Nail psoriasis can be treated effectively using topical treatments, intralesional treatments, and systemic treatments, but an optimal effect may take up to 1 year. |
The role of non-pharmacological treatment options, including phototherapy, photodynamic therapy, and laser therapy, is limited. |
An undesirable heterogeneity of outcome measures and scoring systems makes it almost impossible to compare trials. |
1 Introduction
2 Pathophysiology
3 Assessment of Nail Psoriasis
4 Management of Nail Psoriasis
5 Topical Treatment Modalities
5.1 Topical Corticosteroids
5.2 Combination Therapy with Corticosteroids
5.3 Intralesional Corticosteroids
Study, year | Gerstein, 1962 [40] | Abell and Samman, 1973 [41] | Bleeker, 1974 [42] | Peachey et al., 1976 [43] | de Berker and Lawrence, 1998 [44] | Saleem and Azim, 2008 [45] | Nantel-Battista et al., 2014 [165] |
---|---|---|---|---|---|---|---|
No. of patients | 4 | 58 | 400 | 28 | 19 | 35 | 17 |
Dose of triamcinolone (mg/ml) | 10 | 5 | 5 | 5 | 10 | 10 | 8 |
Injection site | Proximal nail fold | Proximal nail fold | Proximal nail fold | Proximal nail fold | Matrix and nailbed | Matrix and nailbed | Proximal nail fold |
Regimen | 1 × 0.2 ml monthly × 6 months | 1–4 × 0.1 ml weekly × 3 weeks | 0.2–0.3 ml monthly × 6 months | 0.1 ml every 4–6 weeks for 6 months | 4 × 0.1 ml once | 4 × 0.1 ml once or twice | 4 × 0.07 ml every 4 weeks |
Follow-up (months) | 14 | 0–24 | 5–20 | 1 | 3–17 | 2–6 | 1 |
Post-therapy improvement (percentage of treated patients) | |||||||
Matrix signs (%) | Combined feature: 35 | ||||||
Pitting | 91 | 68 | 86 | 46 | 71 | ||
Ridging | 94 | 58 | |||||
Thickening | 83 | 18 | |||||
Nailbed signs (%) | |||||||
Onycholysis | 50 | 34 | 19 | 50 | 37 | ||
Subungual hyperkeratosis | 100 | 57 | |||||
Mean target NAPSIa
| −46 % | ||||||
Nail matrix target NAPSIa
| −50 % | ||||||
Nail bed target NAPSIa
| −38 % |
5.4 Vitamin D3 Derivates: Calcipotriol, Tacalcitol, Calcitriol
5.5 Tazarotene
5.6 Topical Calcineurin Inhibitors
5.7 Anthralin
5.8 5-Fluorouracil
5.9 Miscellaneous Topical Therapies: Allopurinol, Intralesional Methotrexate, Colloidal Silicic Acid, Indigo Naturalis Extract
6 Systemic Treatment Modalities
7 Oral Systemic Treatments
7.1 Methotrexate
Study, year | Dose | Study design | Inclusion | Outcome measure | Observations (weeks) | Baseline | 10–20 weeks | 21–30 weeks | >30 weeks | No. of patients |
---|---|---|---|---|---|---|---|---|---|---|
Acitretin (A)/etretinate (E) | ||||||||||
Demirsoy et al., 2013 [80] | A: unknown | PCS | PP | NAPSI | 16 | 23.8 | −25 % | 25 | ||
Mahrle et al., 1995 [82] | E: 0.5–0.75 mg/kg/day | RCT | PP | Not specified | 10 | −9 % | 47 | |||
Sanchez-Regana et al., 2011 [79] | A: 25 mg/day, >6–12 weeks: 2–4×/week | RCS | PP | NAPSI | 12, 24, 48 | 12.7 | −19 % | −41 % | −52 % | 7 |
Tosti et al., 2009 [87] | A: 0.2–0.3 mg/kg/day | PCS | Nails only | NAPSI, target NAPSI | 26 | NAPSI: 31.5, target NAPSI: 7.6 | NAPSI: −41 %, target NAPSI: −50 % | 36 | ||
Apremilast | ||||||||||
Papp et al., 2015 [89] | 30 mg bid | RCT | PP | Target NAPSI, NAPSI-50d
| 16, 32 | −23 % | −44 % | 558 | ||
Rich et al., 2016 [91] | 30 mg bid | RCT | PP | Target NAPSI, NAPSI-50e
| 16, 32 | −29 % | −60 % | 266 | ||
Cyclosporine | ||||||||||
Feliciani et al., 2004 [53] | 3–4.5 mg/kg/day | PCS | PP | Involved area (<10/10–50/>50 %) | 14 | −48 % | 21 | |||
Feliciani et al., 2004 [53] | 3–4.5 mg/kg/day, calcipotriol cream bid | PCS | PP | Involved area (<10/10–50/>50 %) | 14 | −79 % | 33 | |||
Gumusel et al., 2011 [77] | 5 mg/kg/day | PCS | PP | NAPSI | 24 | 16.3 | −37 % (NS)c
| 17 | ||
Karanikolas et al., 2011 [84] | 2.5–3.75 mg/kg/day | PCS | PsA | NAPSI-50 | 52 |
f
| 18 | |||
Karanikolas et al., 2011 [84] | 2.5–3.75 mg/kg/day, 40 mg adalimumab EOW | PCS | PsA | NAPSI-50 | 52 |
g
| 21 | |||
Mahrle et al., 1995 [82] | 2.5–5 mg/kg/day | RCT | PP | Not specified | 10, 22 | −18 % | −46 % | 90 | ||
Sanchez-Regana et al., 2011 [79] | 3 mg/kg/day | RCS | PP | NAPSI | 12, 24, 48 | 12.7 | −38 % | −72 % | −89 % | 9 |
Syuto et al., 2007 [83] | 3 mg/kg/day, in case of improvement 1.5 mg | PCS | PP | Not specified | 16–65 |
a
| 16 | |||
Leflunomide | ||||||||||
Behrens et al., 2013 [94] | According to daily clinical practice | PCS | PsA | 5-point scale | 24 | 32 % of treated patients showed improvement at 24 weeks | 466 | |||
Methotrexate | ||||||||||
Demirsoy et al., 2013 [80] | Unknown | PCS | PP | NAPSI | 16 | 25.1 | −18 % | 20 | ||
Gumusel et al., 2011 [77] | Initial dose 15 mg qw | PCS | PP | NAPSI | 24 | 16.3 | −43 % (NS)b
| 17 | ||
Reich et al., 2011 [78] | 5–15 mg qw (weeks 0–9), 20 mg qw (weeks 10–15), 25 mg qw (>week 16) | RCT | PP | Target NAPSI | 24 | 4.8 | −30 % | 108 | ||
Sanchez-Regana et al., 2011 [79] | 7.5–25 mg qw | RCS | PP | NAPSI | 12, 24, 48 | 12.7 | −7 % | −31 % | −35 % | 9 |
7.2 Cyclosporine
7.3 Retinoids
7.4 Apremilast
7.5 Miscellaneous Systemic Therapies: Fumaric Acid Esters, Sulfasalazine, and Leflunomide
8 Biologics
Study, year | Dose | Study design | Inclusion | Outcome measure | Observation (weeks) | Outcomes (as defined in ‘Outcome measure’) | No. of patients | |||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Baseline (target) NAPSI | 11–20 weeks | 21–30 weeks | >30 weeks | NAPSI-50 | NAPSI-75 | NAPSI-90 | Complete clearance | |||||||
Adalimumab | ||||||||||||||
Al-Mutairi et al., 2013 [103] | 80 mg at baseline, 40 mg q2w | ROL | PP | NAPSI | 24 | 32.9 | −71 % | 105 | ||||||
Bardazzi et al., 2013 [123] | Unknown | RCS | PP | NAPSI, NAPSI-75 | 12, 24, 36 | 32.0 | −66 % | −89 % | −94 % | 89 % (36 weeks) | 16 | |||
Van den Bosch et al., 2010 [95] | 40 mg q2w | PCS | PsA | NAPSI, NAPSI-50 | 12 | 14 | −57 % | 54 % | 259 | |||||
Karanikolas et al., 2011 [84] | 40 mg q2w | PCS | PsA | NAPSI-50 | 52 | 56 % | 16 | |||||||
Karanikolas et al., 2011 [84] | 40 mg q2w, CsA 2.5–3.75 mg/kg/day | PCS | PsA | NAPSI-50 | 52 | 100 % | 21 | |||||||
Kyriakou et al., 2013 [124] | 80 mg at baseline, 40 mg q2w | RCS | PP | NAPSI | 12, 24, 48 | 25.8 | −36 % | −71 % | −87 % | 14 | ||||
Leonardi et al., 2011 [119] | 80 mg at baseline, 40 mg q2w | RCT | PP | Target NAPSI | 16, 28 | 3.9 | −50 % | −54 % | 28 | |||||
Ozmen et al., 2013 [125] | 80 mg at baseline, 40 mg q2w | PCS | PP | NAPSI, modified NAPSI, NAPSI-50, NAPSI-75, NAPSI-90 | 48 | NAPSI: 72.0, modified NAPSI: 71.8 | NAPSI: −54 %, modified NAPSI: −49 % | 75 % | 13 % | 0 % | 0 % (48 weeks) | 8 | ||
Rigopoulos et al., 2010 [96] | 80 mg at baseline, 40 mg q2w | PCS | PP, PsA− | NAPSI | 12, 24 | 10.6 | −47 % | −85 % | 7 | |||||
Rigopoulos et al., 2010 [96] | 80 mg at baseline, 40 mg q2w | PCS | PP, PsA+ | NAPSI | 12, 24 | 24.9 | −46 % | −86 % | 14 | |||||
Rudwaleit et al., 2010 [116] | 40 mg q2w | PCS | PsAe
| NAPSI | 12 | 18 | −42 % | 36 | ||||||
Rudwaleit et al., 2010 [116] | 40 mg q2w | PCS | PsAf
| NAPSI | 12 | 14 | −33 % | 223 | ||||||
Saraceno et al., 2013 [126] | 80 mg at baseline, 40 mg q2w | PCS | PP | NAPSI, NAPSI-75 | 12, 24 | 33.1 | −37 % | −66 % | 50 % | 20 | ||||
Sanchez-Regana et al., 2011 [79] | 80 mg at baseline, 40 mg q2w | RCS | PP | NAPSI | 12, 24, 48 | 17.5 | −37 % | −73 % | −84 % | 8 | ||||
Sola-Ortigosa et al., 2012 [122] | 80 mg at baseline, 40 mg q2w | RCS | PP | NAPSI | 24 | 18,9 | −57 % | 15 | ||||||
Thaci et al., 2015 [117] | 80 mg at baseline, 40 mg q2w | RCT | PP | NAPSI, matrix NAPSI, bed NAPSI | 8, 16 | 25.4 | −40 % | 457 | ||||||
Briakinumab | ||||||||||||||
Reich et al., 2011 [78] | 200 mg weeks 0, 4, +100 mg q4w | RCT | PP | Target NAPSI | 24 | 4.8 | −56 % | 115 | ||||||
Certoluzimab Pegol | ||||||||||||||
Mease et al., 2014 [135] | 200 mg q2w | RCT | PsA | Modified target NAPSI | 24 | 3.1 | −52 % | 92 | ||||||
Mease et al., 2014 [135] | 400 mg q4w | RCT | PsA | Modified target NAPSI | 24 | 3.4 | −59 % | 105 | ||||||
Etanercept | ||||||||||||||
Al-Mutairi et al., 2013 [103] | 50 mg biw, >12 weeks: 25 mg biw | ROL | PP | NAPSI | 24 | 33.8 | −68 % | 110 | ||||||
Bardazzi et al., 2013 [123] | Unknown | RCS | PP | NAPSI, NAPSI-75 | 12, 24, 36 | 32.0 | −62 % | −85 % | −90 % | 89 % (36 weeks) | 18 | |||
Barrera et al., 2008 [131] | 25 mg biw | RCS | PP | Descriptive | 24 | Significant improvement <12 weeks | 39 | |||||||
Barrera et al., 2008 [131] | 50 mg biw, >12 weeks: 25 mg biw | RCS | PP | Descriptive | 24 | Significant improvement <12 weeks | 27 | |||||||
Kyriakou et al., 2013 [124] | 50 mg biw, >12 weeks: 25 mg biw | RCS | PP | NAPSI | 12, 24, 48 | 23.4 | −42 % | −76 % | −92 % | 13 | ||||
Luger et al., 2009 [13] | 50 mg biw, >12 weeks: 25 mg biw | PCS | PP | Target NAPSI | 12, 54 | 4.6 | −29 % | −51 % | 30 % (54 weeks) | 562 | ||||
Ortonne et al., 2013 [132] | 50 mg biw, >12 weeks: 50 mg qw | ROL | PP | NAPSI, target NAPSI, NAPSI-50, NAPSI-75, CC | 24 | NAPSI: 34.8, target NAPSI: 6.0 | NAPSI: −65 %, target NAPSI: −72 % | 58 % (12 weeks), 82 % (24 weeks) | 57 % (24 weeks) | 14 % (24 weeks) | 38 | |||
Ortonne et al., 2013 [132] | 50 mg qw | ROL | PP | NAPSI, target NAPSI, NAPSI-50, NAPSI-75, CC | 24 | NAPSI: 31.4, target NAPSI: 5.8 | NAPSI: −72 %, target NAPSI: −76 % | 51 % (12 weeks), 81 % (24 weeks) | 69 % (24 weeks) | 31 % (24 weeks) | 34 | |||
Ozmen et al., 2013 [125] | 50 mg biw, >12 weeks: 25 mg biw | PCS | PP | NAPSI, modified NAPSI, NAPSI-50, NAPSI-75, NAPSI-90 | 48 | NAPSI: 86.7, modified NAPSI: 81.2 | NAPSI: −58 %, modified NAPSI: −60 % | 78 % | 0 % | 0 % | 0 % (48 weeks) | 9 | ||
Saraceno et al., 2013 [126] | 50 mg biw, >12 weeks: 25 mg biw | PCS | PP | NAPSI, NAPSI-75 | 12, 24 | 34.8 | −32 % | −70 % | 45 % | 20 | ||||
Sanchez-Regana et al., 2011 [79] | 50 mg biw, >12 weeks: 50 mg qw | RCS | PP | NAPSI | 12, 24, 48 | 17.5 | −24 % | −68 % | −87 % | 9 | ||||
Golimumab | ||||||||||||||
50 mg/4 weeks | RCT | PsA | Target NAPSI, PGAa
| 14, 24, 52 | 4.7 | −25 % | −43 % | −52 % | 95 | |||||
100 mg/4 weeks | RCT | PsA | Target NAPSI, PGAb
| 14, 24, 52 | 4.6 | −33 % | −54 % | −66 % | 109 | |||||
Infliximab | ||||||||||||||
Al-Mutairi et al., 2013 [103] | 5 mg/kg weeks 0, 2, 6, +8w | ROL | PP | NAPSI | 24 | 34.1 | −86 % | 100 | ||||||
Bardazzi et al., 2013 [123] | Unknown | RCS | PP | NAPSI, NAPSI-75 | 12, 24, 36 | 32.0 | −64 % | −86 % | −91 % | 89 % (36 weeks) | 14 | |||
Bianchi et al., 2005 [114] | 5 mg/kg weeks 0, 2, 6, +8w | PCS | PP | NAPSI | 16, 22 | 28.3 | −65 % | −100 % | 100 % (22 weeks) | 9 | ||||
Bianchi et al., 2005 [114] | 5 mg/kg weeks 0, 2, 6, +8w | PCS | PsA | NAPSI | 16, 22 | 33.3 | −61 % | −100 % | 100 % (22 weeks) | 16 | ||||
Fabroni et al., 2011 [113] | 5 mg/kg weeks 0, 2, 6, +8w | RCS | PP | NAPSI, NAPSI-50, NAPSI-75, NAPSI-90 | 14, 22, 38 | 49.7 | −63 % | −81 % | −86 % | 98 % (38 weeks) | 81 % (38 weeks) | 29 % (38 weeks) | 10 % (38 weeks) | 48 |
Kyriakou et al., 2013 [124] | 5 mg/kg weeks 0, 2, 6, +8w | RCS | PP | NAPSI | 12, 24, 48 | 25.2 | −49 % | −80 % | −95 % | 80 % (48 weeks) | 12 | |||
Ozmen et al., 2013 [125] | 5 mg/kg weeks 0, 2, 6, +8w | PCS | PP | NAPSI, modified NAPSI, NAPSI-50, NAPSI-75, NAPSI-90 | 48 | NAPSI: 69.6, modified NAPSI: 72.7 | NAPSI: −40 %, modified NAPSI: −40 % | 55 % | 0 % | 0 % | 0 % (48 weeks) | 11 | ||
Reich et al., 2005 [100] | 5 mg/kg weeks 0, 2, 6, +8w | RCT | PP | Target NAPSI, CC target fingerc
| 10, 24 | 4.6 | −56 % | 26 % (24 weeks) | 235 | |||||
Rich et al., 2008 [106] | 5 mg/kg weeks 0, 2, 6, +8w | RCT | PP | Target NAPSI, CC target finger | 50 | 4.6 | −56 % | 45 % (50 weeks) | 235 | |||||
Rigopoulos et al., 2008 [105] | 5 mg/kg weeks 0, 2, 6, +8w | PCS | PP | NAPSI | 14, 22, 38 | 55.8 | −47 % | −61 % | −94 % | 61 % (38 weeks) | 18 | |||
Saraceno et al., 2013 [126] | 5 mg/kg weeks 0, 2, 6, +8w | PCS | PP | NAPSI, NAPSI-75 | 12, 24 | 33.3 | −55 % | −91 % | 65 % | 20 | ||||
Sanchez-Regana et al., 2011 [79] | 5 mg/kg weeks 0, 2, 6, +8w | RCS | PP | NAPSI | 12, 24, 48 | 17.5 | −50 % | −81 % | −92 % | 81 % (48 weeks) | 8 | |||
Torii et al., 2010 [108] | 5 mg/kg weeks 0, 2, 6, +8w | RCT | PP | Target NAPSI, involved number of nails | 10, 14, 26, 42, 62 | Target NAPSI: 3.7, involved nails: 7.3 | −28 % | Target NAPSI: −46 %, involved nails: 3.0 | Target NAPSI: −46 %, involved nails: 1.6 | 29 | ||||
Torii et al., 2011 [109] | 5 mg/kg weeks 0, 2, 6, +8w | PCS | PP | Target NAPSI | 10, 25, 50 | 4.4 | −59 % | −57 % | 59 % (50 weeks) | 56 | ||||
Ixekizumab | ||||||||||||||
Langley et al., 2015 [143] | RCT | PP | NAPSI | 24, 48 | 36.4 | −78 % | −79 % | 51 % (48 weeks) | 50 | |||||
Leonardi et al., 2012 [142] | 10 mg, weeks 0–2–4–8–12 | RCT | PP | NAPSI | 20 | 41.9 | 14 % | 13 | ||||||
Leonardi et al., 2012 [142] | 25 mg, weeks 0–2–4–8–12 | RCT | PP | NAPSI | 20 | 34.9 | −24 % | 10 | ||||||
Leonardi et al., 2012 [142] | 75 mg, weeks 0–2–4–8–12 | RCT | PP | NAPSI | 20 | 45.0 | −57 % | 10 | ||||||
Leonardi et al., 2012 [142] | 150 mg, weeks 0–2–4–8–12 | RCT | PP | NAPSI | 20 | 26.5 | −49 % | 10 | ||||||
Secukinumab | ||||||||||||||
Paul et al., 2014 [139] | 150 mg week 0 | RCT | PP | Composite fingernail score (affected area) | 12 | 8.9 | −4 % | 51 | ||||||
Paul et al., 2014 [139] | 150 mg weeks 0, 4, and 8 | RCT | PP | Composite fingernail score (affected area) | 12 | 8.9 | −11 % | 110 | ||||||
Paul et al., 2014 [139] | 150 mg weeks 0, 1, 2, and 4 | RCT | PP | Composite fingernail score (affected area) | 12 | 8.9 | −19 % | 101 | ||||||
Ustekinumab | ||||||||||||||
Bardazzi et al., 2013 [123] | Unknown | RCS | PP | NAPSI, NAPSI-75 | 12, 24, 36 | 32.0 | −51 % | −82 % | −88 % | 89 % (36 weeks) | 6 | |||
Igarashi, 2012 [149] | 45 mg (weeks 0–4–16–28) | RCT | PP | Target NAPSI | 12 g
| 3.7 | NS | −57 % | 44 | |||||
Igarashi et al., 2012 [149] | 90 mg (weeks 0–4–16–28) | RCT | PP | Target NAPSI | 12 g
| 4.1 | NS | −64 % | 40 | |||||
Patsatsi et al., 2013 [148] | 45 mg (weeks 0–4–16–28) | PCS | PP | NAPSI | 12, 28, 40 | 76.7 | −44 % | −87 % | −97 % | 27 | ||||
Rich et al., 2014 [150] | 45 mg (weeks 0–4–16–28) | RCT | PP | Target NAPSI, number of nails involved | 12, 24 | Target NAPSI: 4.4, involved nails: 6.6 | Target NAPSI: −27 %, involved nails: 6.1 | Target NAPSI: −47 %, involved nails: 5.1 | 182 | |||||
Rich et al., 2014 [150] | 90 mg (weeks 0–4–16–28) | RCT | PP | target NAPSI, number nails involved | 12, 24 | Target NAPSI: 4.4, involved nails: 6.7 | Target NAPSI: −25 %, involved nails: 6.0 | Target NAPSI: −49 %, involved nails: 5.3 | 187 | |||||
Rigopoulos et al., 2011 [147] | <100 kg: 45 mg (weeks 0–4–16–28); >100 kg: 90 mg | PCS | PP | NAPSI, QoL | 4, 16, 28, 40 | 19.6 | −50 % | −80 % | −90 % | 27 | ||||
Vitiello et al., 2013 [146] | <100 kg: 45 mg (weeks 0–4); >100 kg: 90 mgh
| RCS | PP | NAPSI, modified target NAPSI | 12 | NAPSI: 22.3, modified target NAPSI: 6.3 | NAPSI: −34 %, modified target NAPSI: −17 % | 13 |