What's the best treatment for nail psoriasis? NPF and GRAPPA offer answers

| Melissa Leavitt

Biologic drugs are among the most effective treatments for nail psoriasis, particularly when topical treatments have failed, according to two recent reviews of clinical trials and other studies on therapy options for the disease.

Nail involvement occurs in up to half of people with psoriasis, and at least 80 percent of people with psoriatic arthritis. The disease, which can be difficult to treat, can also negatively impact quality of life, authors of the reviews note.

One review, authored by the National Psoriasis Foundation Medical Board and published in January 2015 in JAMA Dermatology, offered treatment recommendations for four kinds of nail psoriasis cases. For patients who primarily have psoriasis on the nails, the authors suggested the use of topical corticosteroids. However, if this treatment has failed, the researchers recommended biologic drugs Humira (adalimumab) and Enbrel (etanercept), or intralesional corticosteroid injections, as the next line of treatment.

For patients who have psoriasis on the skin as well as the nails, the authors most strongly recommended Humira, Enbrel and Stelara (ustekinumab) if topicals fail. These three drugs also earned the highest recommendation for patients with joint involvement.

Another review, published in November 2014 in the Journal of Rheumatology, showed biologic therapies to be some of the best—and best-tested—treatments for the disease, according to the review authors, members of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) Nail Psoriasis Work Group.

Studies have also shown that some topicals, including Dovonex (calcipotriol), Taclonex (a combination of calcipotriol and betamethasone dipropionate), and Protopic (tacrolimus) could be a modestly effective initial treatment for nail psoriasis, according to the researchers. In addition, oral systemics, including methotrexate and cyclosporine A, can be helpful at high doses, the researchers reported.

But the review also highlighted a need for more high-quality randomized controlled trials evaluating nail psoriasis treatments, according to Dr. April Armstrong, an NPF Medical Board member who was the lead author of the study. Authors of the NPF review agree, noting that clinical data is limited.

"Although several therapies exist for nail psoriasis, the quality of evidence supporting each treatment is variable," said Armstrong. "To date, biologic medications seem most effective for psoriatic nail disease."


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