Nail Psoriasis: Drug Therapy

Therapy target

Improvement of the symptomatology

Therapy recommendations

The therapeutic approach to psoriasis is classic dermatologic: it consists of basic therapy, topical (local) therapy, and systemic treatment:

• All severities of psoriasis receive basic therapy:
  • Topical therapy:
    • Body (psoriasis)
      • Oil or salt water baths, 2 times initially, then 1 time daily (15-20 min each time), depending on age.
      • Active ingredient-free ointment bases as well as topical urea preparations (5-10%) and salicylic acid preparations (for circumscribed plaques in the head area (from 6 years of age; 1%ig; in children < 8 years total treatment area max. palm size) (= keratolysis).
      • Creams, emulsions or pastes with a low fat content are preferred.
    • Nails (nail psoriasis).
      • First choice
        • Urea: e.g., 15% nail polish (daily for six weeks) or 40% ointment with wing patch.
        • Glucocorticoids (steroids): e.g., betamethasone dipropionate or clobetasol propionate.
        • Vitamin D analogues, e.g. calcipotriol, calcitriol or tacalcitol.
        • If necessary, combinations of steroids and vitamin D analogues.
      • Second choice
        • Intralesional steroids, e.g. triamcinolone.
        • Tacrolimus (0.03-0.1%)
        • Retinoids: tazarotene 0.1 %
• Mild forms (less than ten percent of the body surface affected, PASI (Psoriasis Area and Severity Index), 10 points out of 72 at worst) receive local therapy:
  • Vitamin D 3 compounds [first-line agent in children: Calcipotriol, either as monotherapy or in combination with topical corticosteroids]
  • Dithrantol (cignolin) [suitable in children and adolescents]
  • Topical calcineurin inhibitors
  • Topical glucocorticoids
  • Tar preparations
• Moderate and severe forms of psoriasis receive systemic therapy
  • Agents according to the guideline: ciclosporin (cyclosporin A), fumaric acid esters, methotrexate, and retinoids; also biologicals (adalimumab, etanercept, infliximab, and ustekinumab), if appropriate.
  • UV-B-311-nm phototherapy (narrow-spectrum UV-B phototherapy) or balneophototherapy [for adults; avoided as much as possible in children because of the unexplained risk of photocarcinogenesis (cancer development by light therapy); reserved for exceptional cases in adolescence].
• Nail psoriasis (systemic therapies):
  • First choice: methotrexate 7.5-25 mg p. o. or s. c. 1 time per week, the following day 5 mg folic acid.
  • Second choice: ciclosporin 2.5-5 mg/kg bw p. o. (no long-term therapy!) or acitretin (retinoids) 0.2-0.7 mg/kg bw p. o.
  • Biologics (eg, TNF antagonists, interleukin-12/23 antibodies, interleukin-17 antibodies) are not yet approved for the indication nail psoriasis.
• See also under “Further therapy“.

Further notes

• Acitretin: Due to lack of study data, the European psoriasis guideline gives an “open recommendation”.
• Ciclosporin (cyclosporin A): duration of therapy > 2 years → nephrologist to co-assess possible nephrotoxicity.
• Methotrexate: In the European psoriasis guideline, methotrexate is “strongly” recommended for both induction therapy and long-term therapy.
• Ustekinumab has the highest five-year efficacy compared with etanercept, (assessed using the PASI/Psoriasis Area Severity Index (PASI)): PASI-75 response by treatment with adalimumab or with ustekinumab is higher than with etanercept.
• Compared with fumaric acid ester, secukinumab showed very large positive effects in remissions.
• Ixekizumab compared with ustekinumab: significantly more remissions occurred under ixekizumab.

Phytotherapeutics

A systematic review is available on this topic. The following phytotherapeutics are supported with studies for adjuvant therapy of psoriasis:

• Cayenne pepper ( Capsicum frutescens): capsaicin; note: do not use on the face! Contraindication: injured skin
• Chrysarobin (component of the bark of the araroba or goa tree (Andira araroba)): Cignolin (anthralin, dithranol); Effects: Inhibition of the release of proinflammatory cytokines and the growth of keratinocytes.
• Cartilage carrot ( Ammi majus): from it psoralens; effects: Inhibition of keratinocyte proliferation; in combination with UV-A irradiation (PUVA) also anti-inflammatory effect.
• Mahonia ( Mahonia aquifolium): 10% mahonia cream.
• Niembaums (Azadirachta indica): nimbidin
• Silver willow (Salix alba; salicylic acid from silver willow bark); Effects: Keratolysis