eMedicine Specialties > Dermatology > Papulosquamous Diseases
Psoriasis, Nails: Treatment & Medication
Updated: Oct 29, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Medical Care
Many treatment options are available after the diagnosis of nail psoriasis is made. The treatments focus on improvement of the functional and psychosocial aspects of psoriatic nail disease. No curative treatment exists at the present time. Onychomycosis (if present) requires antifungal therapy for improvement. The treatment options for nail psoriasis include topical corticosteroids, intralesional corticosteroids, psoralen plus ultraviolet light A (PUVA),3 topical fluorouracil,4 topical calcipotriol,5 topical anthralin,6 topical tazarotene,7,8 topical cyclosporin,9 avulsion therapy,10 and systemic therapy for severe cases.
For preventive care, keep the nails dry and protect them from trauma to avoid the Koebner effect. In areas of onycholysis, the nail plate should be trimmed to the point of separation for medications to be effective.
- Topical treatment with high-potency corticosteroid solution or ointment under occlusion with cellophane wrap at bedtime can improve nail psoriasis. Avoid long, continuous therapy with corticosteroids to avoid tachyphylaxis. Also, avoid prolonged occlusion (not to exceed 2 wk). Topical 1% 5-fluorouracil solution or 5% cream applied twice daily to the matrix area for 6 months without occlusion improves pitting and subungual hyperkeratosis. A topical preparation of a combination of high-potency corticosteroid and calcipotriol may benefit some patients.11
- PUVA is very effective for cutaneous psoriasis and can improve nail psoriasis. Both oral and topical PUVA therapies have improved nail psoriasis in 3-6 months. A possible adverse effect of PUVA may be nail discoloration.
- Intralesional triamcinolone acetonide suspension of 2.5 mg/mL into the proximal nail fold is very helpful for nail matrix psoriasis (eg, pitting, ridging, leukonychia). This medication may be administered every 4-6 weeks. The proximal nail fold is sprayed first with a refrigerant spray for anesthesia, and the injection is given with a 30-gauge needle.
- Systemic therapies have been used in patients with severe cutaneous psoriasis. Few studies have shown significant improvement in nail psoriasis with long-term results. At present, 3 systemic medications are most commonly used for psoriasis and nail psoriasis: methotrexate, retinoids,12 , and cyclosporin.13 All 3 agents have potential serious adverse effects and toxicities. In most cases, the psoriatic nail disease recurs after the systemic therapy is stopped. Carefully weigh the risk-to-benefit ratio in the treatment of nail psoriasis. Systemic therapies are seldom a first-line therapy for nail psoriasis. Topical treatment with calcipotriol can be used as adjunctive therapy and maintenance therapy with systemic treatment. Biological therapy for psoriasis and psoriatic arthritis may have a significant benefit for some patients with psoriatic nail disease.14
- Avulsion therapy with chemical or surgical means can be used as an alternative therapy for psoriatic nail disease. Chemical avulsion therapy includes the use of urea ointment in a special compound to the affected nail under occlusion for 7 days, and the nail is removed atraumatically. Chemical avulsion therapy is painless, involves no blood loss, and is less expensive than surgical avulsion.
- At present, no definitive and curative treatment has been agreed upon by medical experts. Discuss all treatment options for psoriatic nail disease with the patient, and choose the best individually tailored regimen.
Surgical Care
Surgical avulsion therapy can be performed for psoriatic nail disease when other treatments have failed. During surgery, the matrix can be electively ablated to prevent regrowth of the nail. This procedure is performed under local anesthesia. Inform patients of postoperative discomfort, limitations, and possible physical nail disfigurement.
Activity
Avoiding trauma to the nail, which prevents onycholysis and possible secondary microbial colonization in the nail, is important. Patients should keep psoriatic nails clean and dry.
Medication
The goals of pharmacotherapy are to reduce morbidity and to prevent complications.
Corticosteroids
These agents have anti-inflammatory properties and cause profound and varied metabolic effects. In addition, these agents modify the body's immune response to diverse stimuli.
Triamcinolone (Aristocort)
For inflammatory dermatosis responsive to steroids; decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing capillary permeability. Many other topical steroids are also available.
Adult
Topical: Apply thin film to affected area bid/tid
Intralesional: 2.5 mg/mL into proximal and/or lateral nail fold q4-6wk; proximal and/or lateral nail fold is sprayed first with a refrigerant spray for anesthesia, and injection is given with a 30-gauge needle
Pediatric
<12 years: Not established
>12 years: Apply as in adults
None reported
Documented hypersensitivity; fungal, viral, and bacterial skin infections
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Do not use in decreased skin circulation; prolonged use, applying over large areas, and using potent steroids and occlusive dressings may result in systemic absorption; systemic absorption may cause Cushing syndrome, reversible HPA-axis suppression, hyperglycemia, and glycosuria
Betamethasone (Diprolene, Betatrex)
For inflammatory dermatosis responsive to steroids. Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing capillary permeability.
Adult
Apply thin film to affected area bid/qid until response
Pediatric
Apply as in adults
Effects decrease with coadministration of barbiturates, phenytoin, and rifampin; decreases effect of salicylates and vaccines used for immunization
Documented hypersensitivity; paronychia; cellulitis; impetigo; angular cheilitis; erythrasma; erysipelas; rosacea; perioral dermatitis; acne
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Do not use in skin with decreased circulation; can cause atrophy of groin, face, and axillae; if infection develops and is not responsive to antibiotic treatment, discontinue until infection is under control; do not use monotherapy to treat widespread plaque psoriasis
Clobetasol (Temovate)
Class I superpotent topical steroid; suppresses mitosis and increases synthesis of proteins that decrease inflammation and cause vasoconstriction.
Adult
Apply to affected area bid for up to 2 wk; not to exceed 50 g/wk
Pediatric
Not established
None reported
Documented hypersensitivity; viral or fungal skin infections
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
May suppress adrenal function in prolonged therapy
Calcipotriene and betamethasone topical ointment
Calcipotriene is a synthetic vitamin D-3 analog that regulates skin cell production and development. Inhibits epidermal proliferation, promotes keratinocyte differentiation, and has immunosuppressive effects on lymphoid cells. Betamethasone is a corticosteroid that decreases inflammation by suppressing migration of PMN leukocytes and reversing capillary permeability. Available as a topical ointment containing calcipotriene 0.005% and betamethasone dipropionate 0.064%.
Adult
Apply to nail area qd for up to 4 wk
Pediatric
Not established
Coadministration with other corticosteroids may increase toxicity
Documented hypersensitivity; known or suspected calcium metabolism disorders; erythrodermic, exfoliative, or pustular psoriasis
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
May cause hypercalcemia; systemic absorption of topical corticosteroids has caused HPA-axis suppression, Cushing syndrome manifestations, hyperglycemia, and glucosuria; not for prolonged use (ie, >4 wk), large surface areas (ie, >30% of body surface area), or application with occlusive dressings; do not use on face, eyes, axillae, or groin; may cause contact dermatitis
Psoralens
These agents are very effective for cutaneous psoriasis and can improve nail psoriasis. They may improve nail psoriasis in 3-6 months.
Trioxsalen (Trisoralen)
Inhibits mitosis by covalently binding, in the presence of UV-A radiation, to pyrimidine bases in DNA.
Adult
0.2-0.5 mg/kg PO 2-4 h before controlled exposure to UV-A or sunlight; not to exceed 14 d
Pediatric
<12 years: Not established
>12 years: Administer as in adults
None reported
Documented hypersensitivity; history of melanoma, acute lupus erythematosus, or porphyria
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Severe burns may occur from sunlight or UV-A exposure if dose or frequency is exceeded
Methoxsalen (8-MOP, Oxsoralen)
Inhibits mitosis by covalently binding to pyrimidine bases in DNA when photoactivated by UV-A.
Adult
0.57 mg/kg 1.5-2 h before exposure to UV light, at least 48 h apart
Pediatric
Not established
Toxicity increases with phenothiazines, griseofulvin, nalidixic acid, tetracyclines, thiazides, and sulfanilamide
Documented hypersensitivity; squamous cell cancer; cataract; light sensitive diseases, such as lupus or porphyria; ingestion of photosensitizing drugs; hepatitic disease; arsenic therapy
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Severe burns may occur; use only if response to other forms of therapy is inadequate
Antimetabolites
These agents inhibit cell growth and proliferation.
Fluorouracil (Efudex)
Interferes with DNA synthesis by blocking the methylation of deoxyuridylic acid and inhibits thymidylate synthetase, which subsequently reduces cell proliferation.
Adult
5% strength recommended; apply sparingly to cover lesions bid; therapy may be required for 10-12 wk (minimum 3 wk)
Pediatric
Not established
None reported
Documented hypersensitivity; potentially serious infections; pregnancy
Pregnancy
X - Contraindicated; benefit does not outweigh risk
Precautions
Incidence of inflammatory reactions may occur with occlusive dressings; porous gauze dressing may be applied for cosmetic reasons without increase in reaction
Methotrexate (Folex, Rheumatrex)
Unknown mechanism of action in treatment of inflammatory reactions; may affect immune function. Ameliorates symptoms of inflammation (eg, pain, swelling, stiffness).
Antimetabolite that inhibits DNA synthesis and cell reproduction in malignant cells; may suppress immune system. Satisfactory response seen in 3-6 wk following administration.
Adult
7.5 mg test dose; check CBC count and LFT in 1 wk; 15-75 mg IM given at q1-2wk; alternatively, 10-25 mg/wk PO/IM or 2.5-7.5 mg PO q12h for 3 doses/wk
Pediatric
Not recommended
Oral aminoglycosides may decrease absorption and blood levels of concurrent oral MTX; charcoal lowers levels; coadministration with etretinate may increase hepatotoxicity; folic acid or its derivatives contained in some vitamins may decrease response; coadministration with NSAIDs may be fatal if high doses of MTX are used, but NSAIDS have been used safely with MTX when doses of 7.5-15 mg/wk have been used (as in treatment of rheumatoid arthritis); indomethacin and phenylbutazone can increase plasma levels; may decrease phenytoin serum levels; probenecid, salicylates, procarbazine, and sulfonamides, including TMP-SMZ, may increase effects and toxicity; may increase plasma levels of thiopurines; NSAIDs increase serum levels by displacing it from albumin and inhibiting renal excretion
Documented hypersensitivity; alcoholism; hepatic insufficiency; documented immunodeficiency syndromes; preexisting blood dyscrasias (eg, bone marrow hypoplasia, leukopenia, thrombocytopenia, significant anemia)
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Monitor CBC counts monthly, and liver and renal function q1-3mo during therapy (monitor more frequently during initial dosing, dose adjustments, or when risk of elevated MTX levels, eg, dehydration); has toxic effects on hematologic, renal, GI, pulmonary, and neurologic systems; discontinue if significant decrease in blood counts; aspirin, NSAIDs, or low-dose steroids may be administered concomitantly with MTX (possibility of increased toxicity with NSAIDs, including salicylates, has not been tested)
Keratolytics
These agents cause cornified epithelium to swell, soften, macerate, and then desquamate.
Anthralin (Anthra-Derm, Drithocreme)
May upset oxidative metabolic processes, decreasing rate of epidermal cell proliferation.
Applications in excessive amounts may stain clothing.
Adult
Apply sparingly and gently to psoriatic lesions qd
Pediatric
Not established
Long-term corticosteroid treatment withdrawal may cause complications of rebound phenomenon (allow 1 wk interval between discontinuation of corticosteroids and initiation of anthralin therapy)
Documented hypersensitivity; acutely or actively swollen psoriatic lesions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in renal disease; do not apply to face or genitalia and avoid eye contact; discontinue application if redness develops
Retinoids
These agents decrease the cohesiveness of abnormal hyperproliferative keratinocytes and may reduce the potential for malignant degeneration. They modulate keratinocyte differentiation. They have been shown to reduce the risk of skin cancer formation in patients who have undergone renal transplantation.
Tazarotene (Tazorac)
Retinoid prodrug whose active metabolite modulates differentiation and proliferation of epithelial tissue; may also have anti-inflammatory and immunomodulatory properties. Mechanism of action in psoriasis is not defined. Has been shown to inhibit cornified envelope formation in human keratinocyte cultures, whose buildup is an element of the psoriatic scale. Use 0.05% or 0.1% gel.
Adult
Begin with lowest formulation and increase as tolerated; apply thin film to cover lesion qd (2 mg/cm2); not to exceed >20% of BSA; lower frequency of application if irritation develops
Pediatric
<12 years: Not established
>12 years: Apply as in adults
Avoid concomitant dermatologic medications and cosmetics that have a strong drying effect
Documented hypersensitivity; pregnancy
Pregnancy
X - Contraindicated; benefit does not outweigh risk
Precautions
Common adverse events reported are limited to the skin and include pruritus, burning, stinging, erythema, irritation, rash, desquamation, and irritant contact dermatitis; discontinue if excessive irritation; rinse thoroughly if contact with eyes, eyelids, or mouth; may cause severe irritation in eczematous skin; photosensitivity may occur
Acitretin (Soriatane)
Retinoic acid analog, like etretinate and isotretinoin. Etretinate is main metabolite and has demonstrated clinical effects close to those seen with etretinate. Mechanism of action is unknown.
Adult
25 or 50 mg/d PO initially given as single dose with main meal
Maintenance dose: 25-50 mg/d PO after initial response to treatment; terminate therapy when lesions have resolved sufficiently
Pediatric
Not established
Increases toxicity methotrexate (avoid concomitant use); interferes with effects of microdosed progestin minipill; coadministration with alcohol may enhance synthesis of etretinate, which has much longer half-life than acitretin (>120 d)
Documented hypersensitivity; pregnancy
Pregnancy
X - Contraindicated; benefit does not outweigh risk
Precautions
Do not use in severe obesity; women of childbearing age must be capable of complying with effective contraceptive measures; recommended that contraception be continued for at least 3 y after stopping treatment with acitretin; etretinate may form from acitretin, which takes about 2-3 y to clear from the body; caution if impaired renal or liver function; perform AST, ALT, and LDH tests prior to initiation of acitretin therapy at 1- to 2-wk intervals until stable and thereafter at intervals as clinically indicated
Immunosuppressives
These agents inhibit key factors of the immune system.
Cyclosporine (Sandimmune, Neoral)
Demonstrated to be helpful in a variety of skin disorders, especially psoriasis. Cyclic polypeptide that suppresses some humoral immunity and, to a greater extent, cell-mediated immune reactions, such as delayed hypersensitivity, allograft rejection, experimental allergic encephalomyelitis, and graft vs host disease for a variety of organs. For children and adults, base dosing on ideal body weight.
Adult
2.5-5 mg/kg/d PO in divided doses
Pediatric
Administer as in adults
Carbamazepine, phenytoin, isoniazid, rifampin, and phenobarbital may decrease concentrations; azithromycin, itraconazole, nicardipine, ketoconazole, fluconazole, erythromycin, verapamil, grapefruit juice, diltiazem, aminoglycosides, acyclovir, amphotericin B, and clarithromycin may increase toxicity; acute renal failure, rhabdomyolysis, myositis, and myalgias increase when taken concurrently with lovastatin
Documented hypersensitivity; uncontrolled hypertension or malignancies; do not administer concomitantly with PUVA or UV-B radiation in psoriasis because it may increase risk of cancer
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Evaluate renal and liver functions often by measuring BUN, serum creatinine, serum bilirubin, and liver enzyme levels; may increase risk of infection and lymphoma; reserve IV use only for those who cannot take PO
Vitamins
These agents are essential for normal DNA synthesis and cell function.
Calcipotriene (Dovonex)
Synthetic vitamin D-3 analog that regulates skin cell production and development. Used in the treatment of moderate plaque psoriasis.
Adult
Apply a thin film to affected skin bid to response
Pediatric
Not established
None reported
Documented hypersensitivity; hypercalcemia; vitamin D toxicity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Discontinue treatment if skin becomes irritated; discontinue if serum calcium level is increased outside of reference range
More on Psoriasis, Nails |
| Overview: Psoriasis, Nails |
| Differential Diagnoses & Workup: Psoriasis, Nails |
 Treatment & Medication: Psoriasis, Nails |
| Follow-up: Psoriasis, Nails |
| Multimedia: Psoriasis, Nails |
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References
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Further Reading
Keywords
psoriasis of nails, nail psoriasis, psoriatic nails, psoriatic nail disease, psoriatic nail disorder, arthritis mutilans, symmetric polyarthritis, psoriatic arthritis, asymmetric oligoarthritis, ankylosing spondylitis
