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Clinical Updates

Amit G. Pandya, MD

Management of Psoriatic Nails

Amit G. Pandya, MD

Wednesday, February 16, 2011

Psoriatic nails are one of the most difficult management problems faced by dermatologists. Although topical agents and phototherapy are effective for plaque-type lesions of psoriasis, nail disease is usually less responsive to these modalities. The nails are among the most visible parts of the body; therefore, patients with psoriatic nails frequently complain of embarrassment when around others, often hiding their hands from view. Although systemic agents can be effective for nail psoriasis, the risk and cost of systemic therapy may not be justified in patients with mainly nail disease. This Expert Opinion article discusses possible approaches to this vexing problem. 

Nails are affected in the majority of patients with psoriasis at some point in their lives.1 In one study, 58% of patients reported that nail psoriasis interfered with their job, and 52% had pain associated with their diseased nails.2 Common changes on physical examination are pitting and surface ridging, onycholysis, oil spots, yellowish discoloration, thickening, splinter hemorrhages, subungual hyperkeratosis, pustules, and partial or complete loss of the affected nails (Figures 1-4). Although it is possible that only one nail is involved, multiple nails are affected in most patients. The various manifestations of nail psoriasis are a result of inflammation in different parts of the nail unit, including the matrix, nail bed and periungual tissues. The most common symptom is pain, particularly when picking up objects, writing, working with the hands or getting the nails caught on an object during activities of daily living.  
 
 

Figure 1. Pitting of the nail. Image courtesy of DermQuest.com

Because psoriasis can be exacerbated by trauma, owing to the Koebner phenomenon, it is important to avoid excessive manipulation of the nail, eg, removing subungual debris, removing the cuticle or brushing the nail bed. Gloves can be worn to help avoid excessive trauma and water exposure, particularly by those who are exposed to these irritants in their workplace. Emollients are important to moisturize the nail unit and minimize scaling and cracking.3

 

Figure 2. Onycholysis, oil spots, longitudinal ridging and rough surface of the nail plates. Image courtesy of DermQuest.com

Topical treatment with potent steroid formulations, such as clobetasol propionate ointment, may be helpful for some patients, particularly those with erythema and scaling of the periungual skin. Because superficial ridging of the affected nails is usually a result of proximal nail fold disease, topical steroids are particularly useful for this abnormality. Fingernails usually grow at a rate of 3 mm per month; therefore, topical therapy has to be continued for several months in order to achieve maximum benefit. However, prolonged steroid application can result in thinning of the periungual skin; as a result, patients need to be monitored carefully for signs of atrophy. Patients with onycholysis, pitting and subungual hyperkeratosis are more difficult to treat with topical steroids, as the disease involves deeper structures, including the matrix and nail bed. Occlusion can help, but this increases the possibility of atrophy. In general, patients with psoriatic nail disease do not respond very well to topical steroid application. Other agents, such as retinoids, 5-fluorouracil, calcipotriol and salicylic acid, have been used topically, with modest results.4-6


 

Figure 3. Splinter hemorrhages and onycholysis. Image courtesy of DermQuest.com


 

Figure 4. Partial loss of nails and subungual hyperkeratosis. Image courtesy of DermQuest.com

Intralesional steroid injection with triamcinolone acetonide is useful for nail psoriasis.7-10 I prefer placing the injections in the lateral nail folds, with blanching under the nail observed to ensure adequate distribution of the drug. Although inflammation in psoriatic nails is in the matrix, in my experience, injections into the proximal nail fold and matrix may cause atrophy and splitting of the nail, and therefore should be avoided. A syringe (containing a concentration of 5-10 mg/mL triamcinolone acetonide) with a built-in needle to prevent the needle from popping off is most useful when performing this procedure. The injections can be repeated every month for the first few months, and then reduced in frequency as the affected nails improve. Multiple nail abnormalities, including onycholysis, subungual debris, pitting and partial nail loss, can be treated successfully in this way (Figure 5). Baseline photographs are useful for monitoring progress and detecting atrophy. Although injections into the lateral nail folds are painful, the pain can be reduced by using small needles, injecting the solution slowly, and using anesthetic spray or ice prior to each injection.


 
 

Figure 5. (Top) Psoriatic nails at baseline. (Bottom) Psoriatic nails after four monthly injections of the lateral nail folds with triamcinolone acetonide (5 mg/mL).

Several systemic therapies can result in substantial improvement of psoriatic nails. However, nail disease alone is seldom a reason to start systemic therapy unless it is associated with significant physical and/or psychological distress. Each patient must be counseled carefully, and the benefits versus the risks must be presented for each systemic agent contemplated.

Additionally, patients must be informed that a prolonged course of systemic treatment will be required to achieve the maximum benefit, sometimes up to 6 months. Oral acitretin 0.2-0.5 mg/kg/day, cyclosporine 3 mg/kg/day and methotrexate 5-15 mg/week have all been reported to be successful for nail psoriasis.11-14 Biological agents, particularly infliximab, help psoriatic nails when given to patients for generalized psoriasis or psoriatic arthritis.15-22

In one study of 18 patients, infliximab resulted in an approximate 50% improvement after 3 months of treatment, rising to almost 90% after 7 months.19 A small study of five patients treated with a pulsed dye laser every month for 3 months showed substantial improvement, particularly for onycholysis and subungual hyperkeratosis. Pain for 24 hours after each treatment was the major side effect in all patients.23 

The treatments summarized in this article pertain mainly to the fingernails. Unfortunately, toenails are even more difficult to treat than fingernails. Patients with painful toenails may improve with systemic therapy, but the results are not as good as those seen for fingernails. Periodic sanding of thickened toenails can help to improve pain and appearance but, again, care must be taken not to cause irritation to the periungual tissue and nail bed.

Conclusions

Psoriasis causes a variety of changes to the nails. While superficial abnormalities can be treated with topical therapy, most patients have deeper involvement, which requires intralesional or systemic therapy in order to see significant improvement. The benefit/risk ratio must be carefully assessed when considering more aggressive therapy for nail psoriasis.

References

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  3. de Berker D. Management of psoriatic nail disease. Semin Cut Med Surg 2009;28:39-43.
  4. Scher RK, Stiller M, Zhu YI. Tazarotene 0.1% gel in the treatment of fingernail psoriasis: a double-blind, randomized, vehicle-controlled study. Cutis 2001;68:355-358.
  5. Frederiksson T. Topically applied fluorouracil in the treatment of psoriatic nails. Arch Dermatol 1974;110:735-736.
  6. Tosti A, Piraccini BM, Cameli N, et al. Calcipotriol in nail. A controlled double blind comparison with betamethasone dipropionate and salicylic acid. Br J Dermatol 1998;139:655-659.
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  16. Reich K, Nestle, FO, Papp K, et al. Infliximab induction and maintenance therapy for moderate-to-severe psoriasis: a Phase III, multicentre, double-blind trial. Lancet 2005;366:1367-1374.
  17. Rich P, Griffiths CE, Reich K, 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;58:224-231.
  18. Bianchi L, Bergamin A, de Felice C, et al. Remission and time of resolution of nail psoriasis during infliximab therapy. J Am Acad Dermatol 2005;52:736-737.
  19. 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. Br J Derm 2008;159:453-456.
  20. Körver JE, Langewouters AM, Van De Kerkhof PC, et al. Therapeutic effects of a 12-week course of alefacept on nail psoriasis. J Eur Acad Dermatol Venereol 2006;20:1252-1255.
  21. Lamerson C, Stevens G, Sax K. Treatment of nail psoriasis with efalizumab: a preliminary study. Cutis 2008;82:217-220.
  22. Rallis E, Stavropoulou E, Rigopoulos D, et al. Rapid response of nail psoriasis to etanercept. J Rheumatol 2008;35:544-545.
  23. Oram Y, Karincaoglu Y, Koyuncu E. Pulsed dye laser in the treatment of nail psoriasis. Dermatol Surg 2010;36:377-381.
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