Local therapies of nail psoriasis only rarely induce complete remission of the disease

When the nail folds are affected, regular application of topical emollients is useful to reduce scaling and prevent self-induced trauma.

Topical steroids, or combinations of topical steroids with salicylic acid and/or retinoic acid, are widely prescribed. Their efficacy is poor, even when applied with occlusive dressing after chemical or mechanical avulsion of the onycholytic nail plate. Long-term application of topical steroids may result in marked atrophy of the soft tissues of the digits or even in focal resorption of the distal phalanges.

A nail lacquer containing 8% clobetasol propionate, formulated to optimize penetration of the drug through the nail plate, has been developed for use in this condition. This topical treatment, which is effective and well tolerated, produces improvement in most cases of nail psoriasis, with effects directly related to the duration of treatment.

Topical calcipotriol is effective when onycholysis and subungual hyperkeratosis are prominent symptoms. Topical tazarotene 0.1 % gel has also been used with good results and tolerability in psoriasis. The latter drug is especially effective in reducing onycholysis (in occluded and non-occluded nails) and pitting (in occluded nails).

Topical psoralens followed by exposure to ultraviolet-A (PUVA) are not very effective owing to poor penetration of the UVA through the nail plate, especially when the plate is thickened. However, this treatment may be useful in pustular psoriasis when recurrent pustular lesions have destroyed the nail plate. Intralesional injections of triamcinolone acetonide 10 mg/ml, at a dose of 0.2-0.5 ml per nail, have proved effective in some cases of nail matrix psoriasis. In patients with nail-plate surface abnormalities the steroids should be injected in the nail matrix, whereas in patients with subungual hyperkeratosis the site of injection should be the nail bed. Injections should be repeated monthly for 6 months, then every 6 weeks for the next 6 months and finally every 2 months for 6-12 months. A digital block is sometimes useful to make the treatment less painful, but when several digits are involved, a wrist block may be the appropriate anaesthesia. However, routine use of this treatment is not recommended because of the pain caused by the injections, the local side-effects and recurrence of the nail abnormalities after discontinuation of the therapy. In addition, the efficacy of intralesional steroids in nail matrix psoriasis is limited, with only 50% success in treating nail pits.

Systemic treatment with methotrexate or cyclosporin can clear the nail changes, but this can be recommended only when nail psoriasis is associated with widespread disease or psoriatic arthritis.

Retinoids are of little value in the treatment of nail psoriasis except for hyperkeratotic nails and pustular psoriasis. Oral administration of etretinate or acitretin can even worsen the nail changes owing to the development of nail brittleness, pyogenic granuloma-like lesions and chronic paronychia. Oral photochemotherapy can improve crumbling of the nail plate and psoriatic involvement of the proximal nail fold, but is less effective in nail pitting or subungual hyperkeratosis. Superficial radiotherapy can have a beneficial effect on psoriatic nails but is not recommended because the benefits are short-lived.

Pustular psoriasis of the nail unit usually fails to respond to conventional topical treatments. Local treatment with topical anti-metabolites (mechlorethamine, 1 % fluorouracil) is an option, even though results are variable. Systemic steroids, PUVA and cyclosporin can arrest the development of pustular lesions and avoid permanent scarring of the nail apparatus. A study of 46 patients with pustular psoriasis of the nails indicates that systemic retinoids at low dosage (less than 0.5 mg of acitretin per day) are the treatment of choice in patients with multiple nail involvement, whereas topical calcipotriol is the best option for pustular psoriasis limited to one or two nails. Topical calcipotriol is also useful as maintenance therapy in patients who responded to retinoids, in order to prevent recurrence.

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