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Moderate improvement in nail psoriasis after methotrexate therapy has been demonstrated in randomized trials 61,62

Nail psoriasis results from psoriatic involvement of the nail bed or nail matrix.Patients with nail psoriasis can develop a wide variety of nail ch. Nail psoriasis has been shown to be associated with longer duration of skin lesions. Recently, a systematic review evaluating the randomized controlled trials has provided some evidence concerning the management of nail psoriasis 16. In a prospective study, the application of 1 fluorouracil solution twice daily for 6 months demonstrated marked improvement in nail pitting and hyperkeratosis in 85 of patients 32. Systemic treatment can be recommended in severe localized nail psoriasis when topical or intralesional therapy has failed or in the treatment of moderate-to-severe psoriasis vulgaris accompanied with nail involvement 4, 7, 9 (Table 2). We have also discussed the available treatment options, including the topical, physical, systemic, and biological modalities, in great detail in order to equip the present day dermatologist in dealing with a big clinical challenge, that is, management of nail psoriasis. A small study showed improvement in pitting and hyperkeratosis after application of 5-FU twice daily for 6 months, although, it was found to worsen onycholysis (4). 1983;5:25962.

Moderate improvement in nail psoriasis after methotrexate therapy has been demonstrated in randomized trials  61,62 2This article has been cited by other articles in PMC. 1a: evidence from meta-analysis of randomized controlled trials (RCTs); Ustekinumab demonstrates strong efficacy data in moderate-to-severe psoriasis (grade A evidence) 2. The EXPRESS RCT found significant improvement in nail disease for improvement in NAPSI score and nail matrix and bed features at weeks 10 and 24 (26. Infliximab has also demonstrated efficacy in psoriasis for patients with an inadequate response to etanercept: in the PSUNRISE RCT, at week 10, 65. There have been no data to support its use in psoriatic arthritis with axial involvement. Van de Kerkhof PC, Segaert S, Lahfa M, Luger TA, Karolyi Z, Kaszuba A et al (2008) Once weekly administration of etanercept 50 mg is efficacious and well tolerated in patients with moderate-to-severe plaque psoriasis: a randomized controlled trial with open-label extension. Psoriasis treatment regimens with CsA have to be adapted to the patient s needs and specific characteristics, after an accurate selection and a careful assessment of the risk/benefit ratio. The most important randomized trials are summarized in Table 1 7, 917. A recent interesting study in 61 obese patients with moderate-to-severe psoriasis evaluated the effects of low-dose CsA (2. While intermittent short courses are associated with dose-dependent, transient, and reversible renal function abnormalities, renal structural alterations have been demonstrated in a small percentage of patients after 2 years of continuous treatment at 5 mg/kg/day 37, 39, 40.

Most patients who respond to treatment will show improvement within 8weeks. Conventional systemic treatments, including methotrexate, cyclosporine, acitretin, and apremilast, as well as intralesional corticosteroids, can also be effective treatments for nail psoriasis. Nail psoriasis can be treated effectively using topical treatments, intralesional treatments, and systemic treatments, but an optimal effect may take up to 1 year. In spite of the long history of corticosteroids in the treatment of nail psoriasis, only a few formal trials of their efficacy have been conducted. The severity of nail disease has been shown to correlate with the severity of skin and joint involvement 2,5.

A Delphi Consensus Approach To Challenging Case Scenarios In Moderate-to-severe Psoriasis: Part 2

Two clinical patterns of nail manifestations have been seen due to psoriasis: nail matrix involvement or nail bed involvement. Sun exposure does not usually improve and may even worsen nail psoriasis. The use of combined local therapies has been demonstrated to produce better results in nail psoriasis. 36 These studies suggest that PDL may be clinically useful in treating lesions caused by nail matrix and bed psoriasis, but more randomized controlled trials are still needed to standardize PDL in nail psoriasis. All three anti-TNF therapies have well-demonstrated efficacy in RA, AS, and PsA 9, 11, 12. Nevertheless, randomised clinical trials (RCTs) in RA strongly suggest that all three TNF inhibitors effectively reduce signs and symptoms, improve physical function, and inhibit progression of structural damage. Rapid improvement in signs and symptoms has been observed following the usual clinical dose of Infliximab (3 mg/kg) in RA patients 34. 2003, 62: 561-564. Psoriasis Online Medical Reference – from diagnosis through treatment. Evidence for this theory derives from the dramatic improvement of severe psoriasis in patients treated with immunosuppressive therapies such as cyclosporine (a potent T cell inhibitor used to prevent transplant rejection) or with TNF- inhibitors (used in other inflammatory diseases such as inflammatory bowel disease, rheumatoid arthritis and ankylosing spondylitis). Arthritis occurs after the onset of skin involvement in two thirds of cases however in 10-15 of patients, it occurs prior to the development of skin lesions. Boehringer Ingelheim has released results of a phase II study of BI 655066 compared to ustekinumab for moderate-to-severe plaque psoriasis. The older Moll and Wright criteria to classify PsA have been largely supplanted by the Classification of Psoriatic Arthritis (CASPAR) classification criteria, which have been shown to have high sensitivity and specificity in diverse settings 4. The MTX in PsA trial randomized 221 PsA patients to placebo or 15 mg of MTX weekly for 6 months 30. In PsA, a small (n 24) double-blind RCT of secukinumab has demonstrated significant improvement in the HAQ disability index (HAQ-DI) and CRP; however, the primary endpoint of ACR20 improvement was not met 62. In vitro studies have demonstrated that cells expressing transmembrane TNF-alfa bound by infliximab are lysed by complement or effector cells. During the 12-week period following infusion, patients treated with infliximab compared to placebo demonstrated improvement in outcomes measured by the Inflammatory Bowel Disease Questionnaire (32 vs. All patients received a single 10 mg/kg dose of infliximab 4 weeks after the initial dose. Psoriasis: In a placebo-controlled trial, 33 patients with moderate to severe plaque psoriasis were randomized to treatment with infliximab 5 mg/kg (n 11), 10 mg/kg (n 11) or placebo (n 11) at 0, 2 and 6 weeks.

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