36 Practical Dermatology March 2005

It’s often viewed as the most difficult

aspect of psoriasis to treat, but success

isn’t just a matter of luck. Specialists offer advice

on treatment regimens and general nail care.

ith the plethora of psoriasis treat-ments available, it seems that at least one

or two agents should stand out as effective,first-line therapy for nail psoriasis. Instead,

psoriasis of the nails poses significant therapeuticchallenges for dermatologists and a cosmetic burden for patients.While systemic agents ranging from methotrexate to the newerbiologic agents often effectively treat nail psoriasis, such therapy isnot indicated for the small percentage of patients who presentwith only nail involvement or who present with only mild psori-asis on other body sites. Yet, even when systemic therapy is indi-cated, patients with widespread disease may require the addition

of topical agents to specifically target the nails.The biologic agents seem to show promise and may one day

become the treatment of choice for recalcitrant or severe cases ofnail psoriasis. Until then, dermatologists are left to rely on topicalagents and steroid injections, which understandably can leaveboth you and your patients frustrated. To help minimize this frus-tration, several specialists offer tips on treatment selection andgeneral nail care.

Treatment SelectionPsoriasis of the nails presents a significant physical, psychological,and cosmetic burden for patients, and simple everyday tasks such

By Angela Batluck,Associate Editor

W

March 2005 Practical Dermatology 37

as buttoning a shirt become arduous, while simple social cus-toms like hand shaking are avoided. “Interestingly, it affectsmen equally if not, in some cases, more so than women becausewomen can disguise it. It’s more acceptable for them to cover itup to a certain extent than it is for men,” says nail specialistPhoebe Rich, MD, Clinical Assistant Professor of Dermatologyat Oregon Health Sciences Center and in private practice inPortland.

Dr. Rich notes that about five percent of psoriasis patientshave psoriasis on their nails alone. “Those are the people thatare most difficult to diagnose and treat because it can look likea lot of different things in the nails,” she states. In fact, somepatients may undergo several courses of antifungal medicationwith their primary care physician before they are referred toyour care.

Of course, with psoriasis of the nails, the possibility existsthat a patient will present with a concomitant infection. As aresult, psoriasis specialist Charles Crutchfield, III, MD ofCrutchfield Dermatology in Eagan, MN, and ClinicalAssistant Professor of Dermatology at the University ofMinnesota recommends doing a DTM culture and a PAS stainto determine if a concomitant fungal infection is present. “Icover both ways because if you have an underlying nail dystro-phy, often times you’re at a higher risk for developing an infec-tion,” Dr. Crutchfield explains.

One of the greatest frustrations for dermatologists treatingnail psoriasis is that what works for one patient doesn’t neces-sarily work for another. In fact, because treatment success variesso greatly from patient to patient, Dr. Crutchfield believes it ishelpful to tell patients from the very beginning that nail psori-asis is one of the most difficult forms of psoriasis to treat.“Once I frame their expectations, and they know that some-times it’s impossible to treat, then they’re not unhappy. They at

least know we’re trying, and about half the time we’ll achievesome degree of satisfactory success,” says Dr. Crutchfield.

Steroid InjectionsIntralesional corticosteroid injections have the reputation ofbeing the most effective treatment—with the exception of oraland biologic therapy—as well as the most potentially uncom-fortable. But, warns nail expert Richard Scher, MD, Professorof Clinical Dermatology and Head of the Section for Diagnosisand Treatment of Nail Disorders at the College of Physiciansand Surgeons at Columbia University, it’s important not toover-state the discomfrot. Unlike topical medications, whichlack the ability to sufficiently penetrate the nail matrix or nailbed, “cortisone injections concentrate medication exactlywhere the problem occurs,” Dr. Scher says.

Although some dermatologists are hesitant to do cortisoneinjections due to the associated discomfort, Drs. Rich, Scher,and Crutchfield routinely turn to this treatment and havedeveloped strategies to enhance patient comfort. Drs. Scherand Rich explain that they anesthetize the site of injection withcooling spray, such as fluoroethyl spray or ethyl chloride, whileDr. Crutchfield finds applying a topical anesthetic such asLMX (4-5% lidocaine, Ferndale) is helpful. Dr. Rich has alsofound that diluting the steroid with lidocaine helps to mini-mize pain. “The first drop is uncomfortable, but after that thearea goes numb,” notes Dr. Rich, adding that even children andadolescents tend to tolerate the discomfort. For the actualinjection, Dr. Scher recommends using a 30-gauge needle toslowly inject 2.5-3mg/mL of triamcinolone acetonide. He sug-gests doing the injections once a month until improvement andthen reducing injections to once every six weeks or once everytwo months.

Whether the psoriasis affects the nail matrix or the nail bed

will determine the site of injection. Dr.Rich says injections tend to work bestfor psoriasis of the nail matrix since it isimpossible to get topical agents downinto the root of the nail. For nail matrixpsoriasis, Dr. Scher says to inject in thenail fold. Dr. Crutchfield additionallycautions against injecting too deeply toavoid bruising. On the other hand, forpatients with psoriasis of the nail bed,Dr. Scher recommends injecting thesteroid along the lateral nail fold. Keepin mind, however, that the nail bed mayrespond to topical agents. “It’s a littleeasier to get medication down therebecause you can drip it under the nail,”Dr. Rich says. Therefore, if a patientpresents with both nail matrix and nailbed psoriasis, then a combinationapproach with a steroid injection andone or more topical agents such as top-ical steroids, topical tazarotene, topicalcalcipotriene, or topical cyclosporinemay be the most effective non-systemicapproach.

Although intralesional steroid injec-tions prove helpful for some patients,results are not long-term. “Even if youcan get patients’ nails looking prettygood, when you stop the injection, theyusually eventually get it back, just likethey do with psoriasis elsewhere,” Dr.Rich states. In addition, not all patientswill respond to this therapy. To sparepatients of unnecessary discomfort, Dr.Crutchfield typically treats only one ortwo fingers initially to see whether thepatient’s nail psoriasis responds.

Topical AgentsTopical agents may also be helpful inthe management of nail psoriasis, but asDr. Rich points out, they tend to targetthe nail bed more effectively than thenail matrix. Unfortunately, no one top-ical agent stands out as the treatment ofchoice for nail psoriasis, but the special-ists we spoke with did offer specificcombinations that have proven benefi-

cial for some of their patients. Psoriasis specialist Lawrence Green,

MD, Assistant Professor ofDermatology at George WashingtonUniversity School of Medicine and inprivate practice in Rockville, MD, hasfound using a combination of Tazoracgel (tazarotene, Allergan) andAquaphor (Beiersdorf ) with or with-out an alternating day class I or IIsteroid ointment for one to twomonths is helpful, particularly forpatients who experience pitting andcrumbling of the nails. He instructspatients to apply the Aquaphor aroundthe edges of the nail plate and then toapply Tazorac over the entire nail, care-fully avoiding the edges to minimizeirritation. He then has patients applyanother layer of Aquaphor over theentire nail. “Aquaphor over Tazorachelps make it more moisturizing,” Dr.Green explains. “A lot of times I’ll useAquaphor and Tazorac without topicalsteroids.”

Dr. Crutchfield notes that for somepatients, a nightly application of a classIII steroid such as triamcinoloneproves helpful. He also has found thattwo-week “bursts”—two weeks on,two weeks off—with Cordran Tape(flurandrenolide, Oclassen) benefitsome patients when applied to the nailmatrix and left on overnight. Dr. Scheralso has found flurandrenolide tape tobenefit some patients, noting that itworks better than steroid creams orointments. Psoriasis specialist RobertKalb, MD of the Buffalo MedicalGroup and Clinical Associate Professorof Dermatology at State University ofNew York at Buffalo, finds a minorityof his patients respond well to a com-bination of topical steroids and topicalcalcipotriene.

Systemic TherapyAlthough nail psoriasis tends to respondbest to systemic agents, not all patients

38 Practical Dermatology March 2005

Treating Nail Psoriasis

Corticosteroid injection for nail psoriasis (top). Fornail matrix psoriasis, inject in the nail fold. Forpsoriasis of the nail bed inject along the lateralnail fold.

Pitting (middle), discoloration, and crumbling ofthe nails usually bothers patients. Nail cosmeticsmay camouflage these.

Even artificial nails (bottom) may be acceptable.Dr. Rich recommends gels and silk wraps ratherthan acrylics and emphasizes that nails must bekept short.

Photos courtesy of Phoebe Rich, MD

Treating Nail Psoriasis

40 Practical Dermatology March 2005

are candidates for such therapy for various reasons.“Methotrexate and cyclosporine should only be used for severe,incapacitating psoriasis because of their adverse effects,” notesDr. Scher. Unlike older systemic agents like methotrexate, thebiologic agents appear to be associated with far fewer side effectsand also appear to be very effective for nail psoriasis, accordingto Dr. Scher and Dr. Rich. Unfortunately, until studies provethat the five percent of patients who present with nail involve-ment alone are candidates for biologic therapy, most insurancecompanies will not cover this therapy.

Even for patients with widespread psoriasis who are candi-dates for systemic therapy, no one agent has proven most effec-tive for the nails. As all the experts noted, any systemic agentthat clears the skin may benefit the nails. At the same time, Dr.Kalb points out, “There are many patients whose psoriasis canclear or clear completely, but their nail psoriasis may not changeat all.” In setting patients’ expectations, it’s particularly impor-tant to educate patients that the nails respond more slowly tosystemic therapy than does the skin. “There’s always a delayfrom the time the skin clears until the time the nails clear,” Dr.Rich explains, pointing out that it takes up to 12 months togrow a new toenail and approximately six months to grow a newfingernail.

Nail CareAlthough all of the agents discussed above can play an impor-tant role in managing nail psoriasis, don’t overlook the impor-tant role general nail care can play in keeping the psoriasis undercontrol. In particular, general nail care should aim at moisturiz-ing, strengthening, and protecting the nails. General moisturiz-ing and strengthening agents can benefit all patients with nailpsoriasis. In fact, Dr. Crutchfield instructs his patients to keepthe cuticle and matrix regions moisturized with AmLactinLotion (Upsher-Smith) and to strengthen the nail by takingAppearex (2.5mg biotin, Merz).

“To minimize trauma, instructpatients to keep fingernails and toenails filed and trimmed short so that they do not extend beyond

the tip of the finger.”

“To minimize trauma, instructpatients to keep fingernails and toenails filed and trimmed short so that they do not extend beyond

the tip of the finger.”

Patients must also understand the importance of protectingthe nails by avoiding any trauma. “That Koebner reaction inthe nail keeps the psoriasis going,” says Dr. Rich. “I don’t meantraumatized by major injury, but rather minor, repetitivebumping all day long.” To minimize trauma, instruct patientsto keep fingernails and toenails filed and trimmed short so thatthey do not extend beyond the tip of the finger. “Keepingthem filed—not filing the surface of the nail—but filing thefree-edge and keeping them clipped back is quite helpful,” Dr.Rich explains. Caution your patientsagainst buffing the nails in attemptto buff out the pits. “I thinkthat can actually worsenthe psoriasis,” Dr.Rich says, notingthat mentend to dothis more sothan women.

Although keep-ing nails short ishelpful for allpatients, this is par-ticularly importantfor patients whocomplain of theirnails catching oneverything due toonycholysis, says Dr.Scher. For patients whocomplain of hyperkerato-sis, Dr. Scher instructsthem to gently smooth thenails down, and for thosewho complain of brittlenails, he recommends keepingthem well lubricated. He adds thatpatients can use a soft toothbrush to gently clean nails. Forpsoriasis of the toenails, Dr. Green advises his patients to avoidtraumatizing the nail. Helpful strategies include wearing shoesthat fit properly, keeping toenails short, and wearing socks tocushion the toes.

Equally important to your male and female patients isadvice on nail cosmetics. Patients are desperate for ways to dis-guise pitting, crumbling, and discoloration and have manyquestions on how they can safely mask the un-appealingappearance of the disease. The experts we spoke with encour-age patients to use nail cosmetics, but Dr. Green does cautionhis patients against overusing nail polish and remover sincethis can dry out the nails. For patients who desire to use nail

polish, recommend that they use formaldehyde-free productsand acetone-free nail polish remover. “Some men do wear clearnail polish. The problem is the shine. There are a few matteones that aren’t shiny and don’t look like nail polish. That canactually give the illusion of the nail plate being more smooth,”explains Dr. Rich. Ridge fillers can also help with pitting bygiving the illusion of a smooth nail, but similar to colorless nailpolish, ridge fillers do not hide the discoloration commonlyassociated with nail psoriasis.

Visits to the nail salon are even acceptable, as longas patients warnthe nail techni-cian not to usem e c h a n i c a li n s t r u m e n t sthat may injurethe nail, advisesDr. Scher.“What I don’tlike to seewomen do isuse acrylic

nails, especiallylong acrylic nails,” states Dr. Rich.

Long acrylic nails not only traumatize thenail but also increase the risk for infec-tion. “You have this space under the nail

and moisture gets under there. It’s a warm,moist, dark place for things to grow,” explains Dr. Rich.

In certain situations, however, when women are willing tokeep the enhancements very short—no longer than the tip ofthe digit—Dr. Rich believes exceptions can be made and rec-ommends patients consider gels and silk wraps rather thanacrylics. “Acrylic nails can be a problem because people wearthem too long,” she explains. “Nail gel overlays and silk wrapsare better than the acrylics that are so hard you really do injurethe nail bed with bumping.”

Best Is Yet to ComeUnfortunately, even patients who comply with their treatmentregimens, practice good nail care, and take advantage of nailcosmetics often find themselves unhappy with their nails.Some of this dissatisfaction may result from putting too muchfaith in the available nail treatments. As Dr. Crutchfield stat-ed, it’s important to frame patients’ expectations from the verybeginning to minimize disappointment. Hope focuses on thefuture role of biologics for nail psoriasis, but until studiesprove this patient group qualifies as candidates, dermatologistsshould focus on making the most of topical agents and steroidinjections.

Biologic agents seem to show

promise and may one day become

treatment of choice for severe

cases of nail psoriasis.

March 2005 Practical Dermatology 41