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recommendations. They provided recommendations for four different scenarios.12

Psoriasis limited to the nails These patients have minimal or no skin disease and no evidence of joint disease. Up to three fingernails have onycholysis, pitting, and/or distal hyperkeratosis. These patients are embarrassed by the appearance of the nails and have mild pain with use. High-potency topical corticosteroids alone or in combination with calcipotriol and intralesional corticosteroids were recommended. Systemic and biologic treatments are not recommended.

Psoriasis limited to the nails for which topical therapy has failed These patients have up to five nails involved and moderate to severe nail pain. Adalimumab, etanercept, intralesional corticosteroids,

ustekinumab, methotrexate, and acitretin are suggested.

Psoriasis of the skin and nails These patients have psoriasis on 8% of their body surface area, five of ten nails with severe nail dystrophy, and moderate to severe nail-associated pain. Topical therapies have proven inadequate to control disease. Adalimumab, etanercept, ustekinumab, methotrexate, acitretin, infliximab and apremilast can be recommended.

Skin, joint and nail disease

These patients have skin disease on 8% of their body surface area, a history of dactylitis and morning stiffness (psoriatic arthritis), and five of ten nails with severe nail involvement and pain. The recommendations for treatment were, ranked in order from highest to lowest: adalimumab; etanercept; ustekinumab; infliximab; methotrexate; apremilast; and golimumab.

A Cochrane review of interventions for nail psoriasis published in 2013 notes that systemic treatments, such as methotrexate and cyclosporine, may produce significant nail improvement, but have been recommended only in people with additionally diffuse skin or joint involvement because of the associated side-effects. Other therapies include oral retinoids, different kinds of photo- and radiotherapy, ultraviolet B phototherapy and photochemotherapy.13

The Cochrane review of interventions for nail psoriasis reports that treatment

“New targeted therapies, that have unprecedented efficacy in hard to treat and typically non-responsive disease are improving the therapeutic scenario”

with infliximab 5 mg/kg resulted in 57.2% nail score improvement compared with –4.1% for placebo (p<0.001); golimumab 50mg and 100mg showed 33% and 54% improvement in NAPSI, respectively, compared with 0% for placebo (p<0.001), both after medium-term treatment. Studies with topical interventions (5-fluorouracil 1% in a lotion containing urea and propylene glycol, tazarotene 0.1%, calcipotriol 50μg/g, calcipotriol 0.005%) were not better than their respective comparators: urea and propylene glycol lotion, clobetasol propionate,

betamethasone dipropionate with salicylic acid, or betamethasone dipropionate.12 Secukinumab is a first-in-class anti-IL-17A inhibitor and is the first biologic treatment in the EU to be approved as first-line systemic treatment of moderate to severe plaque psoriasis.14,15 In patients with nail psoriasis in the TRANSFIGURE study (n=198), the change from baseline in NAPSI score at week 16 (primary endpoint) was –37.9 and –45.3 versus –10.8 % (p<0.0001) in secukinumab 150 and 300mg versus placebo recipients, respectively.15


response rates (77.0 and 87.1 versus 5.1%; p<0.0001), PASI90 response rates (54.0

and 72.5 versus 1.7%; p<0.0001) and IGAmod2011 response rates (68.3 and 74.0 versus 3.1%; p<0.0001) were also significantly higher in secukinumab recipients.16

Palmo-plantar psoriasis Palmo-plantar psoriasis can be symptomatic and resistant to topical and systemic treatments, in part owing to the increased thickness that hinder drug penetration into the skin.17

These lesions

can lead to painful fissures compromising the ability to carry out activities of daily living, cause psychological distress and reduced quality of life.18

not usually as effective as monotherapy and patients may find the formulations unpleasant.

Crude coal tar ointment with or without a topical steroid under occlusion has been reported to be effective in treating palmo-plantar psoriasis. In one study by Kumar et al, 13 out of 17 (76.5%) patients treated with 6% crude coal tar ointment under occlusion (achieved by wearing socks and gloves) nightly for eight weeks showed greater than 50% improvement with no reported side effects. That compared with 5 out of 11

Topical therapy is


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