By Gary M. White, MD
Psoriasis of the nail bed may manifest itself as onycholysis, oil spots and nail bed thickening. Psoriasis of the matrix results in nail surface pits, leukonychia, longitudinal ridging and rarely, severe thickening. Often, there is an associated redness and scale of the proximal nail fold. Patients may have associated psoriatic arthritis. Sometimes the pitting may be the first manifestation of psoriasis and may occurs as early as in infancy [BJD 1994;130;800]. Pustular psoriasis may rapidly cause separation and/or destroy multiple nails. Many patients are embarrassed by their nail disease.
One review found that 32% of children with psoriasis had nail involvement [PD 2017;34;58]. As in adults, nail psoriasis is closely associated with psoriatic arthritis. The most common clinical findings were pitting (69%) for fingernails and onycholysis (40%) and pachyonychia (28%) for toenails.
Given the growth characteristics of the nail, any treatment should be done for at least 6-9 months to demonstrate efficacy. Tumor necrosis factor inhibitors (e.g. adalimumab and ustekinumab) have the best supporting evidence for efficacy, but are very expensive and the clinical disease must be severe enough to warrant their use. Apremilast in a DBPCT showed significant benefit for nail psoriasis over placebo. Other oral agents such as methotrexate and cyclosporin may help. The evidence for benefit of topical therapy is weak. However, they are often given initially and even as the only option for therapy.
A high potency topical steroid combined with calcipotriol is recommended. If that fails, IL steroids may be done although this can be quite painful. In rare, severe cases of nail involvement only, adalimumab, apremilast, etanercept or other systemic agents may be considered.
Those most frequently recommended are adalimumab, etanercept, and ustekinumab. Secondary choices are methotrexate, acitretin, infliximab and apremilast.
Experts recommend with most enthusiasm the following (highest to lowest): adalimumab, etanercept, ustekinumab, infliximab, methotrexate, apremilast and golimumab [JAMA Derm 2015;151;87].
For psoriasis of the nail bed, clobetasol solution may be applied under the nail BID. This may be augmented by cutting back the nail and/or occlusion. In one study, betamethasone dipropionate plus 3% salicylic acid in an ointment base BID for 3-5 months reduced thickness and hyperkeratosis from 30-50%. In that same study, calcipotriol ointment did just as well [BJD 1998;139;655]. For psoriasis of the proximal nail fold, a class one topical steroid may be applied BID. Alternatively, intralesional kenalog, e.g. 5-10 mg/cc may be injected every 3-4 weeks for up to 4-6 injections. (Pain will be significant. Use a 30-gauge needle and nerve blocks and/or topical anesthetic) One may enter at one point at the DIP joint crease and direct the needle successively to the center and two lateral areas, but never inject into the matrix.
Soak PUVA may be tried for any psoriasis of the nails. The patient can soak just the distal fingers and expose only this area to the light. This approach combined with clobetasol liquid QD has worked wonderfully well in one of this author's patients.
Classic nail pits and onycholysis in psoriasis.
New onset pitting and onycholysis of only 3 nails.
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