During his session, “Management of Nail Psoriasis,” presented at the 2023 AAD Annual Meeting, Bertrand Richert, MD, PhD, FAAD, discussed the risks associated with arthropathic psoriasis, and how to treat nail psoriasis.

At the start of his session, Dr Richert reminded physicians about the clinical features of psoriasis. First, with proximal matrix, there is surface alteration, which is mainly pitting but could also include trachyonychia. He then showcased distal matrix, which has a similar see-through nail plate, which is either leukonychia or mottled lunula. When there is involvement of the median nail bed, an oil spot is often present, and when the oil spot reaches the distal end of the plate or the bed, then parakeratosis is the result. However, sometimes this can result in onycholysis when all the pancreatic cells remain or distal subungual hyperkeratosis.

“Sometimes nail psoriasis may involve a total nail unit, and you can get a complete distortion of the nail plate, which might be a very big problem,” he stated.

He continued by asking, what is the risk of arthropathic psoriasis? He shared that onycholysis is often associated with arthropathic psoriasis and suggested that physicians ask patients if they are experiencing any joint pain. If so, then a full examination is warranted. He also emphasized that there is no correlation when it comes to skin or nail severity and arthropathic risk. However, risk is associated with the duration of nail involvement.

Next, Dr Richert covered when physicians should treat patients, noting that the treatment will depend on several factors, such as:

• Sex and age
• Disease location in the nail unit
• Whether there is a presentation of skin or joint disease
• Quality of life impact (professional, social, and/or psychological)
• Whether there is a presence of comorbidities
• Health Insurance

He continued onto topical treatments, sharing that whether physicians use topical steroids, tazarotene, vitamin D analogues, or combination calcipotriol/ betamethasone, they will all work the same. Additionally, when using topical treatments, physicians need to remember to clip away the infected nail bed. He noted that further studies are needed on intralesional injections; however, these have shown promising results following a study that utilized triamcinolone 10 ml every 3 to 8 weeks. He then touched on systemic treatments such as methotrexate, which presents an increase matrix involvement that overpowers bed involvement. He also introduced acitretin, which is mainly used for subungual hyperkeratosis. Finally, he showcased cyclosporine, which has an opposite mechanism of action from methotrexate, where the bed involvement is superior to the matrix involvement.

Dr Richert then highlighted a study that compared all psoriasis treatments;  within a 24-month period, all treatments worked the same. However, the only one that worked faster was cyclosporine, which could be beneficial to manage flare ups after treatment. The final treatment he covered was apremilast. Although apremilast shows promising and effective results in current studies, he noted that larger studies are needed.

At the conclusion of his session, Dr Richert stated, “Nail psoriasis is hard and long to treat. Remember that onycholysis is the one which is high risk for psoriatic arthritis. All topicals work the same, and all biologics work the same.”

Reference
Richert B. Management of nail psoriasis. Presented at: AAD Annual Meeting; March 17–21, 2023; New Orleans, LA.