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Nail and scalp involvement

there is still a lack of efficient, safe, and patient-accepted modalities.

Systemic therapy

The use of systemic therapies can be slightly more promising compared with topical therapy. In a retrospective study involving 84 patients with moderate to severe psoriasis and/or psoriatic arthritis, the authors concluded a higher effectiveness of biological therapy (efalizumab, infliximab, etanercept and adalimumab) compared with classical systemic therapy (acitretin, cyclosporine, methotrexate, PUVA and narrowband UVB) at the endpoints of 12, 24 and 48 weeks.6 Thus, biologic therapy, despite its limitations, has to be considered nowadays as the best option in the management of severe nail psoriasis7

(Table 1).

In the double-blind, placebo-controlled European Infliximab for Psoriasis Efficacy and Safety Study (EXPRESS), 305 patients with baseline nail involvement showed significantly greater reductions in Nail Psoriasis Severity Index (NAPSI) scores with infliximab (5mg/kg intravenously at weeks 0, 2, 6 and every eight weeks to week 46) than with placebo. From week 24 onwards, patients in the placebo group of this trial were crossed over to infliximab therapy and treatment was continued for up to one year. At weeks 10, 24 and 50,6.9%, 26.2% and 44.7%, respectively, of patients in the infliximab group had complete clearing of nail involvement, as compared with 1.7%, 5.1% and 48.2% in the placebo-infliximab group.8 In the CRYSTAL study, the

improvement of NAPSI in the 711 (352 in 359 in continuous therapy and intermittent therapy) patients treated with etanercept was of 51%.9

In the NAIL study, Ortonne et

al conducted a randomised clinical trial the main objective of which was to analyse the efficacy and safety of etanercept in patients with nail psoriasis. At 24 weeks of treatment, a significant correlation between the values of NAPSI and PASI was detected, and NAPSI showed a significant decrease in both groups.10

Up to 6.5% of subjects treated with adalimumab in the REACH study, a randomised, placebo-controlled clinical trial, achieved NAPSI 50 versus placebo (12.5%) at week 16.2


In the multinational, open-label Safety and Efficacy Study of Adalimumab in Patients with Active Psoriatic Arthritis (STEREO) in 442 patients, 259 of whom had nail involvement, mean NAPSI scores improved with adalimumab treatment

Table 1: Strength of recommendation and level of evidence in biologic therapy in nail and scalp psoriasis Strength of recommendation

Nail psoriasis Infliximab Etanercept Adalimumab Ustekinumab

Scalp psoriasis Infliximab Etanercept Adalimumab Ustekinumab






I=at least one controlled/randomised clinical trial; III=expert opinion, descriptive studies; clinical observations or consensus documents . Adapted from Sanchez-Regana et al2

Level of evidence21

“Biologic therapy has to be considered nowadays as the best option in the management of severe nail psoriasis”

from 20.6 at baseline to 11.5 at week 12 and 7.3 at week 20.11

In the PHOENIX 1 trial (randomised, Phase III), an average reduction of 25% NAPSI at 12 weeks and 50% at 24 weeks were shown in patients treated with ustekinumab. Also, significant improvements in nail psoriasis have been observed in other studies involving ustekinumab.

Scalp psoriasis

The scalp is one of the most common sites of psoriasis involvement at the onset and throughout the course of psoriasis.12


psoriasis (SP) is present in 80% of patients with psoriasis, often being the starting point of the disease. SP, however, can range from very mild disease to severe disease with thick, crusted plaques covering the entire scalp. An additional characteristic is that the psoriatic areas often advance beyond the hair border on the face, neck, or retro auricular regions. Pruritus is common in patients with SP. In severe, recalcitrant, or prolonged disease, occurrence of alopecia can be found to some degree. SP is associated with a significant deterioration in the quality of life, affecting self-esteem, social life and lifestyle of the affected patients. In fact, 57% of the affected patients present psychological disorders and social stress related to itching and scaling.13

Topical therapy

Topical treatments are the main option for SP, whatever the level of disease severity. In this sense, this location represents one of the most challenging aspects of the disease to manage, because

the presence of hair makes the use of ointments and cream-based products difficult to use. Moreover, all topical therapeutic strategies finally affect cosmetic hair condition.

A recently published systematic review identified 26 trials of scalp psoriasis with 8020 participants.14

Despite a range of

topical therapeutic options, there is substantial evidence for only a few of them: clobetasol propionate; betamethasone dipropionate; betamethasone valerate; calcipotriol; and calcipotriol combined with potent steroid. Other corticosteroids suggest similar performance, although findings are based on single trials. In the study,14


treatments were more effective than placebo, meaning that all may have clinical value in the management of individual patients.

Corticosteroid creams have been the mainstay of treatment for SP for over 30 years. Efficacy and rapid action of this family of topical treatments has made them one of the most frequently prescribed in the short term. They have been considered as more effective than calcipotriol and coal tar, although there are very few comparative studies in the literature. Regarding long-term treatment (more than four weeks), there is insufficient evidence to support any conclusions concerning the efficacy and safety of corticosteroids in general or the advantages of one formulation over another.15

The galenic preparation could be relevant in scalp psoriasis. In this sense, the application of a topical corticosteroid in the form of a shampoo improves the quality of life and satisfaction

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