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Nail psoriasis: An important target to be treated

Presented by
Prof. Peter van de Kerkhof , Radboudumc, the Netherlands
Conference
EADV 2021
Nail psoriasis has a significant impact on patients’ quality of life. Topical options may result in improvement, but biologic agents have demonstrated greater success rates and are recommended for moderate-to-severe nail psoriasis.

When addressing nail psoriasis, a first step is to distinguish the origin of the different nail changes as these can influence the choice of treatment [1]. One should recognise that onycholysis, hyperkeratosis, and discolouration emerge from the nail bed, whereas pitting originates from the nail matrix. Another important consideration is the link between nail psoriasis and psoriatic arthritis. “There is an anatomical association between the nail matrix and the distal interphalangeal joints, which means if there is inflammation in the joints, the nail matrix may be involved and vice versa,” Prof. Peter van de Kerkhof (Radboud University Medical Center, the Netherlands) pointed out. He further indicated that patients with nail psoriasis have a 3-fold risk to develop psoriatic arthritis and thus nail psoriasis might be seen as a biomarker for increased risk to develop psoriatic arthritis [1,2].

There are various topical treatment options for nail psoriasis that are likely more efficacious in nail bed changes than those stemming from the matrix. Calcipotriol, both as monotherapy and in combination with corticosteroids, has a long-standing, large body of evidence with reports of around 50% improvement [3–6]. “There is 1 important aspect: you have to treat long term, you have to be patient and the patient has to be patient and consistent; otherwise topical treatments will be a disappointment,” emphasised Prof. van de Kerkhof.

Also, in non-biologic systemic therapy, long-term treatment is necessary. Agents that have shown efficacy in Nail Psoriasis Severity Index (NAPSI) score are acitretin, cyclosporine, and apremilast [7–9]. However, impressive changes in the treatment of nail psoriasis came with the advent of biologics. “Most convincing are the reports of the IL-17 treatment studies: at week 60, improvements of NAPSI of 80% has been reported with ixekizumab, and 63% improvement with secukinumab at week 32, which really is considerable,” Prof. van de Kerkhof said. With biologics, substantial improvement may be already seen after 8 weeks [10]. According to a network meta-analysis of biologics for nail psoriasis, the most effective agent is currently ixekizumab, followed by etanercept [11]. However, when comparison trials are performed for nail psoriasis, one has to bear in mind that there is heterogeneity in the outcome parameters as, for example, even the NAPSI score definition is not overall consistent [1,11,12].

Treatment for nail psoriasis should be individualised, taking into account the impact of the disease on the quality of life of the patient, while also assessing the objective severity [1]. Topicals may be a first step, classical systemics need especially long-term treatment and will not be effective for all patients, and biologics have the greatest efficacy. “My choice is etanercept in case of more moderate nail psoriasis, in more severe nail psoriasis I would opt for ixekizumab,” Prof. van de Kerkhof added.

“Regard nail psoriasis as an important aspect of psoriasis, because serious nail psoriasis makes that the patient requires an effective treatment,” he encouraged dermatologists in his conclusion.

 


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