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Nail and scalp involvement


Effect of treatments on nail and scalp psoriasis


Both nail and scalp involvement is common in the course of psoriatic disease and impacts significantly on quality of life; biologic therapies appear to offer a new perspective and promise for better treatment response and patient satisfaction


José Manuel Carrascosa MD PhD Servei de Dermatologia, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Spain


Nail involvement is common in the course of psoriatic disease and can be observed in 50–80% of the patients.1 Recently, it has been shown how psoriatic patients with nail psoriasis have a more severe form of psoriasis, with higher Psoriasis Area Severity Index (PASI) scores body mass index. Although there are reports of isolated nail psoriasis, it usually precedes or accompanies other manifestations of skin and/or joints. In the past few years, the role of the nails as an early marker of enthesitis in the context of the psoriatic arthritis has been shown (a frequency of approximately 85% is found in the latter group). The clinical manifestations may range from minimal involvement, for example, in the form of simple pitting, to extensive changes involving virtually the entire nail units, with destruction and interference with normal function.2


Nail psoriasis is a very visible and exposed disease and therefore may cause significant negative impact on quality of life. Thus, most affected patients wish for a rapid improvement. Even with the availability of modern biologics, no currently available treatment is able to presently meet the patients' demand.3


Topical therapy


Despite advances in the treatment of cutaneous disease, the treatment of nail


“Scalp involvement is present in 80% of patients with psoriasis, often being the starting point of the disease ”


psoriasis remains challenging because of inherent difficulties in topical drug delivery to the involved site. The physical barrier of the nail plate is not penetrated by topical therapies, which therefore have limited efficacy.


There are only a few clinical trials referring to the use of topical therapies in nail psoriasis. In a randomised controlled trial, 58 patients with a long history of the disease were treated with betamethasone dipropionate (64mg/g) in combination with salicylic acid ointment (0.03%/g) and calcipotriol ointment twice a day for three


to five months. Both drugs were able to reduce thickness of nails by about 50% in five months of treatment.4


Another study


compared occlusion and non-occlusion technique using tazarotene 0.1% gel versus vehicle gel in 31 patients showed that onycholysis and pitting tazarotene significantly reduced both symptoms compared with vehicle after 24 weeks.5 The use of phototherapy, anthralin and topical cyclosporin has been successfully tried in a few patients. Summarising the data on topical treatment modalities in nail psoriasis,


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