Nail Psoriasis: A Review of Treatment Options

Breakthrough Opportunities of Nanotheranostics in Psoriasis: From Pathogenesis to Management Strategy

BACKGROUND

In this paper, we have discussed recent advances in our understanding of the aetiology of psoriasis, particularly as they relate to aryl hydrocarbon receptors in DCs, Langerhans cells, macrophages, signal transducer and activator of transcription 3 pathways, and dermal vascular endothelial cells. Here, we have shown that the ability to target specific cellular and molecular components of psoriasis pathogenesis with nanoscale precision using phosphodiesterase 4 inhibitors represents a transformative opportunity to address the complex nature of this dermatological condition.

OBJECTIVE

In this review, we have examined the molecular mechanisms behind the pathogenic features of psoriasis and new treatments being tested in clinical settings. There is research being done on new treatments created in the last ten years. This field highlights the advantages of nanotechnological technologies as cutting-edge candidates for drug delivery systems in psoriasis and other inflammatory chronic skin disorders. Future Developments: Nanotechnology-based treatments currently under study show good efficacy and low side effect profiles. However, long-term prospective trials are required to demonstrate long-term safety and effectiveness. Phosphodiesterase inhibitors, Janus kinase inhibitors, nonsteroidal anti-inflammatory drugs, combinations of vitamin D3 derivatives and corticosteroids, and coal tar formulations are some of the newer topical treatments for psoriasis.

CONCLUSION

The psoriasis treatment continues to involve conventional medications (i.e., medicines that are generally acknowledged as either normal therapy or outdated remedies), whether used topically or orally. Nonetheless, we are starting to see initiatives to create pharmaceuticals and biosimilars with better therapeutic results, fewer side effects, and greater efficacy.

Efficacy of Ixekizumab in Chinese Patients with Moderate-to-Severe Psoriasis and Special Body Area Involvement: Sub-analysis of a Randomized, Double-Blind, Multicenter Phase 3 Study

INTRODUCTION

Special body area involvement is common in psoriasis and can be challenging to treat. We investigated the efficacy of ixekizumab (IXE) in Chinese patients with moderate-to-severe psoriasis and fingernail, scalp, or palmoplantar involvement.

METHODS

A post-hoc sub-analysis of a phase 3 trial, in which patients were randomized to receive placebo, IXE 80 mg every 2 (IXE Q2W) or 4 (IXE Q4W) weeks. At Week 12, patients classified as IXE responders [static Physician's Global Assessment (sPGA) score of 0 or 1 [0,1)] were re-randomized (2:1) to IXE Q4W or placebo until Week 60. Efficacy was assessed by body-region specific parameters including Nail Psoriasis Severity Index (NAPSI), Psoriasis Scalp Severity Index (PSSI), and Palmoplantar Psoriasis Area Severity Index (PPASI).

RESULTS

Of 438 patients, 99.1% (434) had ≥ 1 special area involvement [fingernail (76.5%, 335), scalp (97.3%, 426), palmoplantar (27.9%, 122)]. Significantly greater improvements from baseline in NAPSI score were observed with IXE Q4W and Q2W at Week 12 versus placebo (p < 0.001 for both). These improvements were further increased and sustained over 60 weeks in IXE Q4W and Q2W responders who were re-randomized to IXE Q4W, who achieved a 77.9% and 89.7% improvement from baseline, respectively, at Week 60. Significantly higher proportions of patients receiving IXE Q4W and Q2W achieved NAPSI 50 at Week 12 versus placebo (44.4%, 36.6% vs. 14.1%; p < 0.001 and < 0.01, respectively). Similarly, significantly higher proportions of patients receiving IXE Q4W and Q2W achieved PSSI 100 and PPASI 100 at Week 12 versus placebo (60.6% and 65.1% vs. 1.2%, and 67.4%, 84.3% vs. 21.4%, respectively; p < 0.001 for all comparisons). Improvements across all outcomes were sustained in patients re-randomized to IXE Q4W until Week 60.

CONCLUSION

IXE led to a rapid onset of action and sustained efficacy over 60 weeks in Chinese patients with moderate-to-severe psoriasis and special body area involvement.

CLINICALTRIALS

gov identifier, NCT03364309.

Combined fractional CO2 laser 10,600 nm with methotrexate 1% gel versus methotrexate 1% gel alone in the treatment of nail psoriasis: a randomized comparative study

Methotrexate injections intralesionally as a treatment for psoriatic nails proved to be effective in large-scale studies as well as individual case reports, but the process is painful and time-consuming. The objective of this study was to compare the efficacy and safety of combined fractional CO2 laser (Fr. CO2) 10,600 nm and methotrexate gel versus methotrexate 1% gel alone in treatment of nail psoriasis. In this intra-patient randomized comparative study, 36 patients were treated for finger nail psoriasis. One hand was randomly selected to be treated with a Fr. CO2 laser at 10,600 nm in monthly sessions in addition to the daily application of methotrexate 1% gel for 4 months (Fr. CO2 group). The other hand was treated with daily application of methotrexate 1% gel alone for the same period (non-laser group). Evaluation was done at the end of 4 months treatment and 3 months after treatment both clinically and dermoscopically. In addition, histopathological evaluation was done 3 months after treatment. At the end of treatment, both hands experienced significant improvement in total nail psoriasis severity index (NAPSI) (P = 0.001,for each hand) with no significant difference between both (p = 0.593). Three months after treatment, the improvement in NAPSI score in Fr. CO2 group was significantly greater than that in non-laser group (p = 0.001). The dermoscopic evaluation showed significant improvement in both hands at the end of treatment and 3 months after treatment. Regarding microscopic examination of nail psoriatic, the mean value of nail plate thickness and subungual thickness significantly decreased, three months after treatment in both groups with significant higher improvement in Fr. CO2 group compared with non-laser group (p = 0.011, 0.000), respectively. Nail plate serous lake, subungual serous lake, parakeratosis and Munro's abscess significantly improved 3 months after treatment. with no significant difference between both sides. Although minimal pain during the session was in 20% and erythema in 37.1% of patients that last less than 24 h were noticed in Fr. CO2 group, patient satisfaction was still higher among patients in this group (p = 0.02). It is concluded that topical methotrexate 1% gel is an effective topical treatment for nail psoriasis. However, Fr. CO2 laser-assisted delivery of methotrexate 1% gel is superior to unassisted methotrexate 1% gel application.

Lasers for the treatment of nail psoriasis: a systematic review

This systematic review assesses the evidence concerning laser treatments for nail psoriasis (NP), a prevalent condition among individuals with cutaneous psoriasis that notably affects their quality of life. Traditional treatments have limitations in terms of drug delivery and poor patient adherence, leading to interest in laser therapies for their targeted approach, extended treatment intervals, and the potential to enhance topical medication effectiveness. The MEDLINE, Embase, Web of Science, and Cochrane Library databases were searched. English-language randomized and non-randomized controlled trials with full-text availability were included. Data on the laser type, treatment protocol, Nail Psoriasis Severity Index (NAPSI) outcomes, and adverse events were extracted, and nail bed and matrix features and patient satisfaction were assessed. The primary effect measure was a percentage reduction in NAPSI scores from baseline. Nineteen studies involving the pulse dye laser (PDL), long-pulsed neodymium:yttrium aluminum garnet (Nd:YAG) laser and fractional carbon dioxide laser (FCL) were identified. Lasers, particularly those used in conjunction with topical agents, have shown favorable results. PDL effectively lowered NAPSI scores, and the Nd:YAG laser had comparable effectiveness but more discomfort. FCL also shows promise, particularly for topical drug delivery. PDL and Nd:YAG laser treatment were more effective at reducing nail bed features, whereas FCL was effective at reducing both nail bed and matrix features. Overall, lasers are promising treatment alternatives for NP, with similar NAPSI outcomes to topical therapies and intralesional injections.

Fast Clinical Response of Bimekizumab in Nail Psoriasis: A Retrospective Multicenter 36-Week Real-Life Study

(1) Background/Objectives: Nail psoriasis (NP) is a chronic and difficult-to-treat disease, which causes significant social stigma and impairs the patients' quality of life. Moreover, nail psoriasis is a true therapeutic challenge for clinicians. The presence of nail psoriasis can be part of a severe form of psoriasis and can have predictive value for the development of psoriatic arthritis. Our real-world-evidence multicenter study aims to evaluate the efficacy of bimekizumab in nail psoriasis. (2) Methods: A retrospective analysis of a multicenter observational study included 834 patients affected by moderate-to-severe psoriasis, in 33 Dermatologic Units in Italy, treated with bimekizumab from December 2022 to September 2023. Clinimetric assessments were based on Psoriasis Area and Severity Index (PASI), Dermatology Life Quality Index (DLQI), and Physician's Global Assessment of Fingernail Psoriasis (PGA-F) for the severity of nail psoriasis at 0, 12, 24, and 36 weeks. (3) Results: Psoriatic nail involvement was present in 27.95% of patients. The percentage of patients who achieved a complete clearance of NP in terms of PGA-F 0 was 31.7%, 57%, and 88.5% at week 4, 16, and 36, respectively. PASI 100 was achieved by 32.03% of patients at week 4, by 61.8% at week 16, and by 78.92% of patients at week 36. The mean baseline PASI was 16.24. The mean DLQI values for the entire group of patients at baseline, at week 4, at week 16, and at week 36 were 14.62, 3.02, 0.83, and 0.5, respectively. (4) Conclusions: Therapies that promote the healing of both the skin and nails in a short time can also ensure a lower risk of subsequently developing arthritis which is disabling over time. Bimekizumab proved to be particularly effective to treat NP, with a fast response in terms of complete clearance, with over 88.5% of patients free from NP after 36 weeks. The findings of our real-world study showed that patients with moderate-to-severe PsO and concomitant NP had significantly faster and more substantial improvements in NP up to 36 weeks with respect to previous research findings. Considering the rapid healing of the nail, the dual inhibition of IL17 A and F might have a great value in re-establishing the dysregulation of keratin 17 at the nail level.

Devices for treatment of nail psoriasis

INTRODUCTION

Nail psoriasis (NP) affects a significant proportion of cutaneous psoriasis patients, often leading to functional impairment and psychosocial distress. Despite available treatment options, challenges persist in achieving efficacy and with drug delivery, prompting investigation into novel therapeutic devices.

EVIDENCE ACQUISITION

A literature search was performed using the PubMed database for devices and lasers for NP on 17 October 2023 using the following search terms: device OR laser AND "nail psoriasis." Twenty-two articles were included describing treatment with pulsed dye laser, fractional carbon dioxide (CO2) laser, long-pulsed Nd:YAG laser, excimer laser, photodynamic therapy, intense pulsed light, and microneedling device.

EVIDENCE SYNTHESIS

While some recent studies on use of therapeutic devices have shown promising results for NP treatment, current evidence supports an algorithmic approach including topical therapies, intralesional kenalog injections, and systemic therapies, depending on number of nails affected, presence of psoriatic arthritis, cutaneous psoriasis, comorbidities, and effect on quality of life. Laser therapy, although promising, requires further validation through extensive randomized trials before its inclusion in treatment regimens.

CONCLUSIONS

These exploratory findings highlight emerging therapies that may expand the spectrum of options available. Use of lasers for NP treatment could provide dermatologists with a broader arsenal for customizing treatment plans that address individual patient needs, taking into account comfort, cost, and compliance to enhance overall patient outcomes.

Treatment of Nail Psoriasis

Nail psoriasis is associated with significant disease burden, negative impact on quality of life, and potential progression to psoriatic arthritis. Initiating timely and appropriate treatment is of the utmost importance, especially because nail disease may be more resistant to therapies than cutaneous psoriasis. This article reviews available intralesional, topical, and systemic treatment options for nail psoriasis, and discusses efficacy and safety of studied agents. Also reviewed are consensus treatment guideline recommendations. An updated algorithm to aid physicians in selection of specific treatment options is provided.

Rapid response of nail psoriasis to secukinumab in patients with moderate to severe psoriasis after 12 weeks of treatment with a total of 24 weeks of follow-up

BACKGROUND/OBJECTIVES

Nail psoriasis, a subtype of psoriasis, can cause significant pain, disability, and reduced quality of life. Despite the established efficacy of anti-IL17 secukinumab in improving skin psoriasis, there is a lack of clinical trials focusing on nail psoriasis as primary endpoint. This study aims to investigate the efficacy of secukinumab in treating nail psoriasis in patients with moderate to severe psoriasis.

METHODS

We prospectively recruited patients newly diagnosed with moderate to severe psoriasis in single centre from January 2021 to January 2022 who were treated with secukinumab.

RESULTS

A total of 16 patients consisting of 9 males and 7 females were included. Their mean age was 38.88 ± 10.29 years. They had an average initial Nail Psoriasis Severity Index (NAPSI) score of 45.06 ± 20.39 and an average NAPSI score at 12 weeks of 8.94 ± 13.50, showing a significant (p < 0.05) decrease of NAPSI score after 12 weeks of secukinumab treatment. After 24 weeks of treatment, NAPSI score was decreased to 5.12 ± 8.52.

CONCLUSION

Secukinumab rapidly improved nail psoriasis after 12 weeks of treatment, with further enhancement at 24 weeks, suggesting its potential as a potent therapeutic option for nail psoriasis.

The Influence of Phytoconstituents for the Management of Antipsoriatic Activity in Various Animal Models

It is possible for psoriasis to manifest at any point in a person's life, regardless of their age, gender, or geographic location. It is a chronic immune-linked inflammatory skin illness that affects individuals of various racial and ethnic origins. It is recognized to be a longlasting condition. Because of the significant contribution that natural products have made, there has been a significant advancement in the treatment of skin illnesses such as psoriasis. The biggest number of phytochemicals derived from a wide range of plants and herbs are now being used in a variety of applications throughout the whole world. Additionally, a number of phytochemicals, including aloe-emodin, psoralen, curcumin, and others, have been effectively extracted in pure or clear form, and they have shown a great deal of efficacy in the treatment of psoriasis illness. There is evidence that few herbal remedies are effective, and the occurrence of these phytochemicals provides more proof. When synthetic medications are used for chronic therapy, they may cause a variety of adverse consequences; hence, the exploration of natural pharmaceuticals can give a successful natural treatment with a minimal amount of adverse effects. Within the scope of this concise review, a number of plant sources that possess anti-psoriatic activity are investigated, and the antipsoriatic effects of these plant sources are shown on a number of animal models using particular pathways.

Efficacy of Guselkumab in Treating Nails, Scalp, Hands, and Feet in Patients with Psoriasis and Self-reported Psoriatic Arthritis

INTRODUCTION

The aim of this study was to evaluate guselkumab efficacy on regional psoriasis in a subset of psoriasis patients with a self-reported psoriatic arthritis (PsA) diagnosis.

METHODS

In the phase 3 VOYAGE-1 and -2 studies, at week (W)0, patients with moderate-to-severe psoriasis were randomized to guselkumab 100 mg, placebo → guselkumab 100 mg at W16 through W44, or adalimumab 80 mg then 40 mg at W1 through W48 (VOYAGE-1) or W24 (VOYAGE-2). Pooled efficacy outcomes, including scalp-specific Investigator's Global Assessment (ss-IGA), hands and/or feet Physician's Global Assessment (hf-PGA), fingernail PGA (f-PGA), Nail Psoriasis Area and Severity Index (NAPSI), and Dermatology Life Quality Index (DLQI), were compared (nominal p-values) through W24 in patients with self-reported PsA diagnosis. Response rates/percentage improvement from baseline were determined, employing treatment failure rules and non-response/no improvement data imputation.

RESULTS

A total of 76, 153, and 106 psoriasis patients with self-reported PsA were randomized to the placebo, guselkumab, or adalimumab groups, respectively; the baseline characteristics of patients in all three arms were comparable. At W16, a greater proportion of guselkumab- versus placebo-treated patients achieved ss-IGA 0/1 (80.6% vs. 22.7%, p < 0.001), hf-PGA 0/1 (68.9% vs. 14.8%, p < 0.001), f-PGA 0/1 (47.6% vs. 17.0%, p < 0.001), and DLQI 0/1 (45.6% vs. 2.7%, p < 0.001) responses; mean percentage NAPSI improvement was also greater with guselkumab (39.5% vs. 6.5%, p < 0.001). At W24, patients receiving guselkumab had higher ss-IGA 0/1 (77.5% vs. 58.5%, p = 0.003) and DLQI 0/1 (47.7% vs. 34.3%, p = 0.024) response rates versus those receiving adalimumab. Response rates/mean percentage improvements at W48 (VOYAGE-1) were numerically greater with guselkumab than adalimumab (e.g., NAPSI improvement: 75.6% vs. 60.9%).

CONCLUSIONS

Guselkumab-treated patients with psoriasis and self-reported PsA showed meaningful improvements in nail, scalp, and palmoplantar psoriasis.

TRIAL REGISTRATION

VOYAGE-1 (ClinicalTrials.gov Identifier: NCT02207231) and VOYAGE-2 (ClinicalTrials.gov Identifier: NCT02207244).

A Comprehensive Review of Ixekizumab Efficacy in Nail Psoriasis from Clinical Trials for Moderate-to-Severe Psoriasis and Psoriatic Arthritis

Nail psoriasis is a difficult-to-treat manifestation of psoriatic disease affecting up to 80% of patients with psoriatic arthritis (PsA) and 40-60% of patients with plaque psoriasis (PsO). Ixekizumab (IXE), a high-affinity monoclonal antibody that selectively targets interleukin-17A, is approved for the treatment of patients with PsA and patients with moderate-to-severe PsO. This narrative review aims to summarize nail psoriasis data generated from IXE clinical trials in patients with PsA (SPIRIT-P1, SPIRIT-P2, and SPIRIT-H2H) and/or moderate-to-severe PsO (UNCOVER-1, -2, -3, IXORA-R, IXORA-S, and IXORA-PEDS) with an emphasis on head-to-head clinical trial data. Across numerous trials explored, IXE treatment was associated with greater improvement in resolution of nail disease versus comparators at week 24, results which were maintained up to and beyond week 52. Additionally, patients experienced higher rates of resolution of nail disease versus comparators at week 24 and maintained high levels of resolution up to week 52 and beyond. In both PsA and PsO, IXE demonstrated efficacy in treating nail psoriasis, and therefore may be an effective therapy option. Trial Registration: ClinicalTrials.gov identifier UNCOVER-1 (NCT01474512), UNCOVER-2 (NCT01597245), UNCOVER-3 (NCT01646177), IXORA-PEDS (NCT03073200), IXORA-S (NCT02561806), IXORA-R (NCT03573323), SPIRIT-P1 (NCT01695239), SPIRIT-P2 (NCT02349295), SPIRIT-H2H (NCT03151551).

Fractional CO2 laser in the treatment of nail psoriasis: how can it help?

Treating nail psoriasis is often a time-consuming challenge with an unsecure outcome. Response to the treatment is variable and relapses are common. Systemic treatments have multiple systemic side effects and lack of the patient compliance makes intra-lesional therapies not the best choice for treatment of nail psoriasis. We aimed to evaluate and compare the efficacy and side effects of methotrexate versus calcipotriol plus betamethasone two-compound formula when applied topically to psoriatic nails after fractional CO2 laser. This comparative pilot study included 20 patients with nail psoriasis. One side was treated with fractional CO2 laser followed by the application of topical methotrexate (Group A) and the other side with fractional CO2 laser followed by topical (Calcipotriol 0.05 mg/gm + Betamethasone 0.5 mg/gm) (Group B). 4 sessions were done, once every 2 weeks. There was a high statistical significant decrease in total NAPSI score in group A at 1(P = 0.000) and 2 months (P = 0.000). There was a high statistical significant decrease in total NAPSI score in group B at 1(P = 0.001) and 2 months (P = 0.001). There was no statistical significant difference regarding total NAPSI score between both group A and B at 0 (P = 0.271), 1(P = 0.513) and 2 months (P = 0.647). Combined fractional CO2 laser with either topical MTX or topical betamethasone plus calcipotriol two-compound formula is effective treatment for nail psoriasis.

Nail Psoriasis: An Updated Review of Currently Available Systemic Treatments

Background

Nail psoriasis (NP) has a prevalence that ranges from 10 to 82% among patients with psoriasis (PsO) and is one of the most common difficult to treat site of psoriasis. We performed a thorough review of the literature, exploring evidence regarding all available NP systemic treatments, describing also in detail NP dedicated clinical trials.

Methods

A literature search was conducted in PubMed and Embase prior to February 2023 using a combination of the terms "nail" AND "psoriasis" AND "systemic therapy" AND/OR "systemic treatment". A total of 47 original studies and case reports were reviewed in this article.

Results

Systemic therapies should be considered when the disorder involves more than 3 nails, has extensive skin and joint involvement, and has a significant impact on QoL, due to their best long-term efficacy. In detail, conventional and biologic systemic drugs demonstrated efficacy in recent trials, including acitretin, methotrexate, cyclosporine, apremilast, adalimumab, infliximab, etanercept, certolizumab, golimumab, ustekinumab, secukinumab, ixekizumab, brodalumab, bimekizumab, guselkumab, risankizumab and tildrakizumab.

Conclusion

Several therapies have demonstrated efficacy and safety in the treatment of NP; however, the choice of treatment depends not only on the severity of the nail involvement, but also on whether PsA is present, the patient's comorbidities other than PsA, previous treatment history, and the patient's drug preferences.

Bayesian network meta-analysis of head-to-head trials for complete resolution of nail psoriasis

BACKGROUND

Almost 50% of patients with skin psoriasis have concomitant nail involvement. The comparative effectiveness of the available biologics for nail psoriasis (NP) is still an area of contention because of limited data on nails.

OBJECTIVES

We conducted a systematic review and network meta-analysis (NMA) to compare the efficacy of biologics in achieving complete resolution of NP.

METHODS

We identified studies in PubMed, EMBASE and Scopus. The eligibility criteria included randomized controlled trial (RCTs) or cohort studies for psoriasis or psoriatic arthritis with at least two arms of active comparator of biologic reporting at least one efficacy outcome of interest: that is the Nail Psoriasis Severity Index (NAPSI), the modified NAPSI or the Physician's Global Assessment of Fingernail Psoriasis with a score of 0.

RESULTS

Fourteen studies comprising seven treatments met the inclusion criteria, and were included in the NMA. The NMA showed the odds of complete NP resolution were superior with ixekizumab [risk ratio (RR) 1.4, 95% confidence interval (CI) 0.73-3.10] compared with the treatment of reference (adalimumab). Brodalumab (RR 0.92, 95% CI 0.14-7.40), guselkumab (RR 0.81, 95% CI 0.40-1.80), infliximab (RR 0.90, 95% CI 0.19-4.60) and ustekinumab (RR 0.33, 95% CI 0.08-1.60) demonstrated worse therapeutic effect compared with adalimumab. According to the surface under the cumulative ranking curve, ixekizumab 80 mg every 4 weeks had the highest probability of being the best treatment.

CONCLUSIONS

The interleukin-17A inhibitor ixekizumab has the highest rate of complete nail clearance and it can be considered the best-ranked therapy from the present evidence. This study is relevant to daily practice as it facilitates the decision when choosing between the wide variety of available biologics in patients for whom clearance of nail symptoms is the first concern.

Topical treatment of psoriasis vulgaris

Topical therapy plays an important role in the treatment of psoriasis. It is the gold standard in mild psoriasis cases and is also recommended in addition to UV and systemic therapy in cases of moderate to severe psoriasis. In this overview article we summarize the current therapeutic options, taking into account special localizations (scalp, facial, intertriginous/genital, or palmoplantar lesions) and situations (hyperkeratotic or inflammatory forms), as well as the therapy options during pregnancy and breastfeeding. In the initial phase, the combination of topical corticosteroids and vitamin D analogues has proven to be the therapy of choice, as well as monotherapy in each case. In maintenance therapy, fixed combination therapy is recommended once or twice a week. In addition to the right choice of active substances, the choice of the right formulation also plays an important role. To increase adherence, it is very important to consider the personal preferences and experiences of the patient. If topical therapy does not lead to a satisfactory result, additional UV therapy or systemic therapy should be considered.

Histone deacetylase inhibitors as a potential new treatment for psoriatic disease and other inflammatory conditions

Collectively known as psoriatic disease, psoriasis and psoriatic arthritis (PsA) are immune-mediated inflammatory diseases in which patients present with cutaneous and musculoskeletal inflammation. Affecting roughly 2-3% of the world's total population, there remains unmet therapeutic needs in both psoriasis and PsA despite the availability of current immunomodulatory treatments. As a result, patients with psoriatic disease often experience reduced quality of life. Recently, a class of small molecules, commonly investigated as anti-cancer agents, called histone deacetylase (HDAC) inhibitors, have been proposed as a new promising anti-inflammatory treatment for immune- and inflammatory-related diseases. In inflammatory diseases, current evidence is derived from studies on diseases like rheumatoid arthritis (RA) and systematic lupus erythematosus (SLE), and while there are some reports studying psoriasis, data on PsA patients are not yet available. In this review, we provide a brief overview of psoriatic disease, psoriasis, and PsA, as well as HDACs, and discuss the rationale behind the potential use of HDAC inhibitors in the management of persistent inflammation to suggest its possible use in psoriatic disease.

Dermatology Life Quality Index in Patients with Psoriasis Treated with Biologic Versus Non-biologic Treatment in Malaysia: A Retrospective Cross-Sectional Study

BACKGROUND

Psoriasis imposes a substantial burden on patients' social, emotional, physical, and family life. Although psoriasis has no complete cure, various treatments are available to control its symptoms and improve a patients' quality of life.

OBJECTIVE

We aimed to compare the effectiveness of biologic versus non-biologic treatments on health-related quality of life among patients with psoriasis in Malaysia.

METHODS

This retrospective cross-sectional study evaluated data of adult patients diagnosed with psoriasis during 2007-18 from the Malaysian Psoriasis Registry. Baseline demographics, disease, and treatment characteristics were described. For a subset of patients treated with biologics and non-biologics who had baseline and 6-month follow-up data available, changes in the mean Dermatology Life Quality Index scores and the proportion of patients with a clinically relevant improvement (≥ 4 points) post-treatment were assessed.

RESULTS

Overall, 15,238 adult patients with psoriasis from the Malaysian Psoriasis Registry were included in the analysis. Patients receiving biologics showed a statistically significant reduction in the mean Dermatology Life Quality Index scores after 6 months compared with those receiving non-biologic treatment (- 5.7 vs - 0.8%; p < 0.001). The proportion of patients who achieved a ≥ 4-point improvement in Dermatology Life Quality Index scores was approximately two times greater in the biologic-treated group versus the non-biologic-treated group (56.4 vs 27.7%).

CONCLUSIONS

Biologic treatment showed a greater reduction in the Dermatology Life Quality Index scores of patients with psoriasis versus non-biologic treatment. These results highlight the importance of early treatment with more efficacious treatment options, such as biologic therapies, to improve the overall health-related quality of life of patients with psoriasis.

Optimal diagnosis and management of common nail disorders

Nail conditions are not only aesthetic concerns, and nail changes may be a clue to an underlying systemic diseases or infection. Without timely treatment, nail diseases can continue to worsen and significantly impair performance of daily activities and reduce quality of life. Examination of the nails is essential at every medical visit, and may uncover important findings. Brittle nail syndrome, onychomycosis, paronychia, nail psoriasis, longitudinal melanonychia, Beau's lines, onychomadesis and retronychia are common nail disorders seen in clinical practice. These conditions stem from infectious, inflammatory, neoplastic and traumatic aetiologies. Though each nail condition presents with its own distinct characteristics, the clinical findings may overlap between different conditions, resulting in misdiagnosis and treatment delays. Patients can present with nail plate changes (e.g. hyperkeratosis, onycholysis, pitting), discolouration, pain and inflammation. The diagnostic work-up of nail disease should include a detailed history and clinical examination of all 20 nail units. Dermoscopy, diagnostic imaging and histopathologic and mycological analyses may be necessary for diagnosis. Nail findings concerning for malignancy should be promptly referred to a dermatologist for evaluation and biopsy. Nail disease management requires a targeted treatment approach. Treatments include topical and/or systemic medications, discontinuation of offending drugs or surgical intervention, depending on the condition. Patient education on proper nail care and techniques to minimize further damage to the affected nails is also important. This article serves to enhance familiarity of the most common nail disorders seen in clinical practice. It will highlight the key clinical manifestations, systematic approaches to diagnosis and treatment options for each nail condition to improve diagnosis and management of nail diseases, as well as patient outcomes.Key messagesNail disease is not only a cosmetic issue, as nail changes can indicate the presence of a serious underlying systemic disease, infection or malignancy.Nail pain and changes associated with NP are physically and emotionally distressing and may contribute to functional impairment and diminished quality of life.LM is a hallmark sign of subungual melanoma and this finding warrants further investigation to rule out malignancy.

A case of nail psoriasis improved with treatment by risankizumab

Nail psoriasis causes significant aesthetic and functional disabilities. The treatment of nail psoriasis is essential to improve the health outcomes and quality of life among patients. Pain associated with intralesional injections, inadequate penetration into the nail and underlying tissue, poor adherence to therapy, limited efficacy and recurrent relapses are among the many challenging issues with topical therapy. While conventional systemic therapies are still useful and often appropriate for some patients, current evidence indicates that highly selective agents including anti-tumor necrosis factor-alpha, anti-interleukin (IL)-17 and anti-IL-12/23 antibodies that are primarily available for plaque psoriasis and psoriatic arthritis have also demonstrated long-term efficacy in the treatment of nail psoriasis. We report a case of nail psoriasis improved with treatment by risankizumab.

Iontophoresis application for drug delivery in high resistivity membranes: nails and teeth

Iontophoresis has been vastly explored to improve drug permeation, mainly for transdermal delivery. Despite the skin's electrical resistance and barrier properties, it has a relatively high aqueous content and is permeable to many drugs. In contrast, nails and teeth are accessible structures for target drug delivery but possess low water content compared to the skin and impose significant barriers to drug permeation. Common diseases of these sites, such as nail onychomycosis and endodontic microbial infections that reach inaccessible regions for mechanical removal, often depend on time-consuming and ineffective treatments relying on drug's passive permeation. Iontophoresis application in nail and teeth structures may be a safe and effective way to improve drug transport across the nail and drug distribution through dental structures, making treatments more effective and comfortable for patients. Here, we provide an overview of iontophoresis applications in these "hard tissues," considering specificities such as their high electrical resistivity. Iontophoresis presents a promising option to enhance drug permeation through the nail and dental tissues, and further developments in these areas could lead to widespread clinical use.

Topical calcipotriol combined with urea 20% versus intralesional injection of triamcinolone acetonide, 5-fluorouracil, and methotrexate in the treatment of nail psoriasis: A comparative study

BACKGROUND

There is no consistently effective treatment for psoriatic nails. Topical and intralesional modalities have been recently investigated and showed promising efficacy and safety.

OBJECTIVE

To compare the efficacy and safety of intralesional injection of 5-fluorouracil (5-FU), methotrexate (MTX), triamcinolone acetonide (TA) versus topical calcipotriol plus urea 20% in the treatment of nail psoriasis.

METHODS

This study included 60 patients with nail psoriasis who were randomly assigned to 4 groups, each containing 15 patients. The first 3 groups received intralesional injection of 0.1 ml of 5-FU (group A), MTX (group B), and TA (group C) into the nail matrix and bed monthly for 3 months. Group D received a topical combination of calcipotriol/urea 20% twice daily for 3 months. Therapeutic response was assessed every month for 3 months using the target nail psoriasis severity index (NAPSI).

RESULTS

The mean percentage of improvement was significantly higher in topical calcipotriol/urea combination (57.1 ± 26.4) than intralesional TA (44.2 ± 32.7), intralesional MTX (37.7 ± 14.2), and intralesional 5-FU (29.6 ± 14). Adverse effects were mild and insignificant in the studied groups.

CONCLUSION

Topical calcipotriol/urea combination seems to be more effective and safe than intralesional injections of 5-FU, MTX and TA. This article is protected by copyright. All rights reserved.

Vergleich der fraktionierten laserunterstützten Medikamentengabe und der intraläsionalen Injektion von Triamcinolonacetonid bei Nagelpsoriasis

HINTERGRUND UND ZIELE

Die Behandlung der Nagelpsoriasis ist wegen mangelnder Penetration topischer Therapeutika durch die Nagelplatte häufig unbefriedigend. Daher sind innovative Methoden zur adäquaten Verabreichung des Arzneimittels in den Nagel erforderlich. In dieser Studie vergleichen wir die Wirksamkeit der intraläsionalen Corticosteroid-Injektion mit topischer Applikation nach fraktionierter CO₂ -Laser-Behandlung bei Fingernagelpsoriasis.

PATIENTEN UND METHODEN

In der Studie wurden 36 Patienten mit Fingernagelpsoriasis in zwei Gruppen eingeteilt. Bei Gruppe A wurden die Nägel mit intraläsionalen Injektionen von Triamcinolon behandelt, in Gruppe B durch fraktionierte CO₂ -Lasertherapie, gefolgt von topischer Applikation des Arzneimittels in sechs Sitzungen. Die Beurteilung erfolgte anhand des NAPSI und eines dermatoskopischen Scores.

ERGEBNISSE

Beide Modalitäten führten zu signifikanter Besserung der Psoriasis an Nagelmatrix und Nagelbett. Statistisch signifikante Unterschiede zwischen den Gruppen bestanden weder klinisch noch dermatoskopisch. Die Laserbehandlung war mit signifikant geringeren Schmerz-Scores (P = 0,03) und höherer Patientenzufriedenheit (P = 0,007) verbunden.

SCHLUSSFOLGERUNGEN

Die fraktionierte CO₂ -Laser-unterstützte Applikation topischer Steroide könnte eine effektive und gut verträgliche Therapie der Nagelpsoriasis sein, die eine der intraläsionalen Injektion vergleichbare Wirksamkeit hat.

Comparison of fractional laser-assisted drug delivery and intralesional injection of triamcinolone acetonide in nail psoriasis

BACKGROUND AND OBJECTIVES

The treatment of nail psoriasis is often unsatisfactory due to poor penetration of topical therapeutics through the nail plate. The development of innovative methods that provide adequate delivery of the drug into the nail is warranted. In this study, we aim to compare the efficacy of intralesional corticosteroid injection versus its topical application after fractional CO₂ laser in the treatment of fingernail psoriasis.

PATIENTS AND METHODS

The study included 36 patients with fingernail psoriasis divided into two groups. The nails in group A were treated with intralesional injection of triamcinolone acetonide while the nails in group B received fractional CO₂ laser therapy followed by topical application of the drug for six sessions. The evaluation was performed using NAPSI and dermatoscopic scores.

RESULTS

Both modalities yielded a significant improvement of the nail matrix and bed psoriatic signs. No statistically significant difference was found between the two groups by both clinical and dermatoscopic assessment. The laser treatment was associated with significantly lower pain scores (P = 0.03) and higher patient satisfaction (P = 0.007).

CONCLUSIONS

Fractional CO₂ laser-assisted delivery of topical corticosteroids can be a potentially effective and well-tolerated therapeutic modality in the treatment of nail psoriasis with comparable efficacy to intralesional injection.

Fractional CO2 Laser-Assisted Delivery Versus Intralesional Injection of Methotrexate in Psoriatic Nails

BACKGROUND

Nail psoriasis has a major negative impact on physical and psychological aspects of the patient's life. Treatment is often unsatisfactory because of difficult penetration of the drug into the nail.

OBJECTIVE

To evaluate and compare the efficacy of laser-assisted delivery of methotrexate versus its intralesional injection in fingernail psoriasis.

MATERIALS AND METHODS

Twenty-eight patients with fingernail psoriasis were divided into 2 groups of 14 patients each. Group A was treated with intralesional injection of methotrexate while Group B received fractional CO2 laser followed by topical application of methotrexate. The treatment was given at a 2-week interval for 6 sessions. The improvement of nail psoriasis was assessed by clinical and dermoscopic evaluation.

RESULTS

At the end of treatment, both laser-assisted delivery and intralesional injection of methotrexate were associated with statistically significant improvement of psoriatic signs. No statistically significant difference was found between the 2 groups regarding total nail psoriasis severity Index (p = .18), matrix score (p = .38), bed score (p = .23), and dermoscopic score (p = .78). However, the pain and subungual hematoma were significantly less in the laser group (p < .001 and p = .03, respectively).

CONCLUSION

Fractional CO2 laser-assisted delivery of methotrexate can be an effective and well-tolerated alternative to intralesional injection in nail psoriasis.

PSORS1 Locus Genotyping Profile in Psoriasis: A Pilot Case-Control Study

(1) Background: The psoriasis susceptibility 1 (PSORS1) locus, located within the major histocompatibility complex, is one of the main genetic determinants for psoriasis, the genotyping profile for three single-nucleotide polymorphisms (SNPs) comprising the PSORS1 locus: rs1062470 within PSORS1C1/CDSN genes, rs887466 within PSORS1C3 gene, rs10484554 within LOC105375015 gene, were investigated and correlated with psoriasis risk and severity. (2) Methods: This pilot case-controlled study involved 100 psoriatic patients and 100 healthy individuals. We investigated three SNPs and assessed the relative gene expression profile for the PSORS1C1 gene. We then correlated the results with both disease risk and severity. (3) Results: The most significantly associated SNP in PSORS1 locus with psoriasis was rs10484554 with its C/T genotype 5.63 times more likely to develop psoriasis under codominant comparison. Furthermore, C/T and T/T genotypes were 5 times more likely to develop psoriasis. The T allele was 3 times more likely to develop psoriasis under allelic comparison. The relative gene expression of PSORS1C1 for psoriatic patients showed to be under-expressed compared to normal controls. (4) Conclusions: Our study revealed the association of the three studied SNPs with psoriasis risk and severity in an Egyptian cohort, indicating that rs10484554 could be the major key player in the PSORS1 locus.

Is there still a place for methotrexate in severe psoriatic arthritis?

The management of psoriatic arthritis (PsA) has long been equated with that of rheumatoid arthritis (RA), particularly because methotrexate (MTX) was found efficient in RA in the 1990s. However, results of collective evidence-based medicine, included and argued in this narrative review, do not currently support the use of MTX as first-line therapy in severe PsA. A recent Cochrane systematic review examining the efficacy of MTX in PsA concluded that low-dose MTX was only slightly more effective than placebo. Questions about a structural effect of MTX in PsA remains non-elucidated. Even if tolerance data on MTX are more consensual and adverse events generally non-severe, subjective side effects such as fatigue might lead to MTX withdrawal based on the patient's decision. PsA patients with axial disease, radiographic lesions, and extensive and disabling skin or joint involvement should receive early treatment with targeted therapy and no longer with MTX. Finally, the usefulness of MTX combined with targeted therapies is limited. MTX does not affect efficacy but only seems to increase the therapeutic maintenance of monoclonal TNF inhibitors. This narrative review may help clarify the place of MTX in PsA management. It allows for reflection on the evolution of current concepts and practices.

Treatment of nail psoriasis with pulsed dye laser versus combined pulsed dye and Nd:YAG lasers-An intrapatient left-to-right study

BACKGROUND AND OBJECTIVES

There are limited treatment options for nail psoriasis. It is important to find new therapies and improve existing ones. The aim of this study was to compare the effectiveness of pulsed dye laser (PDL) versus combined PDL and Nd:YAG lasers in patients with nail psoriasis.

METHODS

Fourteen patients (with a total of 126 nails affected by nail psoriasis) were treated with PDL (6 J/cm2, 7 mm, 0.45 milliseconds) on both hands and additionally with Nd:YAG (10 J/cm² , 6 mm, 15 milliseconds) on the right hand. Three treatment sessions were applied at 4-week intervals and patients were followed up for 6 months after the last session. Disease severity was assessed using the Nail Psoriasis Severity Index, both 8- and 32-point variant. Additionally, Dermatology Life Quality Index was assessed before and after treatment.

RESULTS

Overall, there was a statistical difference in 8- and 32-point NAPSI score before and after treatment for both hands. However, there was no statistical difference between the score for the right and left hands based on both scale variants. Some aspects of patients' lives showed improvement due to the treatment.

CONCLUSIONS

Both PDL in monotherapy and combined Nd:Yag+PDL lasers are safe and effective in treatment of nail psoriasis, although combined therapy shows no advantage over the use of a single laser.

Challenge of Nail Psoriasis: An Update Review

Nail psoriasis is a refractory disease that affects 50-79% skin psoriasis patients and up to 80% of patients with psoriatic arthritis (PsA). The pathogenesis of nail psoriasis is still not fully illuminated, although some peculiar inflammatory cytokines and chemokines seems to be the same as described in psoriatic skin lesions. Psoriatic nail involving matrix can cause pitting, leukonychia, red spots in lunula, and nail plate crumbling, while nail bed involvement can result in onycholysis, oil-drop discoloration, nail bed hyperkeratosis, and splinter hemorrhages. The common assessment methods of evaluating nail psoriasis includes Nail Psoriasis Severity Index (NAPSI), Nail Assessment in Psoriasis and Psoriatic Arthritis (NAPPA), Nail Psoriasis Quality of life 10 (NPQ10), and so on. Treatment of nail psoriasis should be individualized according to the number of involving nail, the affected site of nail and presence of skin and/or joint involvement. Generally, topical therapies are used for mild nail psoriasis, while biologic agents such as etanercept are considered for severe nail disease and refractory nail psoriasis. Even though the current literature has shown some support for the pathogenesis, clinical presentation, or therapies of nail psoriasis, systemic review of this multifaceted disease is still rare to date. We elaborate recent developments in nail psoriasis epidemiology, pathogenesis, anatomy, clinical manifestation, diagnosis, differential diagnosis, and therapies to raise better awareness of the complexity of nail psoriasis and the need for early diagnosis or intervention.

Nail Psoriasis: A Review of Effective Therapies and Recommendations for Management

Nail psoriasis has a prevalence that ranges from 10 to 82% and can significantly impact the quality of life of patients. Nail psoriasis is one of the most challenging areas to treat, and multiple therapies have been explored. Topical and injectable therapies are recommended for few-nail disease. Systemic therapies, including biologics, can be considered for patients with multiple and resistant nail disease, impaired quality of life, and severe skin and joint involvement, due to their long-term efficacy. Although outcome data are difficult to compare, interleukin (IL)-17 inhibitors may have superior short-term efficacy when compared to IL-23 inhibitors and tumor necrosis factor (TNF)-alpha inhibitors, although long-term efficacy is similar to TNF-alpha inhibitors. IL-23 inhibitors and TNF-alpha inhibitors have a similar efficacy for nail psoriasis.

Psoriasis Exacerbation after Candida Antigen Immunotherapy Injection

Background

Immunotherapy as wart treatment has been proposed as a successful and well-tolerated treatment option. However, as their action is not confined to the site of injection, the activation of the immune system in a way may alter the immune state of the patient.

Case Presentation

A case of 29-year-old patient who experienced psoriasis exacerbation and psoriatic arthritis within days following Candida antigen immunotherapy injection for resistant filiform wart management.

Conclusion

Candida antigen injection may cause psoriasis exacerbation, as TNFα and subsequent T-helper 1 induction is crossroad in both psoriasis and Candida antigen immunotherapy. Therefore, we report this case to state that besides the effectiveness of Candida antigen for wart therapy, caution should be considered if used in patients who are susceptible to psoriasis with meticulous follow-up or better to apply an alternative treatment option.

Novel drug delivery strategies and gene therapy regimen as a promising perspective for management of psoriasis

Psoriasis is an autoimmune disorder; however, an exact underlying mechanism responsible for psoriasis is yet not known. A hypothesis put forward is an abnormal proliferation of keratinocytes due to faulty signals brought about by T-cells. Due to the lack of evidence of the exact cause, a variety of treatments have been used of which topical therapy is usually the first option in most patients. Topical therapy has several shortcomings and barriers of drug delivary which may be effectively overcome using novel drug carrier systems which exhibit maximum penetration, controlled release, reduced irritancy and, overall, a better efficacy. Thus, novel treatment strategies based on gene therapy such as antisensing nucleotide, silencing RNA complex, stem cell therapy and antibody-based therapy are being envisaged. This review article discusses the concepts and background of current novel delivery systems and gene therapy tools for effective management of psoriasis.

Nail Psoriasis in Older Adults: Epidemiology, Diagnosis, and Topical Therapy

Nail involvement is common in patients with cutaneous psoriasis, which is prevalent among older adults. Nail psoriasis greatly impacts patients' quality of life and self-esteem. Concomitant psoriatic arthritis is common. Treating nail psoriasis in the geriatric population may be challenging. General nail care measures may prevent exacerbations. Topical therapy is relatively effective, with a low rate of adverse events and little to no risk of systemic toxicity or drug interactions. However, application under occlusion may be cumbersome. There is a need for randomized controlled clinical trials in the elderly population to make more evidence-based treatment guidelines.

Management of Nail Psoriasis

Nail psoriasis is a chronic nail disorder that requires personalized treatment. General prophylactic measures are suggested for all patients. Topical treatment is considered when treating a few-nail disease, with involvement of 3 or fewer nails, without joint involvement and without (or with mild) skin psoriasis. The ideal formulation should be ointment, solution, or foam. When moderate to severe skin psoriasis or psoriatic arthritis coexists, systemic treatment is suggested. This also should be considered when more than 3 nails are affected or significant impairment of quality of life is present. Conventional systemic agents, biologics, and small molecules are highly efficacious.

Nail Psoriasis in Older Adults: Intralesional, Systemic, and Biological Therapy

Psoriasis may affect the skin, scalp, joints, and nails and is common in older adults. Intramatrical injections with triamcinolone acetonide are safe and effective in older individuals. Conventional systemic medications are relatively effective, but side effects, including laboratory abnormalities and drug interactions, are particularly common among older adults. Biologic medications have shown excellent efficacy in treating nail psoriasis. Their safety profile is favorable, but data assessing long-term safety are lacking. Randomized controlled trials in older adults exclusively are necessary to develop evidence-based treatment guidelines in this population.

Efficacy of Systemic Treatments of Nail Psoriasis: A Systemic Literature Review and Meta-Analysis

Importance: Nail involvement is a common condition in patients with psoriasis. The treatment of nail psoriasis is considered challenging and is often left untreated by physicians. Objective: To assess the efficacy of current systemic treatments on nail psoriasis. Data Sources: PubMed, EMBASE, and Cochrane Central Register of Controlled Trials (CENTRAL) were searched for relevant articles from inception to September 1, 2020. Included articles were restricted to English language and human studies. Study Selection: This was a systematic literature review with meta-analysis. Thirty-five random control trials that evaluated systemic therapies for nail psoriasis were selected in the systemic review. Among them, we retained 14 trials for meta-analysis. Data Extraction and Synthesis: This study was conducted in accordance with the preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. All steps were performed by two independent investigators, and any disagreements were resolved by a third investigator. Meta-analysis of aggregated study data was conducted to assess therapeutic efficacy. The use of random-effects model was based on high heterogeneity as a variable endpoint in different studies. Main Outcomes and Measures: Therapeutic effects on nail psoriasis were expressed in terms of effect sizes with 95% CIs. Results: We included 35 random control trials (RCTs) in this systemic review. At baseline, a high prevalence (62.1%) of nail psoriasis was confirmed. The meta-analysis included 14 trials highlighting that biologic and small-molecule therapies were effective in treating nail psoriasis with variable effect size magnitudes [-0.89 (-1.10, -0.68), I ² = 84%]. In particular, tofacitinib and ixekizumab showed the most significant scale of effect size magnitudes in treating nail psoriasis (-1.08 points and -0.93 points, respectively). We also found that a higher dose of tofacitinib and ixekizumab had similar effectiveness, and anti-IL-17 agents seem to be superior in effectiveness compared to anti-TNF-α therapies in the treatment of nail psoriasis. However, these results must be displayed carefully as variable endpoints in different studies. Conclusions and Relevance: This study provides a comprehensive overview of systemic treatments for nail psoriasis. For patients with psoriatic nail damage who are candidates of systemic therapies, the priority should be given to administering biologic and small-molecule therapies, especially anti-IL-17 drugs.

Smoking habits amongst patients with psoriasis and the effect of smoking on clinical and treatment-associated characteristics: A cross-sectional study

BACKGROUND

Psoriasis is a multifactorial, chronic inflammatory skin disease where genetic and environmental factors play a role in the pathogenesis. Smoking is one of the critical environmental factors triggering psoriasis.

OBJECTIVE

The purpose of the present study was to analyse the smoking habits of patients with psoriasis and the effect of smoking on disease characteristics.

METHODS

One hundred and thirty-three patients who applied to the department of Dermatological and Venereal Diseases, Ankara Numune Education and Research Hospital, between May 2018 and May 2019 and were diagnosed with psoriasis participated in the study. Clinical, demographical, and treatment-related characteristics, and smoking habits of patients were recorded.

RESULTS

Sixty-seven point six percent of psoriasis patients were smokers. The presence of moderate to severe psoriasis (P = .028), nail involvement (P = .004), administration of systemic treatment (P = .024) and additional cardiovascular disease (P = .038) frequencies was higher in smokers compared to non-smokers. Besides, a positive correlation was observed between the amount of smoking and psoriasis area and severity index (PASI) (P = .003; r = .32).

CONCLUSIONS

Smoking has many negative effects on patients with psoriasis including higher PASI levels, increased frequency of nail involvement, and cardiovascular diseases. Questioning cigarette smoking in psoriatic patients and supporting smoking cessation may contribute to reducing the adverse impact of smoking on psoriasis.

Small molecule inhibitors and biologics in treating nail psoriasis: A systematic review and network meta-analysis

BACKGROUND

Various systemic immunomodulating therapies have been investigated to treat nail psoriasis, but the efficacy remains unclear.

OBJECTIVE

To perform a systematic review and network meta-analysis to evaluate the efficacy of small molecule inhibitors and biologics in treating nail psoriasis.

METHODS

Eligible studies in online databases were identified until March 10, 2020. To assess the efficacy of small molecule inhibitors and biologics, network meta-analyses with surface under the cumulative ranking curve of improvement in nail score at 10 to 16 and at 24 to 26 weeks, as well as 100% improvement of Nail Psoriasis Severity Index (NAPSI), were performed.

RESULTS

Thirty-nine studies with a total of 13 treatment arms involving 15,673 patients with nail psoriasis were included. An network meta-analysis showed that tofacitinib (weighted mean difference, 56.67; 95% confidence interval [CI], 35.87-77.48) and ixekizumab (weighted mean difference, 59.40; 95% CI, 45.87-72.93) presented the most improvement of nail score at 10 to 16 weeks and 24 to 26 weeks, respectively. For 100% improvement of the Nail Psoriasis Severity Index, ixekizumab showed the best efficacy among all treatments (odds ratio, 2.98; 95% CI, 1.74-5.10).

LIMITATIONS

Insufficiency of eligible data and no long-term follow-up data.

CONCLUSION

Tofacitinib and ixekizumab presented the best efficacy for treating nail psoriasis in 10 to 16 weeks and 24 to 26 weeks, respectively.

Spondylitis-psoriasis-enthesitis-enterocolitis-dactylitis-uveitis-peripheral synovitis (SPEED-UP) treatment

Axial spondyloarthritis (axSpA), psoriatic arthritis (PsA), psoriasis, inflammatory bowel disease (IBD), and noninfectious uveitis form a distinct group among the immune mediated inflammatory diseases. Thus, many patients suffer from more than one of these disease manifestations. Here, we will use the term spondylitis-psoriasis-enthesitis-enterocolitis-dactylitis-uveitis-peripheral synovitis (SPEED-UP) spectrum disease. The aim is to review the new targeted pharmacological treatment options for all these diseases. All biological or targeted synthetic drugs with U.S. Food and Drug Administration (FDA) or European Medicines Agency (EMA) approval for any of the diagnoses axSpA, PsA, psoriasis, IBD, or non-infectious uveitis were included. Some of the drugs have documented efficacy in more than one of the diseases, e.g. tumor necrosis factor (TNF) inhibitors. However, other drugs are particularly effective for a specific inflamed tissue and approved in only one or two of the disease entities, e.g. abatacept for peripheral arthritis and vedolizumab for inflammatory bowel disease. This contributes with bedside to bench understanding of the immunology underlying this disease spectrum and provides clinicians with an overview that can assist stratified treatment decisions. We hope that this review will help guide clinicians to speed up treatment of patients with this disease spectrum.

Association of Nail Psoriasis With Disease Activity Measures and Impact in Psoriatic Arthritis: Data From the Corrona Psoriatic Arthritis/Spondyloarthritis Registry

OBJECTIVE

To examine the association of nail psoriasis with disease activity, quality of life, and work productivity in patients with psoriatic arthritis (PsA).

METHODS

All patients with PsA who enrolled in the Corrona PsA/Spondyloarthritis Registry between March 2013 and October 2018 and had data on physician-reported nail psoriasis were included and stratified by presence vs absence of nail psoriasis at enrollment. Patient demographics, disease activity, quality of life (QOL), and work productivity at enrollment were compared between patients with vs without nail psoriasis using t-tests or Wilcoxon rank-sum tests for continuous variables and chi-square or Fisher exact tests for categorical variables.

RESULTS

Of the 2841 patients with PsA included, 1152 (40.5%) had nail psoriasis and 1689 (59.5%) did not. Higher proportions of patients with nail psoriasis were male (51.9% vs 44.1%) and disabled from working (12.3% vs 7.8%) compared with patients without nail psoriasis (all P < 0.05). Patients with nail psoriasis had higher disease activity than those without nail psoriasis, including higher tender and swollen joint counts, worse Disease Activity Index for Psoriatic Arthritis and Psoriatic Arthritis Disease Activity Score values, and increased likelihood of having enthesitis and dactylitis (all P < 0.05). Patients with nail psoriasis had worse pain, fatigue, and work and activity impairment than those without nail psoriasis (all P < 0.05).

CONCLUSION

Patients with PsA who have nail psoriasis had worse disease activity, QOL, and work productivity than those without nail involvement, emphasizing the importance of identification and management of nail disease in patients with PsA.

Etablierung des Schwerpunktes Psoriasis an der Universitätshautklinik Rostock und eine praxisbezogene Übersicht über die Biologikatherapie der Psoriasis

Die Diagnostik und Behandlung der Psoriasis stellt einen Schwerpunkt an der Universitätshautklinik Rostock dar. Aufgrund des breiten Spektrums verfügbarer Biologikatherapien für die Behandlung der Psoriasis werden in diesem Artikel praxisbezogene Ratschläge für diese Therapieform gegeben. Dabei wird aufgezeigt, wie das optimale Biologikum für einen individuellen Patienten unter Berücksichtigung möglicher Kontraindikationen, krankheitsspezifischer Aspekte und unerwünschter Wirkungen ausgewählt werden kann. Außerdem wird ein mögliches Vorgehen bei Unterbrechung, Wiederaufnahme oder Umstellung von Biologika erwähnt.

Apremilast as a target therapy for nail psoriasis: a real-life observational study proving its efficacy in restoring the nail unit

PURPOSE

Psoriasis, Psoriatic Arthritis and Nail psoriasis are chronic diseases that share a common underlying etiology of immunity dysregulation, enhanced activation of inflammatory pathways and remitting-relapsing course. Although nails represent a small percentage of the body surface involvement of this site can lead to impaired quality of life, severe discomfort and even result in permanent disability. Current therapeutic options for nail psoriasis include a variety of topical and systemic treatments although they are often reported as unsatisfactory from patients either due to their poor effectiveness or disturbing side effects. Recently small molecule drugs such as the PDE4 inhibitors were introduced in clinical practice and specifically apremilast has shown to be an effective new treatment option for psoriasis and psoriatic arthritis. Considering either the specific mechanism of action of apremilast, we performed a real-life observational study of 24 weeks assessing apremilast role in nail psoriasis.

MATHERIALS AND METHODS

Patients received apremilast 30mg bid, orally. Safety and efficacy were assessed at weeks 0, 4, 8, 12 and 24 using Dermatologic Life Quality Index (DLQI) and Nail Area Psoriasis Severity Index (NAPSI). At T0 we took a nail sample to investigate the presence of onychomycosis. Culture tests were performed in all the patients to search for fungi.

RESULTS

We recruited a total of 15 patients with nail psoriasis. The analysis of variance (one-way ANOVA) showed the following results: DLQI (F.15.7; p-value < .00001) and NAPSI (F.9.4; p-value < .00001). Three patients (20%) presented also onychomycoses at the beginning of the treatment.

CONCLUSIONS

Apremilast showed fast and sustained improvement of nail psoriasis over time and a complete resolution of life quality impairment due to the disease.

Management of nail psoriasis

Nail involvement is estimated to affect 80-90% of patients with psoriasis at some point in their lives and is often associated with severe disease. Patients with nail involvement experience pain, functional impairment and social stigma, with significant restriction of daily activities and quality of life. Nail psoriasis is also considered a risk factor for the development of psoriatic arthritis (PsA). Management of nail psoriasis is deemed challenging and as a result, it is often left untreated by physicians. Assessing the severity of nail disease can also be difficult in clinical practice. While the Nail Psoriasis Severity Index is used widely in trials, it is time-consuming and rarely used in the clinic, highlighting the need to develop a simplified disease severity score for nail psoriasis. All patients should be advised to keep their nails short, wear gloves for wet and dirty work, and regularly apply emollient to the nail folds and nail surface. Patients with mild nail psoriasis, without signs of severe cutaneous psoriasis or PsA, may benefit from topical treatment, while systemic treatment is indicated in patients with severe nail involvement. Evidence suggests that all anti-tumour necrosis factor (TNF)-α, anti-interleukin (IL)-17, and anti-IL-12/23 antibodies available for plaque psoriasis and PsA are highly effective treatments for nail psoriasis. This article aims to provide an up-to-date review of the therapeutic options currently available for the management of nail psoriasis in patients with or without skin psoriasis. Therapeutic options for the management of nail psoriasis in children will also be discussed.

Inflammatory nail conditions. Part 1: nail changes in psoriasis

Nail changes are visible in a variety of inflammatory dermatoses. The commonest dermatological condition with nail manifestations is chronic plaque psoriasis. This two-part article reviews the nail signs in psoriasis in Part 1, and the nail changes in cutaneous lichen planus and alopecia areata in Part 2. It provides a brief summary of the salient points in the clinical features, management and prognosis of these entities, with practical recommendations that may be beneficial to all dermatologists.

Ixekizumab and Ustekinumab Efficacy in Nail Psoriasis in Patients with Moderate-to-Severe Psoriasis: 52-Week Results from a Phase 3, Head-to-Head Study (IXORA-S)

Introduction

Patients with plaque psoriasis often have nail psoriasis, which is difficult to treat. Ixekizumab (IXE) and ustekinumab (UST) are biologics with established efficacy in nail psoriasis. We present post hoc data from a head-to-head trial of IXE and UST (IXORA-S) to examine the efficacy in nail psoriasis in patients with moderate-to-severe plaque psoriasis over 52 weeks.

Methods

In IXORA-S,  randomised patients received IXE (N = 136) or UST (N = 166) per label for 52 weeks. Eighty-four (61.8%) and 105 (63.3%) of the patients treated with IXE or UST, respectively, had baseline fingernail psoriasis (Nail Psoriasis Severity Index [NAPSI] > 0); of these, 54 (64.3%) and 63 (60.0%) patients, respectively, had significant baseline fingernail psoriasis (defined as NAPSI ≥ 16 with ≥ 4 fingernails involved). The proportion of patients achieving NAPSI = 0, a NAPSI score change from baseline and correlations in Psoriasis Area of Severity Index (PASI) and NAPSI improvement over 52 weeks were examined.

Results

Progressive improvement occurred in both treatment groups over 52 weeks. Statistically significantly more patients achieved NAPSI = 0 with IXE versus UST by week 16–20, and the proportions continued to increase through week 52 among patients with baseline nail psoriasis (61.9 vs. 28.6%, respectively; P < 0.001), including those with significant nail psoriasis (57.4 vs. 17.5%, respectively; P < 0.001). Similar results were observed for NAPSI score improvement from baseline to week 52. Interestingly, the presence of nail psoriasis was associated with lower skin response with UST but not with IXE.

Conclusions

Ixekizumab was superior to UST in the clearance of nail psoriasis, with earlier improvement continued through 52 weeks regardless of baseline nail severity.

Trial Registration

ClinicalTrials.gov identifier; NCT02561806.