New guidelines on nail psoriasis address four clinical manifestations of the disease. The recommendations by the Medical Board of the National Psoriasis Foundation appeared as a consensus statement in the January issue of JAMA Dermatology.
Limitations in clinical trial data make comparing treatments difficult, noted lead author Dr. Jeffrey J. Crowley of Bakersfield (Calif.) Dermatology and his associates. “There are limited data to evaluate or support the use of combination therapy in nail psoriasis. Thus, treatment options recommended in this review are monotherapy,” the guidelines authors added (JAMA Dermatol. 2015;151:87-94).
To develop the guidelines, the research team searched PubMed for articles on nail psoriasis dating from Jan. 1, 1947 through May 11, 2014. They evaluated these studies for level of evidence based on recommendations for writing guidelines from Dr. Paul G. Shekelle of the VA West Los Angeles Medical Center and his associates (BMJ 1999;318:593-6).
They also polled the Medical Board of the National Psoriasis Foundation regarding their treatment approach for four clinical presentations of nail psoriasis:
• For treatment-naive patients with psoriasis of the nails only (affecting at least 3 of 10 fingernails), the board recommended initial treatment with high-potency topical corticosteroids (with or without calcipotriol), with intralesional corticosteroids as a secondary option. Intralesional corticosteroids have been used for decades, but clinical data supporting their use are “extremely limited,” the guidelines state.
• For extensive nail psoriasis (affecting at least five fingernails and causing moderate to severe pain) that has failed topical treatment, the board recommended adalimumab most enthusiastically, followed by etanercept, intralesional corticosteroids, ustekinumab, methotrexate sodium, and acitretin in decreasing order.
• For concurrent skin and nail disease without joint involvement (defined as skin disease on at least 8% of the body surface and moderately to severely painful dystrophy of at least 5 of 10 nails), the board strongly recommended adalimumab, etanercept, and ustekinumab, and also recommended methotrexate, acitretin, infliximab, and apremilast.
• For concurrent nail, skin, and joint involvement (defined as skin disease on 8% of the body surface, a history of dactylitis and morning stiffness (psoriatic arthritis), and severe, painful involvement of at least 5 of 10 nails), the board most strongly recommended adalimumab, followed by etanercept, ustekinumab, infliximab, methotrexate, apremilast, and golimumab.
Continue for study findings >>