, sc, MTX 5–25 mg/week for 51 weeks	NAPSI scores of the target fingernail significantly lower with the briakinumab group at weeks 24 and 52, as compared with the methotrexate group	N/A

Infliximab is a chimeric, human-murine IgG1 monoclonal antibody against TNF-α, which acts by neutralizing its biological activity. It is administered intravenously, with a dose of 0.5 mg/kg at weeks 0, 2, 6 and repeated every 8 weeks. In the first study evaluating the efficacy of infliximab in nail psoriasis, 25 patients with plaque-type psoriasis or psoriatic arthritis achieved a 50% reduction in mean NAPSI scores at week 14, while at week 22, the mean NAPSI score was 0 [53]. In a 50-week RCT (randomized controlled trial) of infliximab, 240 of 305 patients with nail psoriasis in the treatment arm started to show clearance of the nail disease as early as in week 10, with complete clearance in 44.7% of the patients at week 50. The treatment group had 26.8% and 57.2% improvements in the NAPSI scores at weeks 10 and 24, respectively, while worsening was observed in the placebo group. On the other hand, when the placebo group was switched to infliximab therapy at week 24, they achieved NAPSI scores comparable to those obtained with the original treatment group [54]. Further assessment of the results showed that the reduction of NAPSI scores was sustained, following 1 year of continuous infliximab therapy [54, 70]. A retrospective analysis of 48 patients with nail involvement confirmed the efficacy of infliximab therapy in nail psoriasis, with rapid and persistent improvements. At week 14, more than 50% reduction was observed in the mean NAPSI scores in 85.4% of patients. Improvement of nail psoriasis continued between weeks 14 and 38, with further reductions in NAPSI scores [55]. Similarly, in another study of 18 patients with psoriasis and psoriatic arthritis, a significant improvement was noted in most of the patients following the third infusion of infliximab, with a reduction of mean NAPSI scores from 55.8 at baseline, to 29.8 at week 14. At week 38, an almost complete resolution of psoriatic nail involvement was demonstrated [56]. Response to infliximab therapy has also been reported to be effective in patients with severe nail psoriasis refractory to other systemic therapies [71].

Adalimumab is a recombinant human IgG1 monoclonal antibody against TNF-α. It is administered subcutaneously, at a dose of 40 mg every other week, usually preceded by an 80 mg loading dose. In a study of 21 patients treated with adalimumab for psoriasis or psoriatic arthritis, with concomitant nail disease, improvement was observed as early as at 12 weeks in both fingernails and toenails [59]. For the fingernails, there was almost a 50% reduction in mean NAPSI scores at week 12 and almost complete resolution at week 24. In another study evaluating the effectiveness of adalimumab for nail psoriasis in 259 patients with psoriatic arthritis in a 12-week study, the mean NAPSI score was reduced by 44% at week 24 [58]. In a RCT of palmoplantar psoriasis, 28 of 36 patients with nail involvement received adalimumab therapy for 16 weeks and showed a higher mean percentage of NAPSI improvement compared to placebo-treated group (50% versus 8%). At week 16, patients from the placebo group were switched to receive active treatment, and a mean improvement of 38% was reported in NAPSI at week 28 [57].

Etanercept is a soluble, human, TNF-α receptor fusion protein. It binds TNF-α with greater affinity than natural receptors, so that TNF-α becomes biologically inactive. Etanercept is administered subcutaneously, usually at a dose of 50 mg twice weekly for 3 months, followed by once weekly thereafter. In a prospective trial of patients with moderate to severe plaque psoriasis, 69 patients with nail psoriasis were treated with etanercept. One treatment arm received etanercept 50 mg once weekly for 24 weeks. The other treatment arm received etanercept 50 mg twice weekly for the first 12 weeks and once weekly for the following 12 weeks. There was a significant improvement in mean NAPSI scores at week 24 in both groups, with significant number of patients showing complete resolution. Both treatment regiments were found to be effective in nail psoriasis [60]. In the post hoc analysis of a RCT, in which the patients were randomized to receive either continuous (25 mg twice weekly for 54 weeks) or paused (50 mg twice weekly up to 12 weeks, followed by 25 mg twice weekly in case of relapse) etanercept therapy, 564 patients with nail involvement were evaluated. The mean NAPSI scores were improved by 28.9% at week 12 and by 51% at week 54, while complete resolution was observed in 30% of patients [61]. There are also case reports demonstrating the rapid and marked improvement of nail psoriasis with etanercept therapy [72–74].

Golimumab is a human monoclonal antibody against TNF-α. It is administered subcutaneously. In a RCT of golimumab for psoriatic arthritis, response to nail involvement in 287 patients was assessed as a secondary outcome. Patients in the treatment arm received 50 mg or 100 mg golimumab every 4 weeks through week 24. Significant improvements in nail symptoms were observed in golimumab-treated patients as early as at week 14 in 50 mg and 100 mg group, with a reduction in NAPSI scores of 25% and 43% by week 14 and of 33% and 54% by week 24, respectively [62].

Alefacept is a recombinant human fusion protein composed of lymphocyte function-associated antigen-3 (LFA-3) and Fc portion of human IgG. It binds to CD2 receptor on T cells and thereby blocks T-cell interactions with antigen-presenting cells. In addition, it triggers the apoptosis of memory T cells and thus decreases the number of pathogenic T cells and the inflammatory response. It is administered weekly either 15 mg intramuscularly or 7.5 mg intravenously, generally for 12 weeks. There are a few studies with small number of patients in the literature, evaluating the efficacy of alefacept in nail psoriasis. In a group of 6 patients with mild nail psoriasis, after 12 weeks of intramuscular etanercept treatment, 3 demonstrated 30% or greater improvement in NAPSI scores at week 18, while 1 remained unchanged and 2 worsened [65]. Similarly in a group of 8 patients, 5 of which having moderate to severe nail psoriasis, 3 patients showed improvement, 3 remained unchanged, and 2 worsened [63]. In another study of 15 patients with severe nail psoriasis, baseline NAPSI scores were reduced by 39% at week 24, after 12 weeks of intramuscular therapy [64, 75].

Ustekinumab is a human monoclonal antibody that binds to the shared p40 subunit of the cytokines interleukin (IL)-12 and IL-23 to inhibit their biologic activity, as a consequence reduces IL-17A and IL-17F, and thus blocks the differentiation and proliferation of T helper (T_H)-1 and T_H-17 populations. It is administered subcutaneously, at a dose of 45 mg (90 mg if patient weight >100 kg), usually at weeks 0, 4 and every 12 weeks thereafter. In a case report of nail psoriasis unresponsive to etanercept, complete improvement was noted after the second injection of 45 mg subcutaneous ustekinumab at week 8 [75]. Igarashi et al. [68] randomized 158 patients with plaque psoriasis to receive ustekinumab 45 or 90 mg at weeks 0, 4 and every 12 weeks or placebo with crossover to ustekinumab at week 12. Among 102 patients with nail psoriasis, the improvements in NAPSI scores were significant at week 12 and continued to increase from week 12 to 64, with reductions of 57% at 45 mg group and 68% at 90 mg group at week 64. In a study of 27 patients with moderate-to-severe plaque psoriasis with nail involvement, excellent response to ustekinumab was demonstrated. NAPSI scores were improved by 42.5% at week 16, by 86.3% at week 28, and by 100% at week 40 [66]. Ustekinumab was also reported to be effective in a case of paradoxical psoriasis with severe scalp and nail involvement, which developed after adalimumab therapy for psoriatic arthritis [76]. In a recently published case series of 13 patients, who had been previously treated with at least four biologics with disappointing results, the patients received ustekinumab either as 90 mg monotherapy or 45 mg in combination with either methotrexate or cyclosporine. The mean percentage of reduction of the NAPSI score was 31.8% at week 12. Two patients treated in combination with cyclosporine 100 mg b.i.d. had complete resolution of their nail psoriasis at week 12 [67]. After longer term safety and efficacy are proven, ustekinumab could become an effective option for treatment of nail psoriasis.

Briakinumab, like ustekinumab, is a monoclonal antibody against p40 subunit of cytokines IL-12 and IL-23. It is administered subcutaneously. In a RCT of 317 patients with psoriasis, patients were randomized to receive either briakinumab (200 mg at weeks 0 and 4, followed by 100 mg every 4 weeks, from week 8 through 48) or methotrexate (5–25 mg per week, from week 0 through 51). Although the primary end point of the study was to assess the improvement in PASI scores, one of the secondary efficacy end points included the change in the NAPSI scores of the target fingernail, which was significantly lower with the briakinumab group at weeks 24 and 52, as compared with the methotrexate group [69].

All biologic agents currently available for the treatment of plaque psoriasis seem to be efficient in treating severe nail psoriasis, although no particular agent is approved for this purpose [7]. In an expert panel, participants strongly agreed that full nail clearance is an achievable goal using biologic therapy in psoriatic patients with nail involvement [52]. However, long-term safety data regarding use of this class of therapy is still being explored, and therefore the possible risks of treatment should be carefully weighted [52]. Most of the studies evaluating the efficacy of biologic agents in nail psoriasis are preliminary [77]. Among these only infliximab and golimumab were evaluated in RCTs, and significant improvements in nail psoriasis were achieved when compared to placebo [62, 70]. Of note, in the phase II trial of ixekizumab, an anti-IL-17 monoclonal antibody for chronic plaque psoriasis, significant improvements in NAPSI scores were reported as early as at 2 weeks with an impressive safety profile [78].

8. Treatment of Nail Psoriasis in Children

Despite the common onset of psoriasis in the childhood, validated clinical data on the epidemiology and the treatment of pediatric nail psoriasis is scant. In a recent multicenter study conducted in US, 39.2% of 181 children with psoriasis were found to have nail involvement [79]. Similar results were reported from Kuwait (37.81%), although in more than half of the cases the changes, pitting being the most common, were so subtle that the children were not aware of them [80]. Nail psoriasis was found to be more common in boys, probably related to koebnerization [78, 79]. There are no studies on the efficacy and safety of various treatments for nail psoriasis in children. The absence of clinical data corresponds with a lack of licensure for the pediatric use of many available treatments [81].

Data was available for the treatment of nail psoriasis from an epidemiologic study of pediatric psoriasis from Turkey. Thirteen children with nail psoriasis were treated with potent topical steroid ointments for onycholysis and nail bed hyperkeratosis; however, the results were unsatisfactory [82]. In a pilot study of 4 children to determine the efficacy of intralesional triamcinolone acetonide in the treatment of nail pitting in children, following a single dose, the degree of pitting was reduced by a mean of 15% in the second month and 42% in the fourth month [83].

In one case report, solely of nail psoriasis in a 6-year-old girl, tazarotene 0.05% gel daily applied for 8 weeks was found to be effective, especially in nail bed hyperkeratosis [84]. A 13-year-old girl with a 3-year history of episodic pustular eruption of the right thumb and psoriasiform changes on the fingers of the right hand, with a clinical diagnosis of Acrodermatitis Continua of Hallopeau, responded well to topical application of 0.1 mg/mL indigo naturalis extract oil [85]. Indigo naturalis, a Chinese herbal remedy extracted from the leaves of indigo-bearing plants, has been demonstrated to have antipsoriatic effects. Another case report of Acrodermatitis Continua of Hallopeau, in a 2-year-old boy, revealing severe nail dystrophy of 19 nails, which was resistant to occluded clobetasol and pimecrolimus and oral acitretin and methotrexate, was reported to demonstrate an excellent response to the combined treatment of thalidomide (50 mg/day for 5 months) and broad band ultraviolet B comb (2 months) [86].

In pediatric nail psoriasis, a combination of calcipotriene (calcipotriol) and betamethasone dipropionate seems to be a rational and simple approach, as both substances have shown to be safe and efficient in children [87].

9. Conclusions

Since severe psoriatic nail disease can lead to functional or emotional impairment, even as a sole manifestation of psoriasis, treatment should be individualized for each patient. Topical approaches or laser treatments may be suitable for limited disease or may take part in combination therapies for more severe disease, while classical systemic agents or biologic treatments are preserved for severe cases with extensive cutaneous disease or psoriatic arthritis.

Conflict of Interests

The authors declare that they have no conflict of interests.

References

1. Jiaravuthisan MM, Sasseville D, Vender RB, Murphy F, Muhn CY. Psoriasis of the nail: anatomy, pathology, clinical presentation, and a review of the literature on therapy. Journal of the American Academy of Dermatology. 2007;57(1):1–27. [PubMed] [Google Scholar]2. Augustin M, Krüger K, Radtke MA, Schwippl I, Reich K. Disease severity, quality of life and health care in plaque-type psoriasis: a multicenter cross-sectional study in Germany. Dermatology. 2008;216(4):366–372. [PubMed] [Google Scholar]3. Armesto S, Esteve A, Coto-Segura P, et al. Nail psoriasis in individuals with psoriasis vulgaris: a study of 661 patients. Actas Dermo-Sifiliograficas. 2011;102(5):365–372. [PubMed] [Google Scholar]4. Wozel G. Psoriasis treatment in difficult locations: scalp, nails, and intertriginous areas. Clinics in Dermatology. 2008;26(5):448–459. [PubMed] [Google Scholar]5. Hallaji Z, Babaeijandaghi F, Akbarzadeh M, et al. A significant association exists between the severity of nail and skin involvement in psoriasis. Journal of the American Academy of Dermatology. 2012;66:e12–e13. [PubMed] [Google Scholar]6. Augustin M, Reich K, Blome C, Schäfer I, Laass A, Radtke MA. Nail psoriasis in Germany: epidemiology and burden of disease. British Journal of Dermatology. 2010;163(3):580–585. [PubMed] [Google Scholar]7. Dehesa L, Tosti A. Treatment of inflammatory nail disorders. Dermatology and Therapy. 2012;25:525–534. [PubMed] [Google Scholar]8. Tan ES, Chong WS, Tey HL. Nail psoriasis: a review. American Journal of Clinical Dermatology. 2012;13:375–388. [PubMed] [Google Scholar]9. de Berker D. Management of psoriatic nail disease. Seminars in Cutaneous Medicine and Surgery. 2009;28(1):39–43. [PubMed] [Google Scholar]10. Gupta AK, Lynde CW, Jain HC, et al. A higher prevalence of onychomycosis in psoriatics compared with non- psoriatics: a multicentre study. British Journal of Dermatology. 1997;136(5):786–789. [PubMed] [Google Scholar]11. Maejima H, Taniguchi T, Watarai A, Katsuoka K. Evaluation of nail disease in psoriatic arthritis by using a modified nail psoriasis severity score index. International Journal of Dermatology. 2010;49(8):901–906. [PubMed] [Google Scholar]12. Mease PJ. Measures of psoriatic arthritis: Tender and Swollen Joint Assessment, Psoriasis Area and Severity Index (PASI), Nail Psoriasis Severity Index (NAPSI), Modified Nail Psoriasis Severity Index (mNAPSI), Mander/Newcastle Enthesitis Index (MEI), Leeds Enthesitis Index (LEI), Spondyloarthritis Research Consortium of Canada (SPARCC), Maastricht Ankylosing Spondylitis Enthesis Score (MASES), Leeds Dactylitis Index (LDI), Patient Global for Psoriatic Arthritis, Dermatology Life Quality Index (DLQI), Psoriatic Arthritis Quality of Life (PsAQOL), Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F), Psoriatic Arthritis Response Criteria (PsARC), Psoriatic Arthritis Joint Activity Index (PsAJAI), Disease Activity in Psoriatic Arthritis (DAPSA), and Composite Psoriatic Disease Activity Index (CPDAI) Arthritis Care & Research. 2011;63:S64–S85. [PubMed] [Google Scholar]13. Rich P, Scher RK. Nail psoriasis severity index: a useful tool for evaluation of nail psoriasis. Journal of the American Academy of Dermatology. 2003;49(2):206–212. [PubMed] [Google Scholar]14. Mukai MM, Poffo IF, Werner B, Brenner FM, Lima Filho JH. NAPSI utilization as an evaluation method of nail psoriasis in patients using acitretin. Anais Brasileiros de Dermatologia e Sifilografia. 2012;87:256–262. [PubMed] [Google Scholar]15. Cassell SE, Bieber JD, Rich P, et al. The modified nail psoriasis severity index: validation of an instrument to assess psoriatic nail involvement in patients with psoriatic arthritis. Journal of Rheumatology. 2007;34(1):123–129. [PubMed] [Google Scholar]16. de Vries AC, Bogaards NA, Hooft L, et al. Interventions for nail psoriasis. The Cochrane Database of Systematic Reviews. 2013;1CD007633 [PubMed] [Google Scholar]17. Nakamura RC, Abreu LD, Duque-Estrada B, Tamler C, Leverone AP. Comparison of nail lacquer clobetasol efficacy at 0.05%, 1% and 8% in nail psoriasis treatment: prospective, controlled and randomized pilot study. Anais Brasileiros de Dermatologia e Sifilografia. 2012;87:203–211. [PubMed] [Google Scholar]18. Fischer-Levancini C, Sánchez-Regaña M, Llambí F, Collgros H, Expósito-Serrano V, Umbert-Millet P. Nail psoriasis: treatment with tazarotene 0.1% hydrophilic ointment. Actas Dermo-Sifiliográficas. 2012;103:725–728. [PubMed] [Google Scholar]19. De Simone C, Maiorino A, Tassone F, D’Agostino M, Caldarola G. Tacrolimus 0.1% ointment in nail psoriasis: a randomized controlled open-label study. Journal of the European Academy of Dermatology and Venereology. 2012 [PubMed] [Google Scholar]20. Tzung TY, Chen CY, Yang CY, Lo PY, Chen YH. Calcipotriol used as monotherapy or combination therapy with betamethasone dipropionate in the treatment of nail psoriasis. Acta Dermato-Venereologica. 2008;88(3):279–280. [PubMed] [Google Scholar]21. Sánchez Regaña M, Márquez Balbás G, Umbert Millet P. Nail psoriasis: a combined treatment with 8% clobetasol nail lacquer and tacalcitol ointment. Journal of the European Academy of Dermatology and Venereology. 2008;22(8):963–969. [PubMed] [Google Scholar]22. Rigopoulos D, Gregoriou S, Katsambas A. Treatment of psoriatic nails with tazarotene cream 0.1% vs. clobetasol propionate 0.05% cream: a double-blind study. Acta Dermato-Venereologica. 2007;87(2):167–168. [PubMed] [Google Scholar]23. Regaña MS, Ezquerra GM, Millet PU, Mateos FL. Treatment of nail psoriasis with 8% clobetasol nail lacquer: positive experience in 10 patients. Journal of the European Academy of Dermatology and Venereology. 2005;19(5):573–577. [PubMed] [Google Scholar]24. Cannavò SP, Guarneri F, Vaccaro M, Borgia F, Guarneri B. Treatment of psoriatic nails with topical cyclosporin: a prospective, randomized placebo-controlled study. Dermatology. 2003;206(2):153–156. [PubMed] [Google Scholar]25. Bianchi L, Soda R, Diluvio L, Chimenti S. Tazarotene 0-1% gel for psoriasis of the fingernails and toenails: an open, prospective study. British Journal of Dermatology. 2003;149(1):207–209. [PubMed] [Google Scholar]26. Rigopoulos D, Ioannides D, Prastitis N, Katsambas A. Nail psoriasis: a combined treatment using calcipotriol cream and clobetasol propionate cream. Acta Dermato-Venereologica. 2002;82(2):p. 140. [PubMed] [Google Scholar]27. Scher RK, Stiller M, Isabel Zhu Y. Tazarotene 0.1% gel in the treatment of fingernail psoriasis: a double-blind, randomized, vehicle-controlled study. Cutis. 2001;68(5):355–358. [PubMed] [Google Scholar]28. de Jong EMGJ, Menke HE, Van Praag MCG, Van De Kerkhof PCM. Dystrophic psoriatic fingernails treated with 1% 5-fluorouracil in a nail penetration-enhancing vehicle: a double-blind study. Dermatology. 1999;199(4):313–318. [PubMed] [Google Scholar]29. Baran R, Tosti A. Topical treatment of nail psoriasis with a new corticoid-containing nail lacquer formulation. Journal of Dermatological Treatment. 1999;10(3):201–204. [Google Scholar]30. Tosti A, Piraccini BM, Cameli N, et al. Calcipotriol ointment in nail psoriasis: a controlled double-blind comparison with betamethasone dipropionate and salicylic acid. British Journal of Dermatology. 1998;139(4):655–659. [PubMed] [Google Scholar]31. Yamamoto T, Katayama I, Nishioka K. Topical anthralin therapy for refractory nail psoriasis. Journal of Dermatology. 1998;25(4):231–233. [PubMed] [Google Scholar]32. Fredriksson T. Topically applied fluorouracil in the treatment of psoriatic nails. Archives of Dermatology. 1974;110(5):735–736. [PubMed] [Google Scholar]33. Usmani N, Wilson C. A case of nail psoriasis treated with topical calcitriol. Clinical and Experimental Dermatology. 2006;31(5):712–713. [PubMed] [Google Scholar]34. Rigopoulos D, Gregoriou S, Belyayeva E, Larios G, Kontochristopoulos G, Katsambas A. Efficacy and safety of tacrolimus ointment 0.1% vs. betamethasone 17-valerate 0.1% in the treatment of chronic paronychia: an unblinded randomized study. British Journal of Dermatology. 2009;160(4):858–860. [PubMed] [Google Scholar]35. Prins AMA, Vos K, Franssen EJF. Instability of topical ciclosporin emulsion for nail psoriasis. Dermatology. 2007;215(4):362–363. [PubMed] [Google Scholar]36. Bleeker JJ. Intralesional triamcinolone acetonide using the Port O Jet and needle injections in localized dermatoses. British Journal of Dermatology. 1974;91(1):97–101. [PubMed] [Google Scholar]37. Saricaoglu H, Oz A, Turan H. Nail psoriasis successfully treated with intralesional methotrexate: case report. Dermatology. 2011;222(1):5–7. [PubMed] [Google Scholar]38. Marx JL, Scher RK. Response of psoriatic nails to oral photochemotherapy. Archives of Dermatology. 1980;116(9):1023–1024. [PubMed] [Google Scholar]39. Stern DK, Creasey AA, Quijije J, Lebwohl MG. UV-A and UV-B penetration of normal human cadaveric fingernail plate. Archives of Dermatology. 2011;147(4):439–441. [PubMed] [Google Scholar]40. Rados J, Dobrić I, Pasić A, Lipozencić J, Ledić-Drvar D, Stajminger G. Normalization in the appearance of severly damaged psoriatic nails using soft x-rays. A case report. Acta Dermatovenerologica Croatica. 2007;15:27–32. [PubMed] [Google Scholar]41. Oram Y, Karincaòlu Y, Koyuncu E, Kaharaman F. Pulsed dye laser in the treatment of nail psoriasis. Dermatologic Surgery. 2010;36(3):377–381. [PubMed] [Google Scholar]42. Treewittayapoom C, Singvahanont P, Chanprapaph K, Haneke E. The effect of different pulse durations in the treatment of nail psoriasis with 595-nm pulsed dye laser: a randomized, double-blind, intrapatient left-to-right study. Journal of the American Academy of Dermatology. 2012;66:807–812. [PubMed] [Google Scholar]43. Fernández-Guarino M, Harto A, Sánchez-Ronco M, García-Morales I, Jaén P. Pulsed dye laser vs. photodynamic therapy in the treatment of refractory nail psoriasis: a comparative pilot study. Journal of the European Academy of Dermatology and Venereology. 2009;23(8):891–895. [PubMed] [Google Scholar]44. Sánchez-Regaña M, Sola-Ortigosa J, Alsina-Gibert M, Vidal-Fernández M, Umbert-Millet P. Nail psoriasis: a retrospective study on the effectiveness of systemic treatments (classical and biological therapy) Journal of the European Academy of Dermatology and Venereology. 2011;25(5):579–588. [PubMed] [Google Scholar]45. Gümüşel M, Özdemir M, Mevlitoğlu I, Bodur S. Evaluation of the efficacy of methotrexate and cyclosporine therapies on psoriatic nails: a one-blind, randomized study. Journal of the European Academy of Dermatology and Venereology. 2011;25:1080–1084. [PubMed] [Google Scholar]46. Tosti A, Ricotti C, Romanelli P, Cameli N, Piraccini BM. Evaluation of the efficacy of acitretin therapy for nail psoriasis. Archives of Dermatology. 2009;145(3):269–271. [PubMed] [Google Scholar]47. Syuto T, Abe M, Ishibuchi H, Ishikawa O. Successful treatment of psoriatic nails with low-dose cyclosporine administration. European Journal of Dermatology. 2007;17(3):248–249. [PubMed] [Google Scholar]48. Feliciani C, Zampetti A, Forleo P, et al. Nail psoriasis: combined therapy with systemic cyclosporin and topical calcipotriol. Journal of Cutaneous Medicine and Surgery. 2004;8(2):122–125. [PubMed] [Google Scholar]49. Mahrle G, Schulze HJ, Färber L, Weidinger G, Steigleder GK. Low-dose short-term cyclosporine versus etretinate in psoriasis: improvement of skin, nail, and joint involvement. Journal of the American Academy of Dermatology. 1995;32:78–88. [PubMed] [Google Scholar]50. Ricceri F, Pescitelli L, Tripo L, Bassi A, Prignano F. Treatment of severe nail psoriasis with acitretin: an impressive therapeutic result. Dermatology and Therapy. 2013;26:77–78. [PubMed] [Google Scholar]51. Handa S. Newer trends in the management of psoriasis at difficult to treat locations: scalp, palmoplantar disease and nails. Indian Journal of Dermatology, Venereology and Leprology. 2010;76(6):634–644. [PubMed] [Google Scholar]52. Langley RG, Saurat JH, Reich K. Nail Psoriasis Delphi Expert Panel. Recommendations for the treatment of nail psoriasis in patients with moderate to severe psoriasis: a dermatology expert group consensus. Journal of the European Academy of Dermatology and Venereology. 2012;26:373–381. [PubMed] [Google Scholar]53. Bianchi L, Bergamin A, De Felice C, Capriotti E, Chimenti S. Remission and time of resolution of nail psoriasis during infliximab therapy. Journal of the American Academy of Dermatology. 2005;52(4):736–737. [PubMed] [Google Scholar]54. Rich P, Griffiths CEM, Reich K, et al. Baseline nail disease in patients with moderate to severe psoriasis and response to treatment with infliximab during 1 year. Journal of the American Academy of Dermatology. 2008;58(2):224–231. [PubMed] [Google Scholar]55. Fabroni C, Gori A, Troiano M, Prignano F, Lotti T. Infliximab efficacy in nail psoriasis. A retrospective study in 48 patients. Journal of the European Academy of Dermatology and Venereology. 2011;25(5):549–553. [PubMed] [Google Scholar]56. Rigopoulos D, Gregoriou S, Stratigos A, et al. Evaluation of the efficacy and safety of infliximab on psoriatic nails: an unblinded, nonrandomized, open-label study. British Journal of Dermatology. 2008;159(2):453–456. [PubMed] [Google Scholar]57. Leonardi C, Langley RG, Papp K, et al. Adalimumab for treatment of moderate to severe chronic plaque psoriasis of the hands and feet: efficacy and safety results from REACH, a randomized, placebo-controlled, double-blind trial. Archives of Dermatology. 2011;147(4):429–436. [PubMed] [Google Scholar]58. Van den Bosch F, Manger B, Goupille P, et al. Effectiveness of adalimumab in treating patients with active psoriatic arthritis and predictors of good clinical responses for arthritis, skin and nail lesions. Annals of the Rheumatic Diseases. 2010;69(2):394–399. [PMC free article] [PubMed] [Google Scholar]59. Rigopoulos D, Gregoriou S, Lazaridou E, et al. Treatment of nail psoriasis with adalimumab: an open label unblinded study. Journal of the European Academy of Dermatology and Venereology. 2010;24(5):530–534. [PubMed] [Google Scholar]60. Ortonne JP, Paul C, Berardesca E, et al. A 24-week randomized clinical trial investigating the efficacy and safety of two doses of etanercept in nail psoriasis. The British Journal of Dermatology. 2012 [PubMed] [Google Scholar]61. Luger TA, Barker J, Lambert J, et al. Sustained improvement in joint pain and nail symptoms with etanercept therapy in patients with moderate-to-severe psoriasis. Journal of the European Academy of Dermatology and Venereology. 2009;23(8):896–904. [PubMed] [Google Scholar]62. Kavanaugh A, Mclnnes I, Mease P, et al. Golimumab, a new human tumor necrosis factor α antibody, administered every four weeks as a subcutaneous injection in psoriatic arthritis: twenty-four-week efficacy and safety results of a randomized, placebo-controlled study. Arthritis and Rheumatism. 2009;60(4):976–986. [PubMed] [Google Scholar]63. Körver JEM, Langewouters AMG, Van De Kerkhof PCM, Pasch MC. Therapeutic effects of a 12-week course of alefacept on nail psoriasis. Journal of the European Academy of Dermatology and Venereology. 2006;20(10):1252–1255. [PubMed] [Google Scholar]64. Parrish CA, Sobera JO, Robbins CM, Cantrell WC, Desmond RA, Elewski BE. Alefacept in the treatment of psoriatic nail disease: a proof of concept study. Journal of drugs in dermatology. 2006;5(4):339–340. [PubMed] [Google Scholar]65. Cassetty CT, Alexis AF, Shupack JL, Strober BE. Alefacept in the treatment of psoriatic nail disease: a small case series. Journal of the American Academy of Dermatology. 2005;52(6):1101–1102. [PubMed] [Google Scholar]66. Patsatsi A, Kyriakou A, Sotiriadis D. Ustekinumab in nail psoriasis: an open-label, uncontrolled, nonrandomized study. Journal of Dermatological Treatment. 2013;24:96–100. [PubMed] [Google Scholar]67. Vitiello M, Tosti A, Abuchar A, Zaiac M, Kerdel FA. Ustekinumab for the treatment of nail psoriasis in heavily treated psoriatic patients. International Journal of Dermatology. 2013;52:358–362. [PubMed] [Google Scholar]68. Igarashi A, Kato T, Kato M, Song M, Nakagawa H. Efficacy and safety of ustekinumab in Japanese patients with moderate-to-severe plaque-type psoriasis: long-term results from a phase 2/3 clinical trial. Journal of Dermatology. 2012;39:242–252. [PubMed] [Google Scholar]69. Reich K, Langley RG, Papp KA, et al. A 52-week trial comparing briakinumab with methotrexate in patients with psoriasis. The New England Journal of Medicine. 2011;365:1586–1596. [PubMed] [Google Scholar]70. Reich K, Ortonne JP, Kerkmann U, et al. Skin and nail responses after 1 year of infliximab therapy in patients with moderate-to-severe psoriasis: a retrospective analysis of the EXPRESS trial. Dermatology. 2010;221(2):172–178. [PubMed] [Google Scholar]71. Hussain W, Coulson I, Owen C. Severe recalcitrant nail psoriasis responding dramatically to infliximab: report of two patients. Clinical and Experimental Dermatology. 2008;33(4):520–522. [PubMed] [Google Scholar]72. Rallis E, Stavropoulou E, Rigopoulos D, Verros C. Rapid response of nail psoriasis to etanercept. Journal of Rheumatology. 2008;35(3):544–545. [PubMed] [Google Scholar]73. Coelho JD, Diamantino F, Lestre S, Ferreira AM. Treatment of severe nail psoriasis with etanercept. Indian Journal of Dermatology, Venereology and Leprology. 2011;77(1):72–74. [PubMed] [Google Scholar]74. Gómez Vázquez M, Navarra Amayuelas R. Marked improvement in nail psoriasis during treatment with etanercept. Dermatology and Therapy. 2011;24:498–500. [PubMed] [Google Scholar]75. Zaiac M. The role of biological agents in the treatment of nail psoriasis. American Journal of Clinical Dermatology. 2010;11(1):27–29. [PubMed] [Google Scholar]76. Puig L, Morales-Múnera CE, López-Ferrer A, Geli C. Ustekinumab treatment of TNF antagonist-induced paradoxical psoriasis flare in a patient with psoriatic arthritis: case report and review. Dermatology. 2012;225:14–17. [PubMed] [Google Scholar]77. Hermanns-Lê T, Berardesca E, Piérard GE, Lesuisse M, Piérard-Franchimont C. Challenging regional psoriasis and ustekinumab biotherapy: impact of the patterns of disease. Journal of Biomedicine and Biotechnology. 2012;2012:6 pages.413767 [PMC free article] [PubMed] [Google Scholar]78. Leonardi C, Matheson R, Zachariae C, et al. Anti-interleukin-17 monoclonal antibody ixekizumab in chronic plaque psoriasis. The New England Journal of Medicine. 2012;366:1190–1199. [PubMed] [Google Scholar]79. Mercy K, Kwasny M, Cordoro KM, et al. Clinical manifestations of pediatric psoriasis: results of a multicenter study in the United States. Pediatric Dermatology. 2013 [PMC free article] [PubMed] [Google Scholar]80. Al-Mutairi N, Manchanda Y, Nour-Eldin O. Nail changes in childhood psoriasis: a study from Kuwait. Pediatric Dermatology. 2007;24(1):7–10. [PubMed] [Google Scholar]81. Ståhle M, Atakan N, Boehncke WH, et al. Juvenile psoriasis and its clinical management: a European expert group consensus. Journal of the German Society of Dermatology. 2010;8(10):812–819. [PubMed] [Google Scholar]82. Seyhan M, Coşkun BK, Sağlam H, Özcan H, Karincaoğlu Y. Psoriasis in childhood and adolescence: evaluation of demographic and clinical features. Pediatrics International. 2006;48(6):525–530. [PubMed] [Google Scholar]83. Khoo BP, Giam YC. A pilot study on the role of intralesional triamcinolone acetonide in the treatment of pitted nails in children. Singapore Medical Journal. 2000;41(2):66–68. [PubMed] [Google Scholar]84. Diluvio L, Campione E, Paternò EJ, Mordenti C, Hachem ME, Chimenti S. Childhood nail psoriasis: a useful treatment with tazarotene 0.05% Pediatric Dermatology. 2007;24(3):332–333. [PubMed] [Google Scholar]85. Liang CY, Lin TY, Lin YK. Successful treatment of pediatric nail psoriasis with periodic pustular eruption using topical indigo naturalis oil extract. Pediatric Dermatology. 2013;30:117–119. [PubMed] [Google Scholar]86. Kiszewski AE, De Villa D, Scheibel I, Ricachnevsky N. An infant with acrodermatitis continua of hallopeau: successful treatment with thalidomide and UVB therapy. Pediatric Dermatology. 2009;26(1):105–106. [PubMed] [Google Scholar]87. Richert B, André J. Nail disorders in children: diagnosis and management. American Journal of Clinical Dermatology. 2011;12(2):101–112. [PubMed] [Google Scholar]

(PDF) Nail psoriasis in an adult successfully treated with a series of herbal skin care products family – a case report

22 (S3) M. TIRANT ET AL.

with psoriasis of the scalp, ears, groin, limbs and

nails. There was a family history of psoriasis and the

patient’s father was conrmed with the condition.

For the cutaneous psoriasis, the patient had used

multiple therapies over time, starting with steroids

such as hydrocortisone acetate Sigmacort 1% twice

daily, then corticosteroids such as betamethasone

dipropionate – Diprosone Ointment 0.05% twice

daily. Only partial resolution was achieved and

relapse followed after stop of treatment. Patient

had also been on several intermittent, sequential

and rotational treatments such as methotrexate,

cyclosporine and oral retinoids, either as standalone

or combination treatment regimes, all providing only

temporary relief of the cutaneous psoriasis but little

or no improvement of the psoriatic nails.

The patient was very stressed and embarrassed

about the aky scalp and affected nails, as he had

a management job which involved meetings and

dealing with the public. The nail dystrophies had

worsened over the last 10 years. It had become

progressively difcult and painful to use the ngers

for gripping cutlery, pens and tools and performing

tasks such as buttoning clothes, which are taken

for granted. The ngertips and joints were painful.

He had to discontinue his sporting activities

including golf and swimming. His cutaneous and

nail psoriasis were severely impacting his social,

personal and marital relationships and his sex life.

He was depressed and lonely and self-conscious. His

condence level was very low. As he had stopped

all physical exercise, his weight had increased and

his blood pressure increased to 148/105. He was on

Micardis 50mg twice daily.

Examination revealed parakeratotic and

hyperkeratotic psoriatic plaques of the scalp, ears,

limbs and groin. Also present were psoriatic nail

dystrophies, including onycholysis, onychomycosis,

leukonychia, transverse grooves, nail plate crumbling

and paronychia on the periungal skin (Fig. 1, 2) .

The patient was prescribed Dr Michaels®

(Soratinex®) cleansing gel, Dr Michaels® (Nailinex®)

lotion and ointment, and oral herbal formulation,

PSC 500.

The cleansing gel contains salicylic acid and

glycolic which have keratolytic, anti-inammatory

of quality of life and work function (2).

Nail psoriasis is characterised clinically by

manifestations on the ngernails and toenails. The

mean delay of onset for nail dystrophies occurs

in individuals with psoriasis between 9 and 11.5

years, explaining the lower prevalence of nail

psoriasis in children (1, 3). Clinically, nail psoriasis

has many presentations depending on the location

of the inammatory process and includes nail

pitting, leukonychia, onycholysis, oil drop patches,

subungual hyperkeratosis and splinter haemorrhages

(4), the most common manifestation of which is nail

pitting (5). Pits generally affect the ngernails more

often than the toenails and are supercial punctate

depressions in the nail plate. Nail pitting occurs as

a result of an interference of normal keratinization

within the nail matrix (6).

The pathogenesis of psoriatic nail disorder is

yet to be fully dened, however, it is thought to

be multifactorial and involve a complex interplay

between genetic, environmental and immune factors.

Recently, there has been strong evidence to suggest

that the pathogenesis of nail psoriasis may be linked

to psoriatic arthritis (7). This study by McGonagle

and colleagues shows that the nail and the enthesis, a

ligament or tendon that directly attaches to the bone,

via the distal interphalangeal (DIP) joint extensor

tendon are key players in the pathophysiology of nail

psoriasis. Specically, they found that the extensor

tendon, at its enthesis, is able to send supercial

bres, which contribute to the formation of a thick

periosteum on the dorsal aspect of the distal phalanx.

Thus, linking the dense brous connective tissue

from the nail plate to the periosteum and indirectly

to the extensor tendon (7). This study suggests

that there is an association between the DIP joint

arthritis and nail disease due to the close interaction

between the nail, joint and its associated tendons and

ligaments. This is supported by the fact that although

the nail system has no neural component as such and

psoriasis is generally considered a painless condition,

50% of patients with nail psoriasis observe pain (8).

Case report

A 50-year-old male is affected by psoriatic nail

dystrophies from the age of 40. The patient presented

How to Care for Your Nails at Home with Psoriasis or Psoriatic Arthritis

Trips to the salon for mani-pedis (or to the podiatrist’s office for medical pedicures) may be mostly a thing of the past during COVID-19, but stay-at-home orders doesn’t mean you have to settle for so-called quarantine nails either. In fact, taking the time to care for your nails is especially important now if you have psoriasis or psoriatic arthritis, two chronic conditions that commonly affect the nails.

The reason has to do with something called the Koebner phenomena, which is an inflammatory response to an injury or trauma that causes or worsens a psoriasis flare. In nails, this leads to changes like discoloration, pitting, ridging, crumbling, thickening, and onycholysis, which is when the nail becomes detached from the underlying nail bed.

“Psoriasis is really driven by the Koebner phenomena,” says Mona Gohara, MD, associate clinical professor of dermatology at Yale School of Medicine in New Haven, Connecticut. And the longer you postpone nail grooming, the more likely you are to physically traumatize your nails or the surrounding skin when you finally attend to it. “It’s a much easier job if you keep on top of it,” says Dr. Gohara.

There’s likely more to stay on top of, as well: Because stress is a key trigger for outbreaks of psoriasis, more frequent and serious outward symptoms of these conditions are likelier now due to stress and anxiety from the COVID-19 pandemic.

But in the good news department — besides providing some welcome pampering at a time of high anxiety — the right nail care can help you get the best results from the many treatments available for psoriasis.

Tips for a DIY Manicure and Pedicure with Psoriasis or Psoriatic Arthritis

If you have psoriasis or psoriatic arthritis, many of the steps of an at-home manicure and pedicure are the same as, or similar to, a traditional treatment.

The key is to avoid traumatizing your nails. “The overall handling — trimming, filing, and buffing — of your nails should be gentle,” says Jacqueline Sutera, DPM, a podiatric surgeon in New York City.

These how-tos will help your nails look their best and possibly even keep your condition from getting worse.

Keep nails short

Long nails are more prone to trauma and are likelier to separate from fingers and toes. Because of their length, they can also harbor more dirt and bacteria than short nails and contribute to the spread of infection, possibly even the coronavirus if you touch your hand to your mouth or nose.

This is why “the best nail hygiene for everyone across the board is to keep nails short,” says Dr. Gohara. Ideally, your nails won’t extend beyond the tips of your fingers and toes. If you have onycholysis, the Psoriasis and Psoriatic Arthritis Alliance recommends trimming nails back to the point of firm attachment.

“This decreases the chance of accidentally snagging or ripping off detached portions of your nails,” explains Dr. Sutera. If nails are thick, keeping them shorter will also decrease the amount of buildup underneath the nails that that can cause pain and bruising.

Trim nails with a clipper or scissors

These tools provide a cleaner, quicker cut than a file. They also eliminate the back-and-forth motion of filing, which can weaken and traumatize nails. Clip toenails straight across to avoid ingrown toenails; trim fingernails straight across, then slightly round the corners while filing nails in one direction. To soften nails and make them easier to cut, soak them in warm water first for five to 10 minutes.

Sterilize your tools before every use

Inflamed skin is more susceptible to infection, so be sure to disinfect clippers, scissors, and glass nail files with an alcohol-soaked cotton ball before using them.

Leave your cuticles alone — unless you’re removing a hangnail

Pushing back or cutting cuticles or dissolving them with a cuticle remover can injure skin and set off a psoriasis flare. Another don’t: cleaning debris (actually, a buildup of keratin, the protein from underneath the nail) with a sharp object or nail brush. “Probing underneath the nails can cause puncture wounds and can encourage detachment of the nail,” says Dr. Sutera.

Soaking the affected nails in soapy warm water may be sufficient to remove the debris.

Buff nails as little as possible

Buffing can help hide mild pitting, but it should be done gently on the thickest part of the nail with a fine-grit file or buff block and only until the surface of the nail is smooth. Another option is to use a product that contains urea or a mild alpha-hydroxy acid like glycolic acid. These ingredients break down the protein nails are made of, which helps smooth them out.

Smooth skin safely

Very gentle use of pumice stones, foot files, and exfoliating scrubs is only to be done on intact skin that is thick and has no psoriatic lesions, says Dr. Sutera. “Instead, focus on DIY massage, soaking in warm water with gentle soap, essential oils, or Epsom salts.”

Avoid artificial nails

Fake nails may cover up nail problems, but they’re actually more likely to make them worse —especially when nails are long. This can increase stress and strain to your real nail, trigger the Koebner phenomenon, and worsen nail psoriasis.

Gel nails are also a no-no, according to Dr. Gohara, who says the physical and chemical insult can be “a recipe for disaster.”

Pick the right polish and polish remover

Polish can go a long way toward improving the appearance of nails, as well as provide a level of protection. A strengthening or ridge-filling base coat can help shore up weak or brittle nails. But some ingredients found in nail lacquer — for instance, formaldehyde and toluene — can cause contact dermatitis in some people with psoriasis, who have sensitive skin. To sidestep them, consider using “5-free” (or “7-free” or “10-free”) nail polish, which refers to products that don’t contain these types of ingredients. Dr. Sutera likes Dr.’s Remedy Enriched Nail Care products.

When it comes to polish removal, opt for a product that doesn’t contain acetone, a harsh solvent. Non-acetone removers are less drying (a plus for weaker nails) and gentler on sensitive skin.

Moisturize regularly

Psoriasis dries your skin and nails, and the uptick in hand washing during the pandemic can only exacerbate the problem. To lock in much-needed moisture, apply a thick cream or ointment every time you wash your hands. These products contain more oil than water-based lotions and are more effective at trapping water in the skin.

The upshot: “Nails that are moisturized can appear less brittle and overall healthier,” says Dr. Sutera. As a bonus, moisturizing will help your manicure last longer, since brittle nails chip more easily.

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Nail Psoriasis – an overview

Clinical Use of 1,25(OH)

₂D₃ and Its Analogs in Psoriasis and Other Skin Diseases

The use of 1,25(OH)₂D₃ and its analogs for the treatment of psoriasis resulted from two independent lines of investigation. Because psoriasis is a hyperproliferative skin disorder, it seemed reasonable that the antiproliferative effects of 1,25(OH)₂D₃ could be used for the treatment of this disease. Although it was known that 1,25(OH)₂D₃ was extremely potent in inhibiting keratinocytes proliferation before launching clinical trials in 1985, MacLaughlin and associates reported the observation that psoriatic fibroblasts were partially resistant to the antiproliferative effects of 1,25(OH)₂D₃[61]. This observation prompted MacLaughlin and associates to speculate, that 1,25(OH)₂D₃ may be effective in the treatment of the hyperproliferative skin disease psoriasis if pharmacologic doses were employed. The other line of investigation resulted from a clinical observation. In 1985, Morimoto and Kumahara reported that a patient, who was treated orally with 1α(OH)D₃ for osteoporosis, had a dramatic remission of psoriatic skin lesions [62]. Morimoto et al. reported a follow-up study, demonstrating that almost 80% of 17 patients with psoriasis who were treated orally with 1α(OH)D₃ at a dose of 1.0 μg/day for up to 6 month showed clinically significant improvement [63].

Currently, numerous studies have reported that various vitamin D analogs, including calcitriol (1,25(OH)₂D₃), calcipotriol, tacalcitol, hexafluoro-1,25(OH)₂D₃[64], and maxacalcitol are effective and safe in the topical treatment of psoriasis [65–73]. It has been shown that topical calcitriol and its analogs are very effective and safe for the long-term treatment of psoriasis [70–72]. Applied twice daily topically in amounts of up to 100 g of ointment (50 μg calcipotriol/g ointment) per week, calcipotriol was shown to be slightly more effective in the topical treatment of psoriasis than betamethasone 17-valerate ointment [72]. Efficacy of topical treatment with maxacalcitol was compared with topical calcipotriol treatment [68]. In this study, investigators’ overall assessment suggests that maxacalcitol 25 μg/g may be more effective than once-daily calcipotriol (50 μg/g). It has been reported that a mild dermatitis can be seen in about 10% of patients treated with calcipotriol (50 μg/g), particularly on the face [73]. This side effect (mild dermatitis on the face) is not reported after topical treatment with calcitriol. Allergic contact dermatitis to vitamin D analogs is very rare; however, cases with allergic contact dermatitis to other ingredients of the ointment including propylene glycol have been reported [74–76]. The most common adverse event observed in psoriasis patients treated with maxacalcitol (6–50 μg/g maxacalcitol ointment), was a burning sensation of the target plaque [68]. In three out of four patients developing this side effect in one study, symptoms were severe enough to require discontinuation of the treatment [68].

A double-blind, right/left comparison, placebo-controlled evaluation demonstrated efficacy and safety of topical treatment with hexafluoro-1,25(OH)₂D₃ (5 μg/g) in psoriasis patients [69]. Adverse events included mild irritation. This irritation did not necessitate discontinuation of the study medication. During the large area topical administration study period a cobblestone appearance was initially noted in a few patients. This resolved with continued therapy after 3–4 weeks. Hexafluoro-1,25(OH)₂D₃-treated plaques also developed very mild perilesional scales as observed with other vitamin D analogs [69]. Efficacy and safety of topical treatment with tacalcitol (4 μg/g and 20 μg/g) has been shown as well [69–71,77]^,. In one study tacalcitol treatment was generally well tolerated, and there were no serious or unexpected adverse events reported. However, discontinuation of treatment as a result of skin irritation was seen in 5.9% of these patients [71]. The greatest frequency of cutaneous side effects occurred during initial treatment, and the incidence decreased markedly as the treatment was well tolerated with continued use [71].

The results of four separate studies designed to evaluate specific local-safety parameters of various vitamin D analogs including cumulative irritancy, cutaneous contact sensitization, photoallergic contact sensitization, and phototoxicity were analyzed [78]. 1,25(OH)₂D₃ (3 μ/g ointment) was classified as nonirritant when compared with calcipotriol, tacalcitol, and white petrolatum (control). Petrolatum and tacalcitol were slightly irritant and calcipotriol moderately irritant. No sensitization was observed with 1,25(OH)₂D₃ (3 μ/g ointment). Regarding phototoxic potential, sites treated with calcitriol 3 μ/g ointment or vehicle ointment were less irritated than those treated with white petrolatum or those that were untreated. Using standard photoallergenicity testing methodology, there were no skin reactions of a photoallergic nature to the study material [78].

A long-term follow-up study demonstrated the efficacy and safety of oral calcitriol as a potential treatment of psoriasis [79]. Of the 85 patients included in that study that received oral calcitriol for 36 months, 88.0% had some improvement in their disease, whereas 26.5%, 26.3%, and 25.3% had complete, moderate, and slight improvement in their disease, respectively. Serum calcium concentrations and 24 h urinary calcium excretion increased by 3.9% and 148.2%, respectively, but were not outside the normal range. Bone mineral density of these patients remained unchanged. A very important consideration for the use of orally administered calcitriol is the dosing technique. To avoid its effects on enhancing dietary calcium absorption, it is very important to provide 1,25(OH)₂D₃ at night time. Perez et al. [79] showed that as a result of this dosing technique, doses of 2 μg/to 4 μg/night 1,25(OH)₂D₃ are well tolerated by psoriatic patients.

Patients with psoriasis may need intermittent treatment for their entire lives. Vitamin D analogs have been shown not to exhibit tachyphylaxis during treatment of psoriatic lesions, and topical treatment can be continued indefinitely.

Treatment of Scalp Psoriasis

A double-blind, randomized multicenter study demonstrated that calcipotriol solution is effective in the topical treatment of scalp psoriasis [80–82]. 49 patients were treated twice daily over a 4-week period [80]. 60% of patients on calcipotriol showed clearance or marked improvement versus 17% in the placebo group. No side effects were reported.

Treatment of Nail Psoriasis

The occurrence of nail psoriasis has been reported in up to 50% of patients. Nails, in general, are very difficult to treat and respond slowly. Until now, there has been no consistently effective treatment for psoriatic nails. It has been reported that calcipotriol ointment is effective in the treatment of nail psoriasis [83].

Treatment of Face and Flexures

Although the use of calcipotriol ointment is not recommended on face and flexures because of irritancy, most patients tolerate vitamin D analogs on these sites. It has been shown that calcitriol ointment (3 μg of 1,25(OH)₂D₃ per gram of petrolatum) was found to be better tolerated and would appear to be more effective than calcipotriol ointment (50 μg of calcipotriol per gram of petrolatum) in the treatment of psoriasis in sensitive areas [84].

Treatment of Skin Lesions in Children

During the past few years it has been shown that topical application of vitamin D analogs including calcitriol ointment (3 μg of 1,25(OH)₂D₃ per gram of petrolatum) is an effective, safe, and reliable therapy to cure psoriatic skin lesions in children [85–87].

Treatment of Psoriatic Lesions in HIV Patients

We have treated an HIV-positive patient suffering from psoriatic skin lesions with topical and oral 1,25(OH)₂D₃. The patient responded well, and there was no evidence of enhancement in HIV-disease activity or alterations in the number of T-lymphocytes, or CD4⁺, and CD8⁺ cells.

Combination of Vitamin D Analogs With Other Therapies

It has been reported that efficacy of topical treatment with vitamin D analogs in psoriasis can be increased by combination with other therapies, including methotrexate (MTX), very low dose oral cyclosporine (2 mg/kg/day), oral acitretin, topical dithranol, topical steroids, PUVA (psoralen plus UV-A) and UV-B, or narrow band UV-B phototherapy [88–96]. It has been shown that the combination of calcipotriol and MTX is safe and well tolerated [95]. The combination resulted in lower cumulative dosages of MTX compared with MTX and vehicle. Therefore the risk of MTX-induced side effects is substantially decreased [95]. Addition of calcipotriol ointment to oral application of acitretin (a vitamin A analog) was shown to produce a significantly better treatment response achieved with a lower cumulative dose of acitretin in patients with severe extensive psoriasis vulgaris, as compared with the group of patients treated with oral acitretin alone. The number of patients reporting adverse events was similar between the two treatment groups [90].

Complete clearing or 90% improvement in PASI was observed in 50% of patients treated with calcipotriol/cyclosporine versus 11.8% in the placebo/cyclosporine group. No difference was found in that study between the groups in short-time side effects. Kragballe and coworkers reported that efficacy of topical calcipotriol treatment in psoriasis can be improved by simultaneous UV-B phototherapy. Combination therapy of psoriasis with topical calcipotriol and narrow-band UV-B has been shown to be very effective for the treatment of psoriatic plaques [92]. One can speculate whether the therapeutic efficacy of UV-B in psoriasis may be at least in part because of increased cutaneous vitamin D synthesis. It has been shown that the combination of topical treatment with vitamin-D analogs and UV-radiation does not alter the tolerability or safety of therapy [97]. Vitamin D analogs may be topically applied at any time up to 2 hours before or immediately after UV-radiation [86]. Results of a controlled, right/left study have demonstrated that pretreatment of psoriasis with the vitamin D₃ derivative tacalcitol increases the responsiveness to 311-nm UV-B [98]. Additionally, it was shown that tacalcitol ointment (4 μg/g) and 0.1% tazarotene gel are both comparably effective in improving the therapeutic result of PUVA therapy in patients with chronic plaque-type psoriasis [99]. The treatment requirements to induce complete or near complete clearing were significantly lower for both combination treatments than for PUVA monotherapy (P < .01). The median cumulative UV-A dose and number of exposures were 30.6 J/cm² (95% CI 22.5–71.2) and 14 (95% CI 11–16) for tacalcitol plus PUVA, 32.3 J/cm² (95% CI 22.5–73.8) and 14 (95% CI 11–19) for tazarotene plus PUVA, and 37.0 J/cm² (95% CI 29.5–83.9) and 16 (95% CI 14–22) for PUVA monotherapy. No difference between the three regimens was observed with regard to duration of remission. Adverse reactions occurred more often with 0.1% tazarotene than with tacalcitol but were, in general, mild and completely reversible on using a lower concentration of 0.05% tazarotene. It has been concluded that besides accelerating the treatment response, both agents, by virtue of their UV-A dose-sparing effect, might also help to reduce possible long-term hazards of PUVA treatment. Previously, a case report described two patients treated with a combination treatment of calcipotriol and bath psoralens and UV-A who developed hyperpigmentation at the lesional sites where calcipotriol ointment was applied [100].

Combined topical treatment with calcipotriol ointment (50 μg/g) and betamethasone ointment was shown to be slightly more effective and caused less skin irritation than calcipotriol used twice daily [91]. A vehicle has been created with the objective of obtaining optimal stability of both calcipotriene and betamethasone dipropionate in the combination product. Early onset of action and efficacy of a fixed combination of calcipotriene and betamethasone dipropionate in this vehicle in the treatment of psoriasis has been reported, making it a standard therapy for the topical treatment of psoriasis [101].

Augustin et al. [102] evaluated scientific evidence about topical long-term therapy with 1,25(OH)₂D₃ analogs, corticosteroids, and their two-compound products in psoriasis vulgaris and scalp psoriasis and developed daily practice recommendations. Best evidence regarding topical long-term treatment was available for the two-compound formulation containing calcipotriene and betamethasone. In a comparative trial in psoriasis vulgaris the two-compound formulation showed superior tolerability and cost effectiveness compared with monotherapy. In scalp psoriasis the two-compound gel was superior compared with calcipotriene monotherapy. The authors concluded that because of a favorable risk–benefit ratio in maintenance trials and better cost-effectiveness, the application of two-compound products once or twice a week after initial therapy is recommended. It has been hypothesized that calcipotriol counteracts glucocorticoid-induced skin atrophy, which is associated with changes in the ECM. To elucidate the combined effects of calcipotriol and betamethasone on key ECM components, a comparative study to the respective monotreatments was carried out. The effect on collagen I synthesis, matrix metalloproteinase (MMP) secretion, and hyaluronic acid (HA) production was investigated in primary human fibroblast and keratinocyte cultures as well as in a human skin explant model. In that study, calcipotriol counteracted betamethasone-induced suppression of collagen I synthesis. Similarly, calcipotriol and betamethasone had opposing effects on MMP expression in both fibroblasts and keratinocytes. Moreover, calcipotriol was able to restore betamethasone-impaired HA synthesis in keratinocytes and prevented betamethasone-induced epidermal thinning in minipigs on treatment with a calcipotriol/betamethasone gel. In summary, these results showed for the first time in primary human skin cultures that calcipotriol reduces early signs of betamethasone-induced skin atrophy by modulation of key ECM components. These results indicate that the calcipotriol component of the fixed combination gel counteracts the atrophogenic effects of betamethasone on the skin [103].

Small Molecules and Biologics in the Treatment of Nail Psoriasis – FullText – Skin Appendage Disorders 2020, Vol. 6, No. 3

Abstract

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.

© 2020 S. Karger AG, Basel

Introduction

Nail psoriasis (PsO) is a disorder with profound impact on patients’ quality of life (QoL), particularly when considering how limited body surface the nails comprise. Both psychological and functional components of QoL are impaired [1]. It affects up to 50% of patients with cutaneous PsO, with a lifetime incidence up to 90% [2]. Nail PsO without skin involvement or arthritis has prevalence ranging from 5 to 10% [3, 4]. Inflammation associated with nail PsO may involve associated structures, including distal interphalangeal joints [5], digital extensor tendons, and the enthesis, which is thought to be a continuation of the supporting fascia of the nail [6, 7]. Psoriatic arthritis (PsA) can also be considered as part of the natural progression of the same disease [8, 9].

Systemic treatment approaches for skin PsO enabled better disease management, and several recommendations for first-line, second-line, and alternative treatments have been published. Management of nail PsO has not enjoyed the number of literature publications of its cutaneous counterpart. Several challenges and unmet needs remain in the treatment of nail PsO. Topical treatment of nail PsO is often difficult due to considerable duration and poor adherence that often results in unsatisfactory efficacy. Systemic treatment for nail PsO without cutaneous involvement, particularly if the number of psoriatic nails is limited, has always been seen with skepticism by many dermatologists.

Treating nail PsO remains a challenge, and even in the era of biologics, it should start with counseling of general prophylactic measures. Behavioral interventions such as the use of cotton gloves when performing household tasks, frequent use of nail moisturizers, cutting nails, and avoidance of trauma are very important for prevention and assisting treatment. The physician should take into consideration that agents effective in the treatment of nail bed signs have often poor efficacy in treating nail matrix signs. Involvement of skin and/or joints, QoL, comorbidities, age and gender of the patient, and productivity or ability to work might also influence treatment choices.

A recent consensus striving to provide recommendations for the treatment of nail PsO suggested that few nails’ disease should be considered as nail PsO affecting 3 or less nails as a general rule for deciding on topical or systemic therapy [10]. Intralesional steroids should be employed as the treatment of choice in nail matrix disease and topical steroids alone or in combination with vitamin D analogues for nail bed disease affecting up to 3 nails. However, if more nails are affected or systemic therapy is indicated for other reasons, acitretin, methotrexate, cyclosporine, small molecules, and biologics can be prescribed. Acitretin is used in a dosage ranging between 0.2 and 0.5 mg/kg/day, resulting in moderate improvement of nail PsO after several months of treatment. Cyclosporin A has been employed at a dosage of 3 mg/kg followed by either the increase of the dosage to 5 mg/kg/day where needed, or tapering of the dosage during the next 12 weeks, with significant improvement in nail PsO features. Methotrexate is usually prescribed at an initial dose of 5–7.5 mg and subsequently increased up to 25 mg/week for 24–52 weeks. A decrease in the Nail Psoriasis Severity Index (NAPSI) ranges between 30 and 50% at 52 weeks. Intralesional methotrexate has been anecdotally used, with injections of 2.5 mg/week for 6 weeks. All classical systemic agents can be used either as monotherapy or combined with topical treatment to achieve a reduced dose and duration of systemic treatment or to maintain disease remission [10].

Introduction of biologics and small molecules in the treatment of nail PsO has allowed for rapid control of the disease and high efficacy. However, most of the studies report results in subpopulations with both cutaneous and nail PsO who were recruited to assess biologics/small molecule efficacy in skin PsO and/or PsA. 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.

Methods

In December 2019, we conducted a systematic search of the PubMed, MEDLINE, and Scopus databases as well as the abstracts for posters of the European Academy of Dermatology and Venereology and American Academy of Dermatology (AAD) annual meetings of 2017–2019 using the following keywords: nail psoriasis, psoriasis, psoriatic arthritis, biologics, small molecules, Nail Psoriasis Severity Index (NAPSI) Investigator’s Global Assessment (IGA), and treatment both alone and in combination with one other. We included studies that focused on nail PsO or studies that focused on nail improvement in patients treated for PsO and PsA, and data on nail PsO efficacy of any intervention were either a primary or a secondary end point.

A total of 44 articles or abstracts published were identified. Heterogeneity in types and reports of nail PsO outcome instruments made it difficult to compare between studies. Adalimumab (ADA) is the only biological agent approved for the treatment of nail PsO; all others are approved for treating skin/scalp/joint PsO and should be used off-label for PsO limited to the nails.

Treatment with Small Molecules and Biologics

Small molecules and biologic agents that have been employed in the treatment of cutaneous PsO and/or arthritis have also been used to treat nail PsO. These agents include phosphodiesterase-4 inhibitors, anti-tumor necrosis factor-alpha (TNF-α), anti-interleukin (IL)-12/23, and anti-IL-17A agents. Retrospective studies comparing the efficacy of multiple anti-TNF-α agents suggest that etanercept, infliximab, secukinumab, and ADA result in a significant improvement of the NAPSI score in patients with nail PsO [11, 12] (Table 1).

Table 1.

Major studies with small molecules and biologics in the treatment of nail PsO

Apremilast

Apremilast (a selective phosphodiesterase-4 inhibitor) is prescribed orally at a dosage of 30 mg twice daily in patients with PsO and nail involvement. The main advantage of apremilast is the lack of need for periodic laboratory monitoring of routine biochemistry of the patient.

When considering apremilast efficacy, a reduction of the NAPSI score of 22.5% for patients in the ESTEEM 1 and 29% for patients in the ESTEEM 2 study was seen at week 16, with improvement in both matrix and bed disease. At week 32, the mean reduction in NAPSI was 43.6 and 60%, respectively, while at week 52, 60.2 and 59.7%, respectively [13].

Apremilast also demonstrated long-term improvement for patients with plaque PsO on their skin, scalp, and nails. In the LIBERATE study, 250 patients were randomized to placebo, apremilast 30 mg BID, or etanercept 50 mg QW through week 16; thereafter, all patients continued or switched to apremilast through week 104. Skin, scalp, and nail involvement was assessed. NAPSI change from baseline was −48.1 to −51.1% [14].

A multicenter noninvasive study of biologics-naive patients with moderate to severe plaque PsO conducted in Germany was presented at the AAD annual meeting in March 2019. The goal of the study was to evaluate the Dermatology Life Quality Index (DLQI), patients’ satisfaction with the treatment, and safety and effectiveness of apremilast in patients who had received systemic treatment. After 4 months of treatment, 24/50 (48.0%) patients reached a 0 NAPSI score [15].

The analysis of 250 patients from the APPRECIATE study with PsO in difficult-to-treat areas was presented in March 2019 at the AAD annual meeting. In the pooled analysis of this study, there were 250 patients evaluated in 43 centers in Germany, the UK, and Ireland having PsO in difficult-to-treat areas. Both patients’ and physicians’ satisfaction ratings documented improvement of pruritus and scalp, nail, palmoplantar, nongenital inverse, and genital PsO [16].

In the Real-World Prospective Study of the Effects of Apremilast on the Quality of Life and Disease Activity Parameters among Patients with Moderate Psoriasis Treated in Greece, the results were also promising. Results of the first 100 patients who completed 24 weeks of treatment, including those who withdrew from the study prematurely, were analyzed. At baseline, patients with evident nail involvement (N = 57) had a median (IQR) NAPSI score of 40 (20.0–70.0). A significant decrease of the median points in weeks 6, 16, and 24 of 9.0, 15.0, and 20.0 points, respectively, was observed [17].

Tofacitinib

Tofacitinib is an oral Janus kinase inhibitor. A randomized, controlled, phase 3 study evaluated the efficacy and safety of tofacitinib in patients with moderate-to-severe plaque PsO and nail PsO. At week 16, significantly more patients receiving tofacitinib 5 and 10 mg versus placebo twice daily achieved NAPSI 50 (32.8, 44.2 vs. 12.0%), NAPSI 75 (16.9, 28.1 vs. 6.8%), and NAPSI 100 (10.3, 18.2 vs. 5.1%), respectively [18]. In a subgroup analysis from a randomized, placebo-controlled, phase 3 trial, reductions from baseline in the NAPSI score were observed at week 16 with both tofacitinib 5 and 10 mg twice daily. NAPSI scores continued to decrease through week 52 in both tofacitinib dose groups. By week 52, 22.2 and 47.6% of the patients who received tofacitinib 5 and 10 mg, respectively, achieved NAPSI 75 [19]. Adverse events most commonly related to laboratory parameter abnormalities were noted. Both studies showed that oral tofacitinib demonstrates efficacy against nail PsO, sustained over 52 weeks, with a manageable safety profile.

Etanercept

Etanercept (a fusion protein) has been established as an effective and safe treatment for nail PsO after more than 15 years of administration. In a study of 564 PsO patients receiving 25 mg or 50 mg of etanercept subcutaneously twice/week, for 54 weeks, NAPSI was improved by 51% at week 24, while complete resolution was seen in 30% of them at week 54 [20]. In an open randomized study, 69% patients with PsO and nail involvement were treated with etanercept 50 mg twice/week for 12 weeks followed by 50 mg once/week for 12 more weeks or 50 mg once/week for 24 weeks. At week 24, NAPSI 75 was documented in 57.0% of patients in the first group and 68.6% of patients in the second group [21].

Adalimumab

A prospective, open-label, uncontrolled study including 244 patients with PsA and nail involvement showed that ADA (a human monoclonal antibody that targets TNF-α) provided significant improvement in nail PsO. By week 12, a 57% decrease in the mean NAPSI score was demonstrated, while by week 20, the decrease was almost 91% [22].

An effort was undertaken by some investigators to document improvement of QoL in patients with nail PsO receiving ADA. The study included 21 patients with nail PsO: 7 of them also had cutaneous PsO and 14 had PsA. Patients were treated with ADA 45 mg twice a month subcutaneously. At week 24, a decrease of the NAPSI score by 85% on fingernail PsO and 71.5% on toenail PsO was observed in patients of the first group, while 86% for fingernail and 64% for toenail PsO were observed in patients of the second group. Statistically significant improvement on patients’ QoL was also seen [23]. A randomized, placebo-controlled, double-blind trial with 36 patients demonstrated an improvement in the NAPSI score as high as 54% at week 28 [24]. A sub-analysis of the effect of ADA on scalp and nail PsO in the population of the BELIEVE study showed improvement of nail PsO by 39.5% at week 16 and a reduction of 74.31% of the patients’ burden on QoL [25].

During a recent randomized, placebo-controlled trial of 217 patients with moderate-to-severe nail PsO and related pain at baseline, 109 patients received ADA, while 108 patients were given placebo. As a result, patients who were treated with ADA showed statistically significant improvement in signs and symptoms of nail PsO versus those with placebo. In almost half of the patients being treated with ADA (46.6%), NAPSI 75 was seen at week 26 (Period A) [26, 27]. A recent publication focusing on the open-label extension of the same trial highlights the results of the study past week 26, up to week 52. During the initial 26 weeks (Period A), 50% of the patients were treated with 40 mg ADA biweekly and 50% were on placebo. After Period A, patients (N = 188) were switched to ADA or continued on 40 mg ADA biweekly for 26 weeks. For the continuous ADA population (N = 109), the rate of achievement of total fingernail modified NAPSI (mNAPSI) 75 was 25.9% at week 16, increasing to 47.4% at week 26 and to 54.5% at week 52. Similar results were seen with the rate of achievement of PGA-F 0/1 with ≥2 grades of improvement from baseline. Improvements in response to ADA long-term treatment were also seen from weeks 16 to 52 for the other efficacy end points in this analysis, including total fingernail mNAPSI = 0. The percent improvement relative to baseline at weeks 4 and 52 was 37 and 76% for nail psoriasis pain numerical rating score (NRS), 28 and 74% for Nail Psoriasis Physical Functioning Severity (NPPFS), 28 and 74% for Nail PsO QoL, and 16 and 48% for nail assessment in psoriasis and psoriatic arthritis (NAPPA)-QoL. The main efficacy analyses across 52 weeks were total fingernail mNAPSI of ≥75% improvement relative to baseline (mNAPSI 75) and achievement of PGA-F 0/1 with a ≥2-grade improvement from baseline [28, 29]. Patients who were randomized to placebo in Period A showed nail improvement once they were switched to ADA, which continued to week 52. The mean improvement in patient-reported outcomes of nail pain NRS, NPPFS, Nail PsO QoL score, and the NAPPA-QoL score also increased from week 26 to week 52 [27-30]. In conclusion, 52 weeks of biweekly treatment with 40 mg ADA improved nail signs and QoL for patients with moderate to severe nail PsO. The achievement rates of mNAPSI and total clearance of nail disease (mNAPSI = 0) improved throughout the 52 weeks. No new safety risks were identified with ADA treatment in this population. When considering side effects, most were mild or moderate in severity; nasopharyngitis and upper respiratory tract infections were mostly observed [27].

Infliximab

Infliximab is a chimeric monoclonal antibody. In a 50-week, phase 3, randomized, double-blind trial in 373 patients with moderate to severe PsO, infliximab demonstrated improvement of NAPSI (56.3%) from baseline to week 24 [31]. Another 25 patients with nail PsO treated with infliximab (5 mg/kg) reported NAPSI 75 was achieved by all patients at week 22 [32]. In an unblended study, 18 patients with nail involvement (13 patients with PsA and 5 with severe plaque PsO) were treated with infliximab infusions. All patients demonstrated almost complete clearance (94% improvement), and a significant reduction of the score of the international QoL questionnaire was reported in all patients [33]. In a randomized, double-blind, placebo-controlled, multicenter study, improvement in the NAPSI score at week 10 was 1.4 ± 2.2 in the infliximab group compared with 0.3 ± 1.0 in the placebo group [34]. An open-labeled study including 48 patients with nail PsO involvement showed a rapid response and 81% improvement of the NAPSI score at week 22 after infliximab initiation [35].

Certolizumab Pegol

A double-blind, randomized, placebo-controlled study (RAPID PsA) in patients with PsA treated with certolizumab pegol (CZP) showed statistically significant improvement of mNAPSI at week 24. The reduction in mNAPSI was −1.6 with CZP 200 mg Q2W and −2.0 with CZP 400 mg Q4W versus −1.1 with placebo [36].

Golimumab

A randomized, double-blind, placebo-controlled trial with golimumab in patients with PsA reported improvement of target median NAPSI by 25 and 33% at weeks 12 and 24, respectively, for patients receiving 50 mg of golimumab and 43 and 54% at weeks 12 and 24 for patients receiving 100 mg of golimumab. Both improvements were statistically significant compared to the placebo groups [37].

Guselkumab

Two multicenter, randomized, double-blind, placebo- and comparator-controlled clinical trials (VOYAGE 1 and VOYAGE 2) showed significantly greater improvements from baseline with guselkumab versus placebo (weeks 8 and 16) and versus ADA (week 24) [38]. A secondary analysis revealed that patients on guselkumab showed significant improvement in PsO of the scalp and palms and/or soles compared to patients on ADA, but the magnitude of improvement did not differ between the 2 treatments in patients’ fingernails [39].

Ustekinumab

In a large, double-blind, randomized, placebo-controlled, multicenter trial, 545 PsO patients with nail involvement were treated with ustekinumab (recombinant, completely human, monoclonal antibody). A significant improvement of the NAPSI score was observed from baseline to week 12 by 26.7% in the 45-mg group and by 24.9% in the 90-mg group of patients, highlighting the early drug’s efficacy. This improvement was further increased at week 24 (46.5 and 48.7%, respectively) [40].

Twenty-seven patients with plaque PsO who had fingernail involvement were treated with the standard ustekinumab regimen in an open-label, prospective study. Most patients’ improvement was evident even at the 4-week evaluation with a reduced mean NAPSI score from 19.59 to 16.96. NAPSI was also significantly reduced at 16, 28, and 40 weeks compared to the baseline score. Even though no control group was used, ustekinumab presented an effective and safe profile for the treatment of nail PsO [41].

In a double-blind, placebo-controlled study, 158 patients with moderate to severe plaque-type PsO were randomized to receive ustekinumab 45 or 90 mg at weeks 0, 4, and every 12 weeks, or placebo with crossover to ustekinumab at week 12 [42]. The authors reported that patients presented a 56.6 ± 43.2% and 67.8 ± 37.5% improvement of NAPSI when using 45 and 90 mg of ustekinumab, respectively, at week 64 [42].

A study by Vittiello et al. [43] included 13 patients with moderate to severe PsO and PsA with nail involvement who had previously tried multiple different therapeutic modalities with poor results. Five patients received ustekinumab 90 mg as monotherapy because they exceeded the 90-mg range. The mean NAPSI score and modified NAPSI for the 13 patients were reduced from 22.3 and 6.3 at week 0, to 14.8 and 5.2 at week 12, respectively, demonstrating a reduction of the NAPSI score and mNAPSI score of 31.8 and 13.3%. A 37.6% reduction of the NAPSI score was noted in the 5 patients with ustekinumab administration monotherapy. The 6 patients with the combination of ustekinumab and methotrexate (MTX) had a 27% reduction of the NAPSI score, while in the 2 patients with the combination of ustekinumab and cyclosporine, complete resolution of nail disease was noted.

An open-label, uncontrolled study evaluated the effectiveness of ustekinumab in 27 patients with nail PsO. A 49% reduction of the NAPSI score was noted at week 16, which was increased to 88% at week 28, highlighting the rapid efficacy of the agent against nail PsO [44].

A case report was recently published about a 69-year-old man with multiple severe psoriatic crumbly nails (NAPSI 69) who started ustekinumab treatment at a standard dosage of 45 mg fl.s.c. After 24 weeks, nail matrix and nail bed disease showed noticeable improvement, and the patient continued therapy with ustekinumab (NAPSI 0 at week 104). At week 136, the patient presented with synovitis of the metacarpophalangeal joints. The patient continued therapy with ustekinumab, adding methotrexate 10 mg/week, resulting in great improvement. Methotrexate treatment was suspended, and the patient continued more than 4 years of ustekinumab treatment without clinical manifestation of synovitis [45].

Secukinumab

A phase 2, double-blind, placebo-controlled, clinical trial evaluating the efficacy of secukinumab (fully human monoclonal antibody) for patients with moderate to severe plaque PsO of the hands, feet, and nails revealed improvement in patients’ disease thus far [46]. Improvement of NAPSI has been reported to be even more rapid in a case series of 15 patients, with a 50% reduction at 6 weeks and an 80% reduction at 12 weeks [47]. A recent case report suggests that secukinumab might also have good efficacy in children with nail PsO [48].

TRANSFIGURE is a double-blind, randomized, placebo-controlled study in patients with moderate to severe plaque and nail PsO. It is one of the few prospective, placebo-controlled trials designed specifically for nail PsO and includes nail-specific QoL measures such as NAPPA-QoL and NAPPA-Patient Benefit Index (PBI). In total, 198 patients were randomized to the 3 study groups: secukinumab 300 mg (n = 66), secukinumab 150 mg (n = 67), and placebo (n = 65). Both doses of secukinumab were superior to placebo. At week 16, the mean percentage NAPSI changes were 45.3% for secukinumab 300 mg, 37.9% for secukinumab 150 mg, and 10.8%, for placebo. The onset of action was apparent by week 2 with secukinumab 300 mg. Further improvements were seen by week 32: total fingernail NAPSI responses improved with changes from baseline of 63.2% for secukinumab 300 mg and 52.6% for secukinumab 150 mg. The target toenail NAPSI score improved in both secukinumab arms compared with the placebo arm by week 8. At week 16, the decreases in the mean target toenail NAPSI score from baseline were 17.2% for secukinumab 300 mg, 18.4% for secukinumab 150 mg, and 9.0% for placebo.

NAPPA-QoL revealed that at baseline, more than half of the patients experienced pain of the fingers and nails, resulting in major discomfort and difficulties for everyday living. However, a significant decrease in NAPPA-QoL was observed at week 16 with secukinumab, with median decreases of 60.9% (300 mg), 49.9% (150 mg), and 15.8% (placebo). The results were promising for the NAPPA-PBI. At week 16, patients on secukinumab 300 mg reported the greatest treatment benefits. They had a median score of 4 (treatment helped “very” much) as opposed to placebo, which was 0. These patients reported confidence in treatment and noticed rapid improvement of nail psoriatic features, leading to an improved life both emotionally and physically. At week 32, the most common side effects were headache, nasopharyngitis, and upper respiratory tract infections, and they were not dose related [49].

A poster was recently presented with the 1-year results (October 2016–September 2017) of the ongoing 5-year SERENA study. It included 904 patients with PsO and PsA followed up in 19 countries across Europe. At baseline, 33.3% of PsO patients who were also affected with PsA had nail involvement. After 12 months, the number of patients with evident nail involvement decreased to 15.6% [50].

Ixekizumab

Ixekizumab’s (a fully humanized monoclonal anti-IL-17A drug) effect on psoriatic nail disease was evaluated in a post hoc analysis of a phase 2 study comprising a 20-week, randomized, placebo-controlled period and 48 weeks of an open-label extension period [51]. There were 142 patients with moderate to severe plaque PsO who were randomized to receive placebo, 10, 25, 75, or 150 mg of ixekizumab, injected subcutaneously at weeks 0, 2, 4, 8, 12, and 16. After week 48, all patients received 120 mg ixekizumab every 4 weeks. Patients with nail PsO in the 75- and 150-mg groups had significant improvements from baseline NAPSI. By week 48, 51.0% of patients with nail PsO experienced complete resolution of lesions, suggesting ixekizumab as a possible option for the treatment of patients with skin and nail PsO. A poster on the results of the IXORA-S trial suggested superior efficacy of ixekizumab over ustekinumab in nail PsO [52].

A subgroup analysis of the UNCOVER-3 trial included only patients with baseline fingernail PsO: 116 (60.1%) placebo, 236 (61.8%) etanercept, 228 (59.1%) IXE Q4W, and 229 (59.5%) IXE Q2W. At week 12, NAPSI improvements were achieved in IXE Q4W (36.7%) and IXE Q2W (35.2%) versus placebo (−34.3%) and etanercept (20.0%). At week 60, NAPSI improvement was >80%, regardless of initial treatment. At week 12, ixekizumab patients presented great improvement. By week 60, more than half the patients achieved complete resolution [53].

A review on the results of the UNCOVER-3 study analyzed the efficacy, sustainability, and safety of ixekizumab treatment for PsO through 156 weeks. Sustainable improvement was evident on the skin, scalp, nails, and palmoplantar area. No new safety concerns occurred throughout the 3 years [54].

Brodalumab

A recent case series literature review analyzed the safety and efficacy of brodalumab (monoclonal immunoglobulin IgG2 antibody) on 4 patients with moderate to severe PsO (2 with PsA). In controlled clinical trials, brodalumab 210 mg was administered by subcutaneous injection during weeks 0, 1, and 2, followed by biweekly injections thereafter. Psoriatic plaques of the scalp, nails, soles, and palms were rapidly treated, while QoL improved for all 4 patients with long-term sustainable results. The 2 patients with PsA also experienced joint pain relief during the treatment [55].

Risankizumab

A recent analysis evaluating the efficacy and safety of risankizumab (a humanized immunoglobulin G1 monoclonal antibody that inhibits IL-23) compared with ustekinumab for the treatment of nail, scalp, and palmoplantar PsO found significant improvement of nail and scalp PsO for the patients receiving risankizumab compared to ustekinumab in 52 weeks (mean baseline NAPSI 13.6 vs. 12.7 and 52-week NAPSI −16.1 vs. −12.2) [56].

Tildrakizumab

A case report of a 40-year-old man with psoriatic nail dystrophy and PsA revealed impressive clinical response to tildrakizumab (IL-23 monoclonal antibody). The administration was 100 mg at weeks 0 and 4. Twelve weeks later when the patient returned for his third administration, his nail dystrophy and arthritis had improved immensely [57].

Conclusion

Treating nail PsO can be challenging. The nail plate’s physical and chemical properties allow for limited penetration of topical treatments through the nail surface, leading to slow improvement and often poor patient compliance. Multiple clinical trials have studied biologics for several years, demonstrating safe, rapid, and effective results regarding the treatment of cutaneous PsO. The few double-blinded comparative studies of biologics and small molecules on nail PsO confirm the excellent efficacy and safety profile.

Long-term clinical trials of biologics, such as ADA and secukinumab designed specifically for patients with nail PsO, have shown that efficacy on indexes improvement is also associated with significant improvement in patients’ functionality and a better QoL. This might provide a strong argument to convince the payers to continue reimbursement of biologics and small molecules for nail PsO patients in a limited-recourse modern era.

Disclosure Statement

The authors have no conflict of interest to declare.

Funding Sources

The authors did not receive any funding.

Author Contribution Statement

All authors contributed in the literature search and writing of this manuscript. In addition, Dimitrios Rigopoulos critically reviewed the submitted manuscript.

References

1. 
   Belyayeva E, Gregoriou S, Chalikias J, Kontochristopoulos G, Koumantaki E, Makris M, et al. The impact of nail disorders on quality of life. Eur J Dermatol. 2013;23(3):366–71.
   




2. 
   Jiaravuthisan MM, Sasseville D, Vender RB, Murphy F, Muhn CY. Psoriasis of the nail: anatomy, pathology, clinical presentation, and a review of the literature on therapy. J Am Acad Dermatol. 2007;57(1):1–27.
   




3. 
   Langley RG, Daudén E. Treatment and management of psoriasis with nail involvement: a focus on biologic therapy. Dermatology. 2010;221(Suppl 1):29–42.
   




4. 
   Salomon J, Szepietowski JC, Proniewicz A. Psoriatic nails: a prospective clinical study. J Cutan Med Surg. 2003;7(4):317–21.
   




5. 
   Williamson L, Dalbeth N, Dockerty JL, Gee BC, Weatherall R, Wordsworth BP. Extended report: nail disease in psoriatic arthritis: clinically important, potentially treatable and often overlooked. Rheumatology. 2004;43(6):790–4.
   




6. 
   Krajewska-Wlodarczyk M, Owczarcyzk-Saczonek A, Placek W, Wojtkiewicz M, Wiktorowicz A, Wojtkiewixz J. Distal interphalangeal joint extensor tendon enthesopathy in patients with nail psoriasis. Sci Rep. 2019;9(1):3628.
   




7. 
   McGonagle D. Enthesitis: an autoinflammatory lesion linking nail and joint involvement in psoriatic disease. J Eur Acad Dermatol Venereol. 2009;23(Suppl 1):9–13.
   




8. 
   McGonagle D, Ash Z, Dickie L, McDermott M, Aydin SZ. The early phase of psoriatic arthritis. Ann Rheum Dis. 2011;70(Suppl 1):i71–6.
   




9. 
   Scher JU, Ogdie A, Merola JF, Ritchlin C. Preventing psoriatic arthritis: focusing on patients with psoriasis at increased risk of transition. Nat Rev Rheumatol. 2019;15(3):153–66.
   




10. 
    Rigopoulos D, Baran R, Chiheb S, Daniel CR, Di Chiacchio N, Gregoriou S, et al. 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. J Am Acad Dermatol. 2019;81(1):228–40.
    




11. 
    Kyriakou A, Patsatsi A, Sotiriadis D. Anti-TNF agents and nail psoriasis: a single-center, retrospective, comparative study. J Dermatolog Treat. 2013;24(3):162–8.
    




12. 
    Bardazzi F, Antonucci VA, Tengattini V, Odorici G, Balestri R, Patrizi A. A 36-week retrospective open trial comparing the efficacy of biological therapies in nail psoriasis. J Dtsch Dermatol Ges. 2013;11(11):1065–70.
    




13. 
    Rich P, Gooderham M, Bachelez H, Goncalves J, Day RM, Chen R, et al. Apremilast, an oral phosphodiesterase 4 inhibitor, in patients with difficult-to-treat nail and scalp psoriasis: results of 2 phase III randomized, controlled trials (ESTEEM 1 and ESTEEM 2). J Am Acad Dermatol. 2016;74(1):134–42.
    




14. 
    Reich K, Gooderham M, Gooderham M, Bewley A, Green L, Soung J, et al. Safety and efficacy of apremilast through 104 weeks in patients with moderate to severe psoriasis who continued on apremilast or switched from etanercept treatment: findings from the LIBERATE study. J Eur Acad Dermatol Venereol. 2018;32(3):397–402.
    




15. 
    Reich K, Fritzlar S, Korge B, Manasterski M, Schwichtenberg U, Morys S, et al. Physician- and patient-reported outcomes for patients with plaque psoriasis treated with apremilast during routine dermatology care in Germany. Presented at: the 2019 American Academy of Dermatology (AAD) Annual Meeting; 2019 March 1–5. Washington, DC; 2019.
    




16. 
    Augustin M, Radtke M, Schneider J, Pinter A, Wilsmann Theis D, Peter RU, et al. Real-world experience with apremilast: analysis of 250 patients from the APPRECIATE study with psoriasis in difficult-to-treat areas. Presented at the 2019 AAD Annual Meeting; 2019 March 1–5. Washington, DC; 2019.
    




17. 
    Papakonstantis M, Georgiou S, Chasapi V, Katsantonis I, Drosos A, Rigopoulos D, et al. nterim results of a nationwide, real-world prospective study of the effects of apremilast on the quality of life and disease activity parameters among patients with moderate psoriasis treated in Greece [APRAISAL study]. Poster: Presented in the EADV 2019 Congress; 2019 October 9–13. Madrid, Spain; 2019.
    




18. 
    Merola JF, Elewski B, Tatulych S, Lan S, Tallman A, Kaur M. Efficacy of tofacitinib for the treatment of nail psoriasis: two 52-week, randomized, controlled phase 3 studies in patients with moderate-to-severe plaque psoriasis. J Am Acad Dermatol. 2017;77(1):79–e1.
    




19. 
    Abe M, Nishigori C, Torii H, Ihn H, Ito K, Nagaoka M, et al. Tofacitinib for the treatment of moderate to severe chronic plaque psoriasis in Japanese patients: subgroup analyses from a randomized, placebo-controlled phase 3 trial. J Dermatol. 2017;44(1):1228–37.
    




20. 
    Luger TA, Barker J, Lambert J, Yang S, Robertson D, Foehl J, et al. Sustained improvement in joint pain and nail symptoms with etanercept therapy in patients with moderate-to-severe psoriasis. J Eur Acad Dermatol Venereol. 2009;23(8):896–04.
    




21. 
    Ortonne JP, Paul C, Berardesca E, Marino V, Gallo G, Brault Y, et al. A 24-week randomized clinical trial investigating the efficacy and safety of two doses of etanercept in nail psoriasis. Br J Dermatol. 2013;168(5):1080–7.
    




22. 
    Van den Bosch F, Manger B, Goupille P, McHugh N, Rødevand E, Holck P, et al. Effectiveness of adalimumab in treating patients with active psoriatic arthritis and predictors of good clinical responses for arthritis, skin and nail lesions. Ann Rheum Dis. 2010;69(2):394–9.
    




23. 
    Rigopoulos D, Gregoriou S, Lazaridou E, Belyayeva E, Apalla Z, Makris M, et al. Treatment of nail psoriasis with adalimumab: an open label unblinded study. J Eur Acad Dermatol Venereol. 2010;24(5):530–4.
    




24. 
    Leonardi C, Langley RG, Papp K, Tyring SK, Wasel N, Vender R, et al. Adalimumab for treatment of moderate to severe chronic plaque psoriasis of the hands and feet: efficacy and safety results from REACH, a randomized, placebo-controlled, double-blind trial. Arch Dermatol. 2011;147(4):429–36.
    




25. 
    Thaçi D, Unnebrink K, Sundaram M, Sood S, Yamaguchi Y. Adalimumab for the treatment of moderate to severe psoriasis: subanalysis of effects on scalp and nails in the BELIEVE study. J Eur Acad Dermatol Venereol. 2015;29(2):353–60.
    




26. 
    Elewski BE, Okun MM, Papp K, Baker CS, Crowley JJ, Guillet G, et al. Adalimumab for nail psoriasis: efficacy and safety from the first 26 weeks of a phase 3, randomized, placebo-controlled trial. J Am Acad Dermatol. 2018;78:90–9.e1.
    




27. 
    Elewski BE, Baker CS, Crowley JJ, Poulin Y, Okun MM, Calimlim B, et al. Adalimumab for nail psoriasis: efficacy and safety over 52 weeks from a phase-3, randomized, placebo-controlled trial. J Eur Acad Dermatol Venereol. 2019;33(11):2168–78.
    




28. 
    Cassell SE, Bieber JD, Rich P, Tutuncu ZN, Lee SJ, Kalunian KC, et al. The modified nail psoriasis severity index: validation of an instrument to assess psoriatic nail involvement in patients with psoriatic arthritis. J Rheumatol. 2007;34(1):123–9.
    




29. 
    Rich P, Scher RK. Nail psoriasis severity index: a useful tool for evaluation of nail psoriasis. J Am Acad Dermatol. 2003;49(2):206–12.
    




30. 
    Augustin M, Blome C, Costanzo A, Dauden E, Ferrandiz C, Girolomoni G, et al. Nail assessment in psoriasis and psoriatic arthritis (NAPPA): development and validation of a tool for assessment of nail psoriasis outcomes. Br J Dermatol. 2014;170(3):591–8.
    




31. 
    Rich P, Griffiths CE, Reich K, Nestle FO, Scher RK, Li S, et al. Baseline nail disease in patients with moderate to severe psoriasis and response to treatment with infliximab during 1 year. J Am Acad Dermatol. 2008;58(2):224–31.
    




32. 
    Bianchi L, Bergamin A, de Felice C, Capriotti E, Chimenti S. Remission and time of resolution of nail psoriasis during infliximab therapy. J Am Acad Dermatol. 2005;52(4):736–7.
    




33. 
    Rigopoulos D, Gregoriou S, Stratigos A, Larios G, Korfitis C, Papaioannou D, et al. Evaluation of the efficacy and safety of infliximab on psoriatic nails: an unblinded, nonrandomized, open-label study. Br J Dermatol. 2008;159(2):453–6.
    




34. 
    Torii H, Nakagawa H, Infliximab monotherapy in Japanese patients with moderate-to-severe plaque psoriasis and psoriatic arthritis. A randomized, double-blind, placebo-controlled multicenter trial. J Dermatol Sci. 2010;59(1):40–9.
    




35. 
    Fabroni C, Gori A, Troiano M, Prignano F, Lotti T. Infliximab efficacy in nail psoriasis. A retrospective study in 48 patients. J Eur Acad Dermatol Venereol. 2011;25(5):549–53.
    




36. 
    Mease PJ, Fleischmann R, Deodhar AA, Wollenhaupt J, Khraishi M, Kielar D, et al. Effect of certolizumab pegol on signs and symptoms in patients with psoriatic arthritis: 24-week results of a phase 3 double-blind randomised placebo-controlled study (RAPID-PsA). Ann Rheum Dis. 2014;73(1):48–55.
    




37. 
    Kavanaugh A, McInnes I, Mease P, Krueger GG, Gladman D, Gomez-Reino J, et al. Golimumab, a new human tumor necrosis factor alpha antibody, administered every four weeks as a subcutaneous injection in psoriatic arthritis: twenty-four-week efficacy and safety results of a randomized, placebo-controlled study. Arthritis Rheum. 2009;60(4):976–86.
    




38. 
    Nakamura M, Lee K, Jeon C, Sekhon S, Afifi L, Yan D, et al. Guselkumab for the treatment of psoriasis: a review of phase III trials. Dermatol Ther. 2017;7(3):281–92.
    




39. 
    Foley P, Gordon K, Griffiths CEM, Wasfi Y, Randazzo B, Song M, et al. Efficacy of guselkumab compared with adalimumab and placebo for psoriasis in specific body regions: a secondary analysis of 2 randomized clinical trials. JAMA Dermatol. 2018;154(6):676–83.
    




40. 
    Rich P, Bourcier M, Sofen H, Fakharzadeh S, Wasfi Y, Wang Y, et al. Ustekinumab improves nail disease in patients with moderate-to-severe psoriasis: results from PHOENIX 1. Br J Dermatol. 2014;170(2):398–407.
    




41. 
    Rigopoulos D, Gregoriou S, Makris M, Ioannides D. Efficacy of ustekinumab in nail psoriasis and improvement in nail-associated quality of life in a population treated with ustekinumab for cutaneous psoriasis: an open prospective unblinded study. Dermatology. 2011;223(4):325–9.
    




42. 
    Igarashi A, Kato T, Kato M, Song M, Nakagawa H. Efficacy and safety of ustekinumab in Japanese patients with moderate-to-severe plaque-type psoriasis: long-term results from a phase 2/3 clinical trial. J Dermatol. 2012;39(3):242–52.
    




43. 
    Vitiello M, Tosti A, Abuchar A, Zaiac M, Kerdel FA. Ustekinumab for the treatment of nail psoriasis in heavily treated psoriatic patients. Int J Dermatol. 2013;52(3):358–62.
    




44. 
    Patsatsi A, Kyriakou A, Sotiriadis D. Ustekinumab in nail psoriasis: an open-label, uncontrolled, nonrandomized study. J Dermatolog Treat. 2013;24(2):96–100.
    




45. 
    Galluzzo M, D’Adamio S, Chimenti MS, Teoli M, Bianchi L, Talamonti M. Successful treatment of psoriatic crumbly nails with ustekinumab. Dermatol Ther. 2019;32(3):e12914.
    




46. 
    Paul C, Reich K, Gottlieb AB, Mrowietz U, Philipp S, Nakayama J, et al. Secukinumab improves hand, foot and nail lesions in moderate-to-severe plaque psoriasis: subanalysis of a randomized, double-blind, placebo-controlled, regimen-finding phase 2 trial. J Eur Acad Dermatol Venereol. 2014;28(12):1670–5.
    




47. 
    Pistone G, Gurreri R, Tilotta G, Castelli E, Bongiorno MR. Secukinumab efficacy in the treatment of nail psoriasis: a case series. J Dermatolog Treat. 2018;29(Suppl 1):21–4.
    




48. 
    Wells LE, Evans T, Hilton R, Wine Lee L, Ruth N. Use of secukinumab in a pediatric patient leads to significant improvement in nail psoriasis and psoriatic arthritis. Pediatr Dermatol. 2019;36(3):384–5.
    




49. 
    Reich K, Sullivan J, Arenberger P, Mrowietz U, Jazayeri S, Augustin M, et al. Effect of secukinumab on the clinical activity and disease burden of nail psoriasis: 32-week results from the randomized placebo-controlled TRANSFIGURE trial. Br J Dermatol. 2019;181(5):954–66.
    




50. 
    Augustin M, Von Kiedrowsky R, Rigopoulos D, Sator PG, Orsenigo R, Gathman S, et al. Effectiveness and safety of secukinumab in real-world clinical setting in Europe: 1-year results from an interim analysis of the SERENA study. Poster 8674, Presented at the 2019 AAD Annual Meeting; 2019 March 1–5. Washington, DC; 2019.
    




51. 
    Langley RG, Rich P, Menter A, Krueger G, Goldblum O, Dutronc Y, et al. Improvement of scalp and nail lesions with ixekizumab in a phase 2 trial in patients with chronic plaque psoriasis. J Eur Acad Dermatol Venereol. 2015;29(9):1763–70.
    




52. 
    Ghislain PD, Conrad C, Dutronc Y, Henneges C, Calderon DS, Vincent M, et al. Comparison of ixekizumab and ustekinumab efficacy in the treatment of nail lesions of patients with moderate-to-severe plaque psoriasis: 24-week data from a phase 3 trial. Abstract 1827; 2017 ACR/ARHP Annual Meeting; 2017 November 3–8. San Diego, CA; 2017.
    




53. 
    Van de Kerkhof P, Guenther L, Gottlieb AB, Sebastian M, Wu JJ, Foley P, et al. Ixekizumab treatment improves fingernail psoriasis in patients with moderate-to-severe psoriasis: results from the randomized, controlled and open-label phases of UNCOVER-3. J Eur Acad Dermatol Venereol. 2017;31(3):477–82.
    




54. 
    Leonardi C, Maari C, Philipp S, Goldblum O, Zhang L, Burkhardt N, et al. Maintenance of skin clearance with ixekizumab treatment of psoriasis: three-year results from the UNCOVER-3 study. J Am Acad Dermatol. 2018;79(5):824–e2.
    




55. 
    Pinter A, Bonnekoh B, Hadshiew IM, Zimmer S. Brodalumab for the treatment of moderate-to-severe psoriasis: case series and literature review. Clin Cosmet Investig Dermatol. 2019;12:509–17.
    




56. 
    Elewski B, Rich P, Crowley J, Foley P, Wu T, Reyes-servin O, et al. Risankisumab profile in nail, scalp and palmoplantar psoriasis: efficacy and safety at weeks 52 in an integrated analysis of patients of moderate to severe plaque psoriasis. Abstract Presented in the 5th World Psoriasis & Psoriatic Arthritis Conference 2018; 2018 June 27–30. Stockholm, Sweden; 2018.
    




57. 
    Ismail FF, May J, Moi J, Sinclair R. Clinical improvement in psoriatic nail disease and psoriatic arthritis with tildrakizumab treatment. Dermatol Ther. 2020;33(2):e13216. Epub ahead of print.
    

Author Contacts

Dr. Stamatios Gregoriou

Hospital for Skin Diseases

PhD “A. Sygros”

5 I. Dragoumi St. GR–16121 Athens (Greece)

[email protected]

Article / Publication Details

First-Page Preview

Received: January 25, 2020
Accepted: March 13, 2020
Published online: April 30, 2020

Issue release date: June 2020

Number of Print Pages: 8

Number of Figures: 0

Number of Tables: 1

ISSN: 2296-9195 (Print)
eISSN: 2296-9160 (Online)

For additional information: https://www.karger.com/SAD

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Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.

Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.

Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

90,000 Nail psoriasis, toenail psoriasis treatment in Rostov-on-Don

01.12.2017

Nail psoriasis is a fairly common non-infectious disease. The reason for its development is a malfunction of the immune system, or a violation of the hormonal background. Without professional medical treatment, the disease progresses, therefore, after the detection of symptoms, you should immediately consult a doctor, and not self-medicate.

Symptoms

Depending on the form and stage of psoriasis, it can manifest itself in different ways.The most common signs are:

• Changing the shade of the nail plate.
• Peeling of the skin around the nail.
• Yellow spots.
• Bruises under the nail plate.
• Constant itching of the skin around the nails.
• Thickening of the nails.
• Roughness.
• Deepening.

The sensitivity of the nails increases.They react painfully to high and low temperatures.

The plates gradually peel off from the soft tissues. In the last stages, they can completely separate. It does not hurt, but it does cause discomfort.

Treatment

To receive quality medical care, you should contact a clinic with a good reputation and qualified specialists. Medical center “PF Clinic” specializes in diseases of nails and feet and fully complies with these requirements.

Treatment of psoriasis is carried out in a comprehensive manner. The technique is selected individually for each patient, taking into account all the features. It is impossible to completely get rid of the disease, since it has a chronic form. But you can achieve lasting remission.

Treatment begins with the use of topical preparations – ointments and creams. They help relieve puffiness and itching. If they do not bring any result, then a decision is made on the appointment of therapeutic treatment.It involves the use of medications that help to normalize hormonal levels and strengthen the body’s protective functions.

It is recommended that the affected nails be trimmed short and that any type of manicure be abandoned. Before each use, the scissors must be disinfected to prevent infection. In case of infection, pain relievers are prescribed.

Be sure to use vitamins containing:

• Zinc.
• Silicon.
• Iron.
• Calcium.

With the help of physiotherapy, cell growth and division are slowed down. Ultraviolet radiation is used more often. The number of procedures required is determined by the doctor.

If psoriasis affects your toenails, it is recommended to replace your shoes with a new one. It needs to be disinfected regularly so that the fungus does not spread. It is better if it is one size larger.Since it is highly undesirable mechanical impact during the progression of the disease.

Correction of the usual way of life is required. You should protect yourself from stressful situations. Refuse to use alcoholic and tobacco products. And also too spicy and fatty foods. It is recommended to consume as much fresh fruits, vegetables and herbs as possible. They contain many beneficial vitamins and minerals.

Lack of professional treatment threatens with various complications, and the spread of the disease throughout the body.Therefore, it is imperative to seek help from specialists. Following the doctor’s recommendations, it will be possible to achieve a stable remission and exclude the possibility of relapses.

How to treat psoriasis at home

Psoriasis, or in another way scaly lichen, is a real mass problem of our time. Its outward manifestation repels others and brings the patient a lot of discomfort and health problems. It is accompanied by damage to the skin, nails, joints, while itching of varying degrees is felt.It is extremely dangerous for pregnant women, since some of its forms can affect the fetus and lead to miscarriage.

The negative effects of psoriasis are not limited to external manifestations and itching. Among other things, it affects the joints, especially the spine and tendons, negatively affects the endocrine system, causing hormonal disruptions. Affects cells of the kidneys, liver and thyroid gland.

Causes of the disease

Psoriasis provokes a combination of external and internal indicators.For the onset of the disease, a combination of several of them is necessary. Among the factors provoking the disease are:

• External stimuli. Constant contact with household chemicals, cosmetics and alcohol-containing substances. This negatively affects the protection of the skin by natural mechanisms and provokes various diseases.
• Heredity. Genes that are responsible for the functioning of the immune system, in particular the action of T-lymphocytes, are carriers of the disease.
• Thin dry skin.In people with oily, moist skin, the disease manifests itself much less frequently.
• Allergic eruptions.
• Inclination to excessive hygiene. Washcloths, detergents that we use when we shower or wash our hands, wash away the skin’s natural barrier and can cause micro-trauma.
• Traumatic effects on the skin.
• Alcohol abuse, smoking and drug addiction.
• Stress or climate change.
• HIV, infections reduce immunity and can provoke psoriasis.
• Certain medicines, especially antidepressants and anticonvulsants.

By its nature, psoriasis is not an infection. There is no specific pathogen that can be transmitted to another person, so it is not contagious.

Characteristic signs of psoriasis

The main clinical manifestation of psoriasis: papule (area that rises above the general skin), which is covered with loose scales. It can be from pink to deep red.Over time, they merge, affecting large areas of the body. The scales are easily removed, since they consist of keratinized parts of the epidermis, alternating with an air gap.

Plaques on the scalp do not affect the hair follicles, so they can often be confused with common dandruff. But the papules rise significantly above the skin.

The nail plate is affected in two types:

1. Thimble. Small pits form, similar to needle pricks.
2. By the type of onychomycosis. The manifestations are similar to a fungus. The plate changes color, exfoliates and thickens.

Symptoms change depending on the stage, accompanied by itching of varying intensity. They are able to replace each other for many years.

What are the stages of psoriasis?

There are three stages that form a cyclic circle:

1. Disease progress. New foci are actively formed and existing ones grow. This is accompanied by intense itching and flaking.
2. Stationary. The rash is crusty and the signs of inflammation disappear. Itching and peeling are relieved, but do not disappear, the skin becomes rough.
3. Regressive. Papules acquire a healthier appearance and appear on healthy skin with slight redness. Itching stops. There is also no formation of new lesions and flaking.

Manifestation on the body

Manifestations of psoriasis are most often noted on the flexion areas of the body: elbows, knees, abdomen, lower back, neck and groin.But the manifestation is not excluded in other areas. This preference is associated with an increased effect on the skin: friction during bending.

No less rare are papules on the scalp, feet, palms and nails. This is also due to the frequent and intense exposure to the skin.

Is psoriasis contagious?

Looking at the patient, the question of the contagiousness of the disease arises involuntarily. As mentioned earlier, the cause of psoriasis is not an infectious factor.The disease is provoked by the body’s own immune system. Therefore, the patient is completely safe for others. No contact contributes to the transmission of psoriasis.

The patient’s relatives, who are in close contact with him, use the same hygiene products and are completely safe.

Treatment and prevention of disease

It is very important to keep the disease under control. Getting rid of psoriasis is difficult, but with proper and regular care, it is possible.

At home, the maximum effect can be achieved with the help of ultraviolet emitters “Sun”.

Ultraviolet lamp for psoriasis:

• helps to reduce psoriatic foci;
• reduces the toxicity of drugs;
• reduces the duration of pharmacological therapy.

Contraindications for the use of ultraviolet emitters:

• individual intolerance;
• pronounced natural pigments on the skin;
• pregnancy and lactation;
• tumor diseases;
• systemic blood diseases;
• pathology of the development of the kidneys or liver.

In other cases, scientists note the high effectiveness of this method of treatment. Before use, be sure to consult with a specialist.

The market leader is the Solnyshko ultraviolet irradiators, which not only relieve symptoms, but also help fight the disease. In particular, OUFK-03 and OUFK-05 devices are suitable for the treatment of this disease – they have an immunostimulating and anti-inflammatory effect.

90,000 Treatment of nail psoriasis in Moscow – treatment of nails on hands and feet in the MedNail clinic

Cost of nail psoriasis treatment *

* The volume of services is determined by the doctor individually in each case

Nail psoriasis is a form of psoriasis in which the nails on the hands and feet are affected.It is important to note that in 30% of cases, psoriatic arthropathy (changes in the joints accompanied by pain) is added to psoriatic nail changes. Often, nail psoriasis occurs along with the vulgar form of psoriasis (skin rashes).

How to suspect psoriatic onychodystrophy?

There are several objective signs characteristic of this pathology:

• symptom of “subungual splinters” – black longitudinal lines under the nails
• “oil stain” symptom – rounded yellow spots
• onycholysis (detachment of the nail plate from the nail bed)
• thimble symptom

Important! Psoriasis has a chronic recurrent course and seasonal exacerbations are often noted, which means that most often nail changes disappear in winter and summer, and become aggravated in autumn and spring.Also, such changes can occur or intensify against the background of nervous stress, and improvements are noticeable at sea and on vacation. Often, recurrent exacerbations begin with pain and tingling sensation in the area of ​​the nails.

Psoriasis is a genetically determined disease. The patient often has a family member who has been diagnosed with psoriasis.

The diagnosis of psoriasis is made only after the exclusion of other pathologies that can cause such changes in the nails and a careful history taking.

Treatment of nail psoriasis

There is an opinion that it is impossible to help a patient with psoriasis, but it is not. Treatment of psoriasis on the nails of the hands and feet (or rather, achieving a stable remission) is quite realistic, however, it requires an integrated approach and the active involvement of the patient in the process:

• At the appointment, the doctor will give advice on changing lifestyle and nutrition.
• It is necessary to choose the right multivitamins, taking into account diet and physical activity.
• Learning how to properly care for nails with minimal trauma or regular care by a specialist is a very important component of preventing relapse.
• In the treatment can be used hormonal and other creams and ointments. In some cases, it is recommended not external, but local injection of drugs and the use of physiotherapy.
• Systemic treatment of psoriasis: PUVA therapy, systemic drugs, including the most modern biological therapy.
• Treatment of complications. With psoriasis of the nails, a secondary infection often joins, most often a fungal infection. For example, psoriatic onychodystrophy is often manifested by onycholysis (detachment of the nail from the bed), fungal spores can enter the cavity formed, for which there are all favorable conditions for reproduction.

It is important not to delay the visit to the doctor if there are changes in the nails, so as not to aggravate the situation. And remember – the treatment of psoriasis of nails on the hands and feet is quite possible!

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Psorix was advised to me on one of the popular medical forums.I thought for a long time whether to order it: I doubted that drugs from the Internet could bring any benefit. However, after rereading the reviews about this tool, and making sure that there are no negative ones among them, I decided to take a chance. I do not regret my decision, with the help of drops and gel I eliminated all the symptoms of the disease in a week and a half. I am planning to buy another complex for my grandmother, I am sure that it will help her to cope with psoriasis.

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Psorix exhibits antihistamine, anti-inflammatory and wound healing activity.Psorix has incorporated the properties of drugs of several groups – retinoids, antiallergic tablets, non-steroidal anti-inflammatory drugs.

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The specialists of the manufacturing company claim that testing of Psorix oil for psoriasis showed almost one hundred percent effectiveness of the drugs they created. Positive reviews about the miraculous properties of Psorix products are constantly found on the net. The natural composition suggests that they really work and help get rid of diseases.

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In order to place an order for PEGANO psoriasis treatment read, you must leave your contact information on the site. The operator will contact you within 15 minutes. Will clarify all the details with you and we will send your order. In 3-10 days you will receive the parcel and pay for it upon receipt.

Customer Reviews:

Marina

Psoriasis is a very serious disease that has tormented me for many years.Where she came from, I did not fully understand and could not, the doctor said that most likely it was something nervous, but I doubt it. My treatment, and one can even say the cure of the disease, since the result, if there was, then not long, lasted several years. Then by chance I read an article on the Internet about this drug and decided to try it. I bought it in the form of an ointment, ordered it via the Internet. And after two weeks of use, I noticed a positive result, before this such a clear improvement I did not observe.The only bad thing is that the drug is sold in a small package.

Elena

The course administration of Psorix reduces inflammation in the skin, eliminates the main signs of scaly lichen.

Psorix works best in the early stages, reducing inflammation, itching and pain. Where to buy pegano psoriasis treatment read? The specialists of the manufacturing company claim that testing of Psorix oil for psoriasis showed almost one hundred percent effectiveness of the drugs they created.Positive reviews about the miraculous properties of Psorix products are constantly found on the net. The natural composition suggests that they really work and help get rid of diseases.

John Pegano, in Treating Psoriasis – The Natural Way, insists that psoriasis is curable and lays out a comprehensive approach that has made thousands of patients cured. The article describes the principles and basic steps of the method. Dr. Pegano’s book “Treating Psoriasis – The Natural Way” firmly convinces me that he has achieved phenomenal success in the art of healing – the most humane of human affairs.It deserves worldwide recognition. Treating Psoriasis – The Natural Way John Pegano, Chapter 6 Is Diet Deviation Allowable? Yes, but only occasionally and only when the regime as a whole has begun to produce undeniable results. You must give time to the regimen to cleanse the body. ◫ Treatment of psoriasis. The natural way John Pegano ◫ Download a free book in fb2, epub, rtf, txt formats from the LifeInBooks.net portal. … Psoriasis Treatment – The Natural Way by John Pegano, download, read online. John Pegano Psoriasis Treatment.The natural way The author sees the cause of psoriasis and eczema in the condition of the intestines. Due to disturbances in its walls, toxins `seep` into the circulatory and lymphatic systems (` leaky gut syndrome`). At some point, the liver and. John Pegano – Psoriasis Treatment. Natural poo. … I am currently reading a book by Pegano. I want to start soon. May God help. … To be honest, his book scares me! I didn’t know that the hair falls out from psoriasis and you can easily become bald, you cannot paint, you cannot eat anything.Well, I don’t know, maybe psoriasis. Psoriasis is a serious dermatological disorder that requires medication and proper nutrition. What is the Pegano diet for psoriasis? What are its features and principles? Book Psoriasis Treatment. The Natural Path from Dr. John Pegano is considered the bestselling among the manuals on. John Pegano is an American osteopath who has studied psoriasis for 30 years. The doctor put his works and recommendations for treatment into his book, which is called Treatment.If you don’t like reading long reviews, but want to know if you need John Pagano’s book “Psoriasis Treatment – The Natural Way”, my answer is definitely YES! And the sooner you read it, the better for you and your loved ones.

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Psorix exhibits antihistamine, anti-inflammatory and wound healing activity. Psorix has incorporated the properties of drugs of several groups – retinoids, antiallergic tablets, non-steroidal anti-inflammatory drugs.

pegano psoriasis treatment read

Psorix was advised to me on one of the popular medical forums. I thought for a long time whether to order it: I doubted that drugs from the Internet could bring any benefit.However, after rereading the reviews about this tool, and making sure that there are no negative ones among them, I decided to take a chance. I do not regret my decision, with the help of drops and gel I eliminated all the symptoms of the disease in a week and a half. I am planning to buy another complex for my grandmother, I am sure that it will help her to cope with psoriasis.

Classification of nail psoriasis. Nail psoriasis can manifest itself in various forms and have different symptoms. … External preparations (ointments, creams). With external remedies, as a rule, the treatment of nail psoriasis begins.With a mild degree of development of symptoms, it is quite possible to cope. Ointments for nail psoriasis. To treat psoriasis on the nails of the hands with a mild form is good with ointments. … The progression of psoriasis is slowed down by a special cream Psorkutan, saturated with D-vitamin. It is not used for disorders of calcium metabolism, it can also not be used in conjunction with salicylic acid. We treat psoriasis of nails with ointments and creams. Treatment of nail psoriasis is carried out in a comprehensive manner, taking into account the volume and type of skin and joint lesions. Local, oral agents, diet, vitamin therapy are used to achieve remission.Let’s take a closer look at the effective course in more detail, literally step by step. Psoriasis on the nail plates is less common than on the skin. With this disease, the nails are severely deformed, have an unaesthetic appearance. For treatment, special medicines and physiotherapy are used. Content. Treatment of psoriasis of the feet. Psoriasis is a very common disease that affects hundreds of thousands of people around the world. To combat it, various ointments for psoriasis are produced, which help, if not cure the disease.Treatment for nail psoriasis should be comprehensive. Therapy includes the use of medication. Creams and ointments penetrate well into the structure of the plate, reliably relieving a person of the symptoms of pathology. Consider several popular medications: Daivonex. Nail psoriasis is an atypical condition. … Zinc ointment acts as an antimicrobial agent in the treatment of nail psoriasis. … If ointments, creams and solutions do not work, then the treatment is supplemented with tablets and injections.These are strong glucocorticoids, immunosuppressants. One of the rare forms of psoriasis is nail psoriasis. Damage to the nail plate can be stopped by applying. Psoriasis of nails – treatment of chronic skin pathology. Nail psoriasis (onychodystrophy, onychia) is diagnosed in 7% of patients with a history of chronic skin pathology. Treatment of nails on the hands is carried out with hormonal creams and ointments, of the antipruritic ones, they are the most effective. Each nail psoriasis varnish contains trace elements and vitamins.Also, such varnishes can be used to treat psoriasis on toenails, after having performed hygienic procedures. Preparations in.

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ASD fraction of psoriasis treatment Nail psoriasis is a special form of psoriasis in which the nails on the hands and / or feet are affected.Causes and mechanism of development of nail psoriasis. In its course – with periodic exacerbations and remissions – psoriasis on the nails resembles a vulgar form of the disease. It is believed to be psoriasis. Diagnosis of nail psoriasis. The causes of psoriasis on the nails. Complications and consequences. Nail psoriasis is a dangerous disease that, in the absence of adequate treatment, can lead to severe (or irreversible) consequences. Therefore, it is important to find the characteristic ones in time. Psoriasis is an autoimmune disease, that is, the cause of a skin rash lies in a negative perception of the immune system of cells.Treatment of nail psoriasis in children. Psoriatic onychodystrophy in a child manifests itself more acutely and is more difficult to tolerate, therefore, if suspicious symptoms appear, it is necessary. Symptoms of nail psoriasis (photo) and treatment. Why does this pathology arise? Symptoms of psoriasis on the nails – photo. Types and stages of development of nail psoriasis. Why is it important to treat nail psoriasis. Nail psoriasis is considered an independent non-infectious disease. However, in 80-90% of cases, it develops as a result of skin lesions or psoriatic arthritis.1 Causes of psoriasis on the nails. 2 Diagnosis of nail psoriasis. Methods for the treatment of nail psoriasis. The question of how to cure psoriasis on nails sooner or later arises in front of a person who is faced with an ailment. Symptoms and treatments for nail psoriasis. Causes of nail psoriasis. Until now, scientists have not been able to accurately figure out the etiology of onychodystrophy, however, one of the main reasons for the development of the disease is considered a failure in the immune system. Violation leads to wrong. Nail psoriasis is a non-contagious skin condition.It is often confused with a fungal disease. The test results will help the doctor make an accurate diagnosis of the disease and prescribe treatment. Treatment of nail psoriasis: effective methods. Is there psoriasis on the nails? Research continues on the causes of the development of damage to the nail plates. Individual treatment is selected depending on the form of nail psoriasis. In children. The therapy takes several years. treatment of psoriasis in yaroslavl patient reviews monoclonal therapy for psoriasis acquired psoriasis treatment

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I have had psoriasis for as long as I can remember and what have I not tried in my life to get rid of it all in vain.Even the expensive pills with which I put my stomach and liver by the way gave a temporary result. My immune defenses weakened when I got the flu and psoriasis reappeared. I had no illusions about the use of this drug, to a greater extent I was attracted by the price and natural composition. And the use of this drug made it possible to get rid of psoriasis, I want to believe that there will be no return. Similar medicines are categorically contraindicated for pregnant and lactating women and children.They should not be consumed by people suffering from chronic diseases. These drugs are chemically or hormonal in nature. They have a destructive effect on the endocrine system, on the processes of hematopoiesis, on the state of internal organs. To forget about psoriasis once and for all, in addition to treatment with a natural complex, you should give up bad habits, pay attention to a healthy lifestyle and a balanced diet. Exercising will also have a positive effect on the body and will allow you to achieve results in the fight against psoriatic plaques.The natural way – characteristics, photos and customer reviews. The author sees the cause of the origin of psoriasis and eczema in the condition of the intestines. Based on more than 30 years of practice, Dr.Pegano recommends a drug-free regimen based on bowel cleansing, diet, herbal teas. Dr. Pegano’s book Treating Psoriasis – The Natural Way firmly convinces me that he has achieved phenomenal success in the art of healing – the most humane of human affairs. It deserves worldwide recognition.Purchase the book Psoriasis Treatment. The natural way at the best price. Download the electronic version. Based on more than 30 years of practice, Dr. Pegano recommends a drug-free regimen based on bowel cleansing, diet, herbal teas and spine therapy. John Pegano Psoriasis treatment is the natural way. In the publishing house KUDITS-OBRAZ, edited by Corresponding Member of RAEN, Doctor of Medical Sciences prof. Korotkiy N.G. the book of Dr. John Pegano was published Treatment of psoriasis – the natural way (circulation 10,000 copies. Treatment of psoriasis – the natural way.Special chapter on eczema. John A. Pegano. The author sees the cause of the origin of psoriasis and eczema in from 453. Treatment of psoriasis – the natural way: a special chapter vol. So how has the book Psoriasis Treatment – The Natural Way influenced me, what’s so special about it ?. All of them have one thing in common – clear skin after following the recommendations of Dr. Pegano. Someone took a couple of weeks, some months. John PEGANO Psoriasis Treatment The Natural Way. Category: Psoriasis in children by doktor. According to the observations of Dr. Pegano, a frequent occurrence during treatment is an unexpected exacerbation of the disease, sometimes mild and sometimes.John Pegano, in Treating Psoriasis – The Natural Way, insists that psoriasis is curable and lays out a comprehensive approach that has made thousands of patients cured. The article describes the principles and basic steps of the method. Psoriasis treatment is a rather complicated multi-stage process. Renowned doctor John Pegano believes that the natural way to get rid of this disease is to normalize bowel function. Book: Treating Psoriasis – The Natural Way. a special chapter on eczema. Based on more than 20 years of practice, Dr. Pegano recommends a drug-free regimen based on bowel cleansing, diet, herbal teas and spine therapy.Correct thinking of the patient also. If you want to permanently get rid of psoriasis naturally according to John Pagano’s system, get ready to follow a strict diet. You can always download it online or buy a paper version from a bookstore. John Pegano has developed a special list of products that. Treating Psoriasis – The Natural Way, Dr. John Pegano, Osteopathic Physician. This book has been a bestseller for 18 years. The Pegano diet for psoriasis is aimed at treating a person by completely revising the nutritional system, due to which, toxins leave the body, the skin is cleansed.The doctor claimed that. Buy the book Treatment of psoriasis. The natural way at favorable prices wholesale and retail you can visit us. Date of first edition Psoriasis Treatment – The Natural Way: January 2001, latest 3rd edition published August 2010. Annotation. Reviews.

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Since the Psorisil formula contains a large amount of oils, extracts and extracts of plants, the composition works in a complex way and works in several directions at once. Thanks to this, not only the aesthetic component associated with psoriasis is solved, but also the internal causes of the exacerbation of the disease are eliminated.Bay leaf for psoriasis is one of the means by which you can cure psoriatic plaques and prolong periods of remission. Useful properties of the product. Treatment of psoriasis with bay leaves has become large. Content. Bay leaves in folk medicine. Oil infusions. Compresses. How does laurel leaf affect the disease? Indications for use. How is bay leaf applied? Bay leaf with psoriasis of nails. Reviews. Recipes. 20 grams. Compresses. Conclusion. Bay leaf is a natural product and can be used in several ways.The most famous recipe for treating psoriasis with bay leaves is the use of a folk recipe – 20 grams of lavrushka. 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How to use bay leaves for psoriasis. A decoction for bathing. Application methods. Infusion. Lotions. Oil infusion. Treatment of psoriasis in the early stages of development with bay leaves brings a positive result. Bay leaf oils can be used to treat psoriatic plaques. Reviews about this tool are mostly positive. So this method of treatment really can.Bay leaf for psoriasis is the basis of many folk recipes. Treatment of psoriasis with bay leaves is carried out at home, and what are the components of the remedy. You can find out in the article! Bay leaf in psoriasis reduces the severity of the main symptoms of the disease. Contraindications to the use of a medicinal plant. Treatment of psoriasis with bay leaves is contraindicated in the presence of the following pathologies: duodenal ulcer; elevated level. How much does bay leaf help with psoriasis?The article contains the most. When studying reviews of bay leaves used for psoriasis, you can. Treatment of psoriasis with one bay leaf will not bring the desired result, since the disease needs to involve different groups and forms. psoriasis on nails causes and treatment . monoclonal therapy for psoriasis. Reviews, instructions for use, composition and properties. Treatment of psoriasis with folk remedies with soda can be in the form. Usually, the course of treatment lasts from 10 to 14 days. Dirt is applied to the body, you can not.Next, we will figure out how to treat psoriasis with folk remedies using a decoction of herbs. For cooking, you will need to pour 2 tbsp. l. herbs. Why does psoriasis occur? Literally translated from Greek, psoriasis is itchy skin. The disease is one of the oldest ailments and is chronic. Folk remedies for psoriasis on the body are becoming more and more popular today. Having lost faith in the effectiveness of many synthetic drugs. Treatment of psoriasis with folk remedies is carried out using mud and clay, which.To treat psoriasis on the scalp, you can use essential oils that are rubbed into the skin. Folk remedies for psoriasis on the body in the form of herbal medicine have long proven themselves on the positive side, but before. Treatment of psoriasis with folk remedies refers to the methods of alternative medicine. With the right choice of homemade ointments, tinctures and decoctions, most patients note a positive trend. In reviews of the treatment of psoriasis with folk remedies, burdock is often mentioned. To prepare healing compresses, you will need a decoction of burdock roots.You can buy them at the pharmacy or get them yourself by picking the plant on the street. Separate them from the stems and leaves, rinse thoroughly, dry. Methods for treating psoriasis at home. 4651. Psoriasis: causes, symptoms, home treatment, advice to patients with psoriasis, patient reviews on the treatment of folk remedies. Treatment of psoriasis with folk remedies. Psoriasis or, as it is called in the common people, lichen scaly is a skin disease characterized by the appearance of reddish plaques on the body.Moreover, unlike most other skin diseases, psoriasis is absolutely not contagious. Methods for treating psoriasis with folk remedies on the head and hands. Recipes and tips for use. There are folk remedies for the treatment of psoriasis, used at the initial stage of the manifestation of symptoms on the body.

90,000 Nail psoriasis home treatment video

Psoriasis is a skin disease that affects not only the skin of the body, but also the nail plate.The percentage of people suffering from a similar problem is 7%. Psoriasis of the nails is accompanied by certain symptoms, which will be discussed below.

Nails affected by psoriasis

Symptoms of the disease

The first description of psoriasis on nails was recorded already in the 19th century. In those days, diagnosing the disease was quite problematic. The only thing that scientists could determine at that time was that psoriasis was a non-infectious disease.They turned out to be right and the hypothesis that the disease proceeds in an isolated form has been confirmed in our time. Psoriasis of the nails can be one of the symptoms of the skin form of the disease, and also be a completely independent lesion of the nails.

The disease manifests itself in a very diverse way, but the following external manifestations can be attributed to the most common symptoms:

1. Thimble lesion of the nail plate. Small dents appear on the nails, resembling dots in shape.
2. Hemorrhage under the nail plate.
3. Changes in the external structure of the nail plate – trachyonychia.
4. Separation of the nail plate from the nail bed – onycholysis.

Each of these symptoms should be considered separately.

Depressions on nails with psoriasis

The first symptom is the most common manifestation of psoriasis on the nails. The disease disrupts the correct development of the nail, which leads to the appearance of pinpoint indentations on the nails .The pits have different shapes and are randomly located on the nail plate. The diameter of the depressions is small and is approximately 0.5-2.0 mm. The nail really takes the form of a thimble.

Hemorrhages under the nails are of two types. In one case, spots of various diameters are formed in the subungual space. The color of hemorrhages can range from red to pink. The second type of this symptom manifests itself in the form of red, brown, and sometimes black hemorrhages in the form of stripes.Such changes are the result of rupture of the capillaries under the nail plate.

In people with psoriasis, another pathology can be observed – trachyonychia . The nail plate loses its natural color and begins to peel off. A faithful companion of this pathology has become such a disease of koilonychia, in which the shape of the nail becomes first flat, and then completely concave.

This is what trachyonychia looks like on nails

Another symptom of psoriasis is the separation of the nail from the skin.Pathology is gradual and painless. Onycholysis is partial and complete. There are no inflammatory reactions. The nail plate can begin to peel off both in the central part and starting from the free edge of the nail. In the formed voids, dirt, dust and epidermis are often clogged. It is this mass under the nails that in most cases is the cause of the unpleasant odor.

It looks like onycholysis on nails

Why does psoriasis occur on the nails?

There can be many prerequisites for the development of the disease.These can be infectious diseases that disrupt blood circulation in the area of ​​the nail plates. Problems with the immune system and hormonal disruptions can give a start for the development of psoriasis. Frequent stress leads to metabolic disorders, which in the future can also cause the development of the disease. Finally, psoriasis can be a hereditary disease embedded in the genetic code.

Treatment of nail psoriasis at home

Psoriasis of the nails is a disease that has to be treated for a long time and persistently.The disease is very persistent and its treatment requires strict adherence to all medical prescriptions. Regardless of what form of psoriasis occurs, do not forget that the disease cannot be completely cured. Like any chronic disease, nail psoriasis requires daily care of the affected areas.

A few simple rules will greatly simplify the treatment of psoriasis. First, you need to cut shortly the nail plates on your hands or feet. You should be more careful and protect your nails from injuries, even minor ones.You will also have to say goodbye to salon procedures. Manicure, pedicure and all kinds of extensions should be forgotten like a bad dream.

Well, the last recommendation is to do any housework with gloves.

It is necessary to treat nail psoriasis in a comprehensive manner. The disease develops from the inside and therefore the treatment should be appropriate. The main recommendation of doctors will be to take a vitamin complex enriched with trace elements such as calcium, silicon, zinc and potassium.The drugs should be taken only as directed by a doctor, because with individual intolerance to any of the microelements, there may be a deterioration in health.

Also, taking medications is strictly prohibited during an exacerbation of the disease.

Baths for nails with psoriasis

With regard to the mild form of psoriasis of the nails, then medication is not required. There are many medicated varnishes that hide external defects and also prevent the recurrence of the disease.Varnishes significantly slow down the development of destructive processes. Therapy in this case can be three months.

Treatment of psoriasis at home is also possible. Just remember an important rule – do no harm. Treatment must be safe. So, in case of itching, you can take medications for allergies. To prevent the destruction of the nail plate, trays with herbal decoctions are recommended. For medicinal baths, plants such as sage, calendula or chamomile are perfect.It is very simple and convenient to do this procedure at home. Rubbing any oil into the nail plate should become a daily habit. It can be corn oil, sesame oil, olive oil, or even sunflower oil.

Can nail psoriasis be treated with folk remedies?

Alternative medicine can be adopted as an adjunct treatment for psoriasis. Home nail treatment mainly relies on herbal medicine. It is not prohibited to treat psoriasis with drugs.Home treatment with herbs helps to simulate the immune system, heals lesions and relieves existing inflammation. For internal use, you can take note of herbal decoctions. A series, elecampane, nettle and St. John’s wort can be used in the form of decoctions even during drug treatment.

For external treatment, you can use folk recipes. For example, a bowl that contains cornstarch or oatmeal. To prepare it, it is necessary to dissolve flour or starch in water and immerse the affected nail plates in the resulting mixture.The procedure can be considered complete as soon as the contents of the bath have cooled down.

Nail psoriasis is a serious disease and therefore it is not recommended to postpone its treatment. The sooner you start treating the disease, the less problems it can cause later. Be healthy.

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traditional nail psoriasis treatment

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What is the alternative treatment for nail psoriasis?

I got psoriasis on nerves.The story is long, I will not describe it. As a result, it got to the point that I had to quit my job and heal my nerves. The diagnosis of psoriasis was not made right away, they were treated as always, at random, by trial and error. The disease progressed, it was finally diagnosed only after 6 years. And then I got hooked on hormone therapy. Firstly, this is just crazy money, and secondly – a waste of time and another undermining of health. While using hormonal ointments and pills, there is some relief.One has only to take a break – the disease manifests itself with renewed vigor, plus withdrawal syndrome. I despaired and decided that there was no such force that would help me get rid of my trouble. My daughter read about Psorix somewhere, we decided to buy the drug, not really hoping for a miracle. According to the principle “will not help, so at least we will try.” I was bribed by the naturalness and organic origin of the components and I decided that it would definitely not be worse from taking it. They did not risk it and ordered it right away on the official website (during the treatment I got burned more than once on all kinds of fakes).I applied the cream and drops at the same time. This is a little inconvenient, which should be used in combination – sometimes, I confess, I forgot to drink a drop. And the taste of the drops is not very pleasant. A week later, to be honest, there was no result and I wanted to quit treatment. But my daughter convinced me to take the course to the end, since they bought it. After a month of admission, the result was evident. Not only did my hands look completely different outwardly, but my general condition came back to normal. I got rid of intestinal dysfunction, my blood pressure returned to normal and depression disappeared somewhere.I do not know if I managed to completely get rid of psoriasis, but I do not observe new manifestations (only 3 months have passed) and I plan to take a course of drops as a preventive measure.

Effect of traditional treatment of nail psoriasis

Psorix for psoriasis is an absolutely organic remedy consisting of medicinal plants, oils and other natural ingredients. It is produced recently, but has already won the trust of a large number of consumers.Russians choose Psorix because it has the following advantages: it is not addictive; has no side effects; suitable for almost all people; sold at an affordable cost.

Expert opinion

Psorix for psoriasis is an absolutely organic remedy consisting of medicinal plants, oils and other natural ingredients. It is produced recently, but has already won the trust of a large number of consumers. Russians choose Psorix because it has the following advantages: it is not addictive; has no side effects; suitable for almost all people; sold at an affordable cost.

How to order

In order to place an order for folk treatment of psoriasis of nails, you must leave your contact information on the site. The operator will contact you within 15 minutes. Will clarify all the details with you and we will send your order. In 3-10 days you will receive the parcel and pay for it upon receipt.

Customer Reviews:

Nika

If you have tried all the remedies for the treatment of psoriasis and nothing has helped you, I recommend buying the Psorix remedy for psoriasis.Light in texture, easy to use and most importantly effective remedy Psorix. For many years I suffered from psoriasis plaques, nothing had a long-term effect, even the use of hormonal drugs made the disease easier for a very short time. Having bought Psorix, I was also skeptical about it, because the completely herbal composition did not make an impression on me, I tried many different herbal preparations, but there was no effect from them. From this oil, the plaques immediately stopped itching, and after a month the small ones disappeared altogether, and the large ones significantly decreased in size, stopped peeling off, and the skin began to renew itself.Now I have clean skin for three months. I can safely say that I have found my magic remedy for psoriasis.

Anna

Psorix was advised to me on one of the popular medical forums. I thought for a long time whether to order it: I doubted that drugs from the Internet could bring any benefit. However, after rereading the reviews about this tool, and making sure that there are no negative ones among them, I decided to take a chance. I do not regret my decision, with the help of drops and gel I eliminated all the symptoms of the disease in a week and a half.I am planning to buy another complex for my grandmother, I am sure that it will help her to cope with psoriasis.

Psorix – a dual-action drug: The cream eliminates redness and flaking and makes the skin look aesthetic, Drops penetrates deep into the dermis and stops the inflammatory process from the inside Where to buy alternative treatment for nail psoriasis? Psorix for psoriasis is an absolutely organic remedy consisting of medicinal plants, oils and other natural ingredients. It is produced recently, but has already won the trust of a large number of consumers.Russians choose Psorix because it has the following advantages: it is not addictive; has no side effects; suitable for almost all people; sold at an affordable cost.

Psoriasis of nails is a manifestation of psoriasis, a chronic skin pathology of a non-infectious nature. … Also, folk remedies are used to treat psoriasis of nails at home. In agreement with the doctor, they are used as an addition to the main drugs. Psoriasis of the nails. Scaly lichen affects more than just the skin.In this article we will talk about psoriasis (another name for scaly lichen) of nails and dwell a little on the issues of modern treatment of this disease. Causes of nail psoriasis. Psoriasis of nails is a polyethylene disease, that is, a combination of several factors serves as an impetus for its development. Typically, their role is played by immune disorders and genetic predisposition. A person can be unaware of his own for years. Psoriasis of the nails. This disease is well researched, but it can be difficult to diagnose, especially.In the treatment of psoriasis, folk remedies have become very famous, but they should be resorted to only with the permission of a doctor. Traditional medicine offers treatments. • One treatment for nail psoriasis, especially with matrix lesions, is intralesional corticosteroid injection. Triamcinolopa acetonide (0.4 ml, 10 mg / ml) is injected into the nail bed and matrix after finger conduction anesthesia, then the procedure is repeated with. Psoriasis (squamous lichen) is a chronic, very common skin disease that has been known for a long time.Its prevalence in various countries ranges from 0.1 to 3%. However, these figures reflect only the proportion of psoriasis in patients with other dermatoses or its frequency. Treatment of psoriasis of nails with folk remedies. Well-proven measures for the treatment of nail psoriasis at home. One of the simplest and most effective folk remedies is nail baths. Psoriasis is a chronic non-infectious disease, dermatosis, which mainly affects the skin. The autoimmune nature of this disease is currently assumed.Psoriasis usually causes overly dry, red, raised patches of the skin. However, some. – Psoriasis is a disease, a predisposition to which is transmitted genetically, proceeding. – Today Belarus has all the necessary drugs for the treatment of psoriasis. … We are trying to contain it, but only with folk remedies. I keep her on a strict diet, and every summer and autumn we go to the sea. Psoriasis is a chronic, immune-dependent inflammatory skin disease. … There are folk remedies that supposedly help with psoriasis and are widely advertised – how do you feel about these methods, are they effective? Indeed, celandine is often used, on the advice of friends.
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Psorix for psoriasis is an absolutely organic remedy consisting of medicinal plants, oils and other natural ingredients.It is produced recently, but has already won the trust of a large number of consumers. Russians choose Psorix because it has the following advantages: it is not addictive; has no side effects; suitable for almost all people; sold at an affordable cost.

alternative treatment for nail psoriasis

I got psoriasis on nerves. The story is long, I will not describe it. As a result, it got to the point that I had to quit my job and heal my nerves. The diagnosis of psoriasis was not made right away, they were treated as always, at random, by trial and error.The disease progressed, it was finally diagnosed only after 6 years. And then I got hooked on hormone therapy. Firstly, this is just crazy money, and secondly – a waste of time and another undermining of health. While using hormonal ointments and pills, there is some relief. One has only to take a break – the disease manifests itself with renewed vigor, plus withdrawal syndrome. I despaired and decided that there was no such force that would help me get rid of my trouble. My daughter read about Psorix somewhere, we decided to buy the drug, not really hoping for a miracle.According to the principle “will not help, so at least we will try.” I was bribed by the naturalness and organic origin of the components and I decided that it would definitely not be worse from taking it. They did not risk it and ordered it right away on the official website (during the treatment I got burned more than once on all kinds of fakes). I applied the cream and drops at the same time. This is a little inconvenient, which should be used in combination – sometimes, I confess, I forgot to drink a drop. And the taste of the drops is not very pleasant. A week later, to be honest, there was no result and I wanted to quit treatment.But my daughter convinced me to take the course to the end, since they bought it. After a month of admission, the result was evident. Not only did my hands look completely different outwardly, but my general condition came back to normal. I got rid of intestinal dysfunction, my blood pressure returned to normal and depression disappeared somewhere. I do not know if I managed to completely get rid of psoriasis, but I do not observe new manifestations (only 3 months have passed) and I plan to take a course of drops as a preventive measure.

Psoriasis of the scalp.Psoriasis on the head is an independent disease, but it can. Treat psoriasis in children in the same way as in adults. But in most cases, they stop at local treatment, using glucocorticoid ointments and moisturizers. With severe forms. The recommended duration of treatment is 4 weeks for psoriasis of the scalp and 8 weeks for skin lesions on other parts of the body. The area of ​​application of the drug should not exceed 30% of the body surface. The drug must remain on the skin c.Seborrheic psoriasis of the scalp In most cases, seborrheic psoriasis. 3. Hormonal ointments (Elokom, Locoid) reduce inflammation, reduce itching. With psoriasis in the scalp, it is recommended to rinse the hair with medicinal tinctures. Diagnostics and effective treatment of scalp psoriasis without hormones, ointments and side effects at any stage. … Folk remedies for psoriasis on the head? Can scalp psoriasis be treated with folk remedies? For the treatment of psoriasis, 10–30% naphthalan ointments and pastes are used.Often Naftalan oil is used in. It is convenient to apply combination lotions with corticosteroids and salicylic acid to the scalp. According to domestic authors (G.I.Sukolin, V.A. scalp, but with the progression of the disease, they may appear in. Scalp psoriasis…. During the period of treatment with Xamiol, the patient is advised to limit or avoid excessive exposure to natural or artificial sunlight. Treatment for head psoriasis – shampoos and diet. Cure scalp psoriasis. If psoriasis of the scalp is mild, then. rubbing ointments with topical steroids into the head and in combination with other medications (selected individually strictly according to the doctor’s indications). Comments: For long-term treatment, the daily dose should not exceed 15 g, and the weekly dose should not exceed 100 g of cream or ointment.