Hope and Healing: Treating Nail Psoriasis Transcript

Roy: My name is Roy Pankey, a psoriasis patient and patient advocate, and I'll be your moderator for today's discussion about nail psoriasis from diagnosis to coping and the latest research and treatments. Joining me today is leading dermatologist, Dr. Paul Yamauchi, who is the President and Medical Director of the Dermatology Institute and Skin Care Center and Clinical Science Institute, and Rebecca Cohen, who offers her experience living with the challenge of nail psoriasis. Welcome Dr. Yamauchi and Rebecca. It's a pleasure having you both on Psoriasis Uncovered. Rebecca, let's start with you.  

Roy: What signs or changes to your nails did you first experience? And how did you learn you had nail psoriasis?

Rebecca: So I was diagnosed with psoriasis as a child. And when I was going through school, I started noticing some changes in my nails. My first signs that I noticed were definitely the thickness, the pitting, the discoloration, some unsightly things I didn't really like. I started getting bullied a lot in school and then realized that my nails were the problem. I went home to my mother. She was a dermatologist, PA, and she was like, it's definitely your psoriasis.  

Roy: And how has it been living with nail psoriasis since that diagnosis?

Rebecca: It has come with its own challenges. I am an interior designer. I spend every day pointing out, pointing to people, pick this instead of that. So everybody looks at my hands and that has been very hard for me to get over emotionally. There is a stigma with the unsightliness of the diagnosis along with the flares that are uncomfortable.   

Roy: You know, the unsightliness is something that all psoriasis patients we can relate to. I have lived with psoriasis now for a decade, have not been diagnosed at any point with nail psoriasis, fortunately at this point. Dr. Yamauchi, we know nail psoriasis which is considered a high impact site, can be difficult to diagnose. What are some of the challenges and how do you diagnose nail psoriasis specifically?   

Dr. Yamauchi: Nail psoriasis affects about 50% of patients with plaque psoriasis and up to 80% of patients with psoriatic arthritis also have nail psoriasis. And nail psoriasis is composed of several elements. Number one, pitting or really tiny dents in the nails. Also white spots can develop on the nail bed as well as red spots and also crumbling. The nails become brittle and start to crumble. In addition, the nail can separate from underneath. It's called onycholysis, and that can be painful for many patients. In addition, the nails themselves can get so thick, it can look like a fungus infection, and also splintered hemorrhages or red streaks can also develop on the nails. Now, if a patient has the nail changes and also has skin psoriasis, then one can make the assumption that the nail changes are due to the psoriasis. However, patients may not have psoriasis on their skin and have only nail changes and that's where it can be challenging to make the diagnosis. So there's other conditions that can look like nail psoriasis but it's not psoriasis itself. And so sometimes you might have to do a biopsy to see if it's nail psoriasis or something else. And there's a research tool called a NAPSI, the Nail Psoriasis Severity Index. It's more of a clinical research tool, but not used in clinical practice because it's a very cumbersome tool to measure. And the NAPSI takes into account what I just talked about. Is there pitting present? Are there white spots present? Any kind of red spots, crumbling, separation of the nail, et cetera. And you have to divide the nail into quadrants and look for those signs in each of the quadrants and use this calculation to come up with the composite score for the NAPSI. So it's more of a research tool that's used but not used in clinical practice.

Roy: Dr. Yamauchi, you mentioned a nail biopsy. I've never heard of that before. How exactly is a nail biopsy conducted if you think somebody has nail psoriasis?

Dr. Yamauchi: So biopsy is done, so first you numb the finger first, and then you take a what's called a punch biopsy. You take like a little cookie cutter, and you take a small circular piece from the nail. It can be any place on the nail, whether it be the bottom of the nail or the middle of the nail. And you take a plug of the nail out, and you send it to the laboratory for analysis.

Roy: That sounds painful.

Dr. Yamauchi: It is painful, but as long as you numb it up properly, then it's very tolerable.

Roy: Rebecca, you were also diagnosed with psoriatic arthritis later in life. What factors related to your nail psoriasis helped make that diagnosis?

Rebecca: Along with the pain and fatigue I was experiencing, thickness in my nails,  ridges, pitting were all key factors in deciding to run blood work to find out if I had psoriatic arthritis.

Roy: Rebecca, related to the physical changes in your nails, can you tell me a little bit more about the ridges that you saw, the pits that you observed, and what changed with the thickness of your nails?                          Rebecca: Yes, my nails became extremely thick. Imagine like a mountain landscape. The ridges were there, very distinct and then pitting like little holes in my nails is what it looked like.

Roy: I know that your nail psoriasis like most psoriasis flares on and off, right? So what would you say triggers your flares and what do you do when your nail psoriasis flares?

Rebecca: A huge trigger of a flare for me is actually external stress from my day to day life. I do have a therapist I speak to regularly. On top of that, there any sort of nail trauma that I might experience from slamming my finger into a door or a cabinet, using chemicals to clean my home, to picking at my cuticles because they're unsightly, will all cause more flaring for me which is even more uncomfortable.

Roy: Mmmm. I'm sure some of those habits can be difficult to avoid, but I am glad to hear that you have some go-to resources whenever those flare-ups do occur. Dr. Yamauchi, once someone is diagnosed with nail psoriasis, what treatment or treatments do you initially start with?

Dr. Yamauchi: In general, you start with topical therapies to treat nail psoriasis. There are several topicals you can choose from. You can choose a steroid cream or ointment to apply on the nail. You can use a vitamin D or vitamin A cream, or you can use a combination of those to apply to the nail. There's also new advanced therapies that do not contain any steroids, such as something called Vtama or Zoryve which can be applied directly to the nail to treat it. However, topical therapy oftentimes is not sufficient to treat nail psoriasis. So then another way to treat it is you do these steroid injections right at the bottom of the nail, at the cuticle. That can be quite painful. And you do that about once every four to six weeks. You can inject steroid injections right into the bottom of nail and that can work. You might have to do several sessions in order to see some degree of improvement. Also, one can use lasers like ultraviolet lasers to treat nail psoriasis and that works fine. But in general, if none of these options work -- topicals, steroid shots or light therapy, then you can go to something more advanced like a advanced pill or an advanced biologic agent to treat nail psoriasis. You have many to choose from. So you might choose the one that might be more convenient for the patient, more preferred. Oftentimes patients will prefer taking a pill to treat nail psoriasis. So the pills available to treat nail psoriasis, the brand ones, are Otzela and Sotyktu, which have demonstrated efficacy to treat nail psoriasis. One can also do a biologic injection to treat nail psoriasis. So a patient has, let's say for example, psoriasis on their skin and their nails, then you can use a biologic agent to treat all areas. Some of the ones that are commonly used are Skyrizi, Tremfya, Bimzelx, Taltz, and Cosentyx. Now it's not a guarantee that any of these advanced systemic agents will improve the nail psoriasis. So you try one option and you give it about maybe four months. If that's not sufficient, if you don't see improvement by four months, then you could try and switch to a different agent, another pill or another injection. In general, it takes about six months for the fingernails to grow from the bottom to the top. So that's why I give it about four months. I think one month into treatment is too early. I've seen patients where they didn't have any kind of progress until three to four months into therapy and you keep doing the therapies and while total resolution of nail psoriasis may not be possible, still any kind of improvement will be a benefit to the patient.

Roy: Rebecca, would you mind sharing your personal experience with medications that you've tried for your nail psoriasis? What's worked best in the past for you?

Rebecca: I’ve tried many different treatments for my nail psoriasis. I started with laser treatments along with topicals and then moved into a biological injection which has seemed to have helped the most. I still will use a topical treatment in partnership with my biologic to help with extreme flares and that seems to be the most effective.

Roy: Gotcha. You know I relate to having myself tried a number of treatment options in the past and sometimes combining those for best effectiveness. Dr. Yamauchi, I've noticed some recent research regarding nail psoriasis, some of which you've actually been a part of yourself. Could you please discuss some of the results with Tildrakizumab, also known as Ilumya, Bimekizumab or Bimzelx, and the topical PDE4 foam, Roflumilast? How effective are these treatments with regards to treating nail psoriasis?

Dr. Yamauchi: So Tildrakizumab or Ilumya, I was a author on this presentation. I presented it at a meeting and it can be quite effective to treat the nail psoriasis. The advantages of Ilumya are that it's an injection every three months. It has a very good safety profile and no significant warnings. So at week 28, a lot of patients did get 75% improvement of their nail psoriasis. So that's one excellent option to treat nail psoriasis is a drug called Ilumya or Tildrakizumab. Another biologic agent called Bimzelx or Bimekizumab, FDA approved for moderate to severe plaque psoriasis also demonstrates very good efficacy to treat the nails and the skin. And so I've had patients where they might have tried one agent and it didn't work and I switched to Bimzelx and that in turn really helped improve the nail psoriasis. I would say that, in my opinion, is a very fast acting drug so I do think that sometimes Bimzelx works faster than the other agents to clear the nail psoriasis. And then the other agent that was mentioned is Zoryve otherwise known as topical roflumilast. Zoryve comes as a cream or a foam 0.3 % and its applied once a day to the psoriasis. And I have used Zoryve to treat nail psoriasis and I've had some patients that have experienced very good results with Zoryve. Overall, in my experience a lot of times the topicals are not sufficient to treat nail psoriasis, then you have to advance to something else. But I do find Zoryve to be very tolerable, very safe, and can be effective to treat nail psoriasis.

Roy: And Dr. Yamauchi, do you foresee any additional research regarding treatment of nail psoriasis given the high impact on quality of life?  

Yamauchi: If nail psoriasis, while it might not sound serious, it does have a high impact on the quality of life. So I've had professionals, attorneys, dentists, where they had nail psoriasis and they were very, very embarrassed by the appearance of nail psoriasis that it affected them in terms of their professional job in dealing with patients and clients. So many patients with nail psoriasis are embarrassed to shake someone's hands, embarrassed to expose their fingernails, because of the fact that they have nail psoriasis and it can be quite unsightly. And so in the future I do anticipate new drugs in development to treat nail psoriasis. Right now all the FDA approved drugs to treat psoriasis whether it be a pill, a topical or injection can be used to treat nail psoriasis and many of these drugs do have data supporting their efficacy to treat nail psoriasis. But in the future, we do have three new oral agents in development. One called Icotrokinra, which works similarly to Ilumya and Skyrizi. It's a pill taken once a day on an empty stomach. And two new oral agents that are called TYK2 inhibitors. So, Sotyktu currently on the market is also a TYK2 inhibitor which I prescribe to treat nail psoriasis and these two new generation TYK2 inhibitors called Zasocitinib and Envudeucitinib hopefully and should get approval to treat nail psoriasis. These new novel oral agents demonstrate very good efficacy to treat psoriasis. I do anticipate using them to treat nail psoriasis and while there may be limited data if at all to treat nail psoriasis, I'm sure that in the future more research will be done to look at the efficacy of these novel oral agents to treat nail psoriasis.                                                                        Roy: Thank you Dr. Yamauchi. The new treatments sound promising. Rebecca, in addition to appropriate treatment for nail psoriasis how you care for your nails is also important. Do you have any nail care tips you would like to share with listeners? And I'm also especially curious to hear about your use of nail polish and if you see an effect on your nails when you use nail polish?

Rebecca: Yeah, when it comes to my nail care, I always go with a motto of less is more. I try to stay away from fake nails and abrasive manicures. I wear gloves when I clean and do my best to keep my hands moisturized. When I'm having an extreme flare and my nails are really painful, occasionally I will use some liquid band aid around my cuticle to prevent from pitting. And I have really noticed an effect on my nails with that. I only polish my nails occasionally for special events, but even then I do notice a difference in the coloration of my nail beds once I take the polish off.  

Roy: Thanks Rebecca. It sounds like you are doing what you need to do. Dr. Yamauchi, are there any additional preventative tips you can add to help reduce the likelihood of developing nail psoriasis?

Dr. Yamauchi: It may be very challenging to prevent nail psoriasis. You never know if it's going to have an impact on your nails if you have psoriasis. But I would say that if you keep your nails short, will be a good way to prevent nail psoriasis. And if you do any kind of manual work, maybe to protect your nails, maybe wear gloves when you're working because sometimes trauma to nails as well as to the skin can cause psoriasis to appear. Also moisturizing your hands and your nails is important. There are several moisturizers out there and many brand names so you just pick and choose which one you like, whether it be a light cream, a heavy cream. Some people like greasy ointments but most people don't. So you want to find a brand that you can pick and choose from that's economic and that's good value to treat and moisturize your hands. So there are many brand names out there. Too many to name, but I would say just maybe ask your dermatologist what moisturizer will be best suited for your hands and your nails.  So there are some products that are nail conditioners and even though you may not have nail psoriasis, if you put a nail conditioner on your nails or any kind of moisturizer on nails that can also prevent the onset of nail psoriasis. And then leave your cuticles alone trying not to pick on your cuticles because that's the case that can cause inflammation and produce nail psoriasis. Also no biting on your nails and also maybe try not to wear artificial nails because sometimes the solvents in these gels can eat away at the nails and cause nail psoriasis. So these are some of the ways one can prevent nail psoriasis from occurring. But if it does happen, then what I just mentioned is a way to keep your nails as healthy as possible and maybe to a certain extent improve the nail psoriasis.                                                                                                                                Roy: And Dr. Yamauchi how do you feel about the use of nail polish?

Dr.  Yamauchi: I know that it’s, it's you’re caught in between a rock and a hard place because I know that people want to use nail polish to hide their nail psoriasis. But at the same time, because they contain solvents that it can eat away at the nails and cause further degradation of the nail psoriasis. So in general, we don’t recommend it. But at the same time, we do understand that people do want to hide the nail psoriasis. So, it's a balance between hiding your nails and preventing them from getting worse.

Roy:  So a lot of people who have special events coming up want to cover their nails with nail polish. Given what you just said, is that OK?

Dr. Yamauchi: Yes, maybe for at certain occasions you could put it on, but not all the time because I've seen many patients where, even people without nail psoriasis, right, these have regular nails, but they keep putting nail polish on every day, it eventually will thin out their nails and make them more brittle.

Roy: Thank you Dr. Yamauchi and Rebecca for such an interesting discussion today about nail psoriasis. It was great to hear an update on the latest treatments and tips for nail psoriasis, which of course Dr. Yamauchi you mentioned will continue to occur, those advancements in treatment options. Do you both have any final comments you would like to share with our listeners today? Rebecca, I'll start with you.

Rebecca: Yeah, when it comes to nail polish, if you're not sure about what you should do with your nails, you can always refer to your dermatologist for advice. Be patient with them. Nail psoriasis is very difficult to treat but be patient with yourself and with your providers to make sure that you get the care that you need.

Roy: Thank you. And Dr. Yamauchi, any final thoughts you would like to mention as well?

Dr. Yamauchi: I would say that of all the different types of psoriasis, psoriasis on the arms, the legs, the torso, scalp psoriasis, psoriasis on the hands and feet - nail psoriasis is probably the most challenging to treat. Probably the most unpredictable variant of psoriasis to treat in terms of the nails. So basically, just be patient with your dermatologist. You try topicals first and don't be skeptical if a dermatologist proposes a advanced systemic option whether it be a pill or an injection to treat your nail psoriasis. In general, these advanced agents are safe and can be effective. So if your nail psoriasis really bothers you, then have an open mind and be willing to take a pill or an injection to treat your nail psoriasis.

Roy: It’s nice to hear you are both in agreement about being patient. Thank you Dr. Yamauchi and Rebecca for being here today to provide some insights on managing nail psoriasis. I learned a lot myself and I'm sure our audience did as well. For our listeners, if you would like more information about nail psoriasis, need help finding a dermatologist, or have questions about treatment options, contact our Patient Navigation Center at education@psoriasis.org. NPF’s work is fueled by our community. If you enjoyed this episode and want to support more great content, please visit psoriasis.org/givepodcast to donate. Thank you for listening to Psoriasis Uncovered where we uncover what you need to know about psoriasis and psoriatic arthritis.  

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