Treatment of Nail Psoriasis With TNF-α or IL12/23 Inhibitors
August 2012 | Volume 11 | Issue 8 | Original Article | 939 | Copyright © August 2012
Nail psoriasis appears to be an important source of psoriatic morbidity through physical impairment, pain, and cosmetic disturbances. Conventional treatment is often unsatisfactory. A systematic review of studies reporting the effect of TNF-α inhibitors and related drugs on nail psoriasis using the Nail Psoriasis Severity Index (NAPSI) as the outcome measure was therefore made. Data are available from randomized controlled trials (RCT) where NAPSI has been studied as a secondary outcome, as well as from case-series in which NAPSI has been the primary outcome studies suggest that adalimumab, briakinumab, etanercept, golimumab, infliximumab, and ustekinumab all improve NAPSI scores. No direct comparative RCTs are available in which NAPSI scores have been reported. The data further suggest that changes in NAPSI mirror changes in disease severity of other psoriatic manifestations, that is, in psoriatic arthritis and skin psoriasis. The effect only appears to be delayed due to the rate of growth of the nail plate.
J Drugs Dermatol.
Psoriasis is a common skin disease with a significant negative impact on health as well as
quality of life and cumulative life course.1,2,3 In addition to systemic co-morbidities and arthritis,
the disease may also affect the nails, where it poses particular problems to patients and physicians.4
It has been estimated that 50% of all psoriasis patients have nail psoriasis, and that 4 to 5 patients with nail
psoriasis have psoriatic arthritis (PsA).5 It is speculated that the close proximity between the
enthesitis of the extensor tendons of the fingers and the nail apparatus, provide an anatomical link between PsA
associated enthesitis and nail changes.6 It may furthermore be estimated that approximately 10% of
psoriasis patients have nail changes without concomitant PsA, most often associated with severe cutaneous
The nail abnormalities range
from discrete pitting of the dorsal nail plate to severe nail dystrophy, and while 90% of the affected patients
have cosmetic problems from psoriatic nail changes, physical problems are not infrequent.5 In a large
Dutch study, approximately half of the 1,728 interviewed patients reported to suffered from pain caused by nail
changes, and similarly large groups of patients were hindered in their private or professional daily activities
due to the nail changes.7 Nail involvement appears to significantly impair the patients' quality of
A number of
treatments are available for nail psoriasis, although the outcome is often unsatisfactory. Furthermore, only
lower levels of evidence are generally available, and patients and physicians therefore often experience a need
for intensified therapy. Although nail involvement is by nature limited, providing only low scores in, for
example, PASI scores, impaired QoL may indicate the need for treatment with TNF-α inhibitors and other
biologicals according to guidelines. We have therefore reviewed the effect of TNF-α inhibitors and other
biologicals on nail psoriasis.
MATERIALS AND METHODS
The Nail Psoriasis Severity Index (NAPSI) is an
established score of nail pathology in psoriasis which allows direct comparisons of results, within the limits
provided by any clinical score.10 Simple numerical scores are given for nail-bed and nail-matrix
features (Table 2). It may be applied as a total score (combined scores of all nails) or an individual nail
score. The interclass correlation coefficients (ICC) for total NAPSI score and nail score have been shown to be
0.781 and 0.649, indicating good agreement.11 Randomized, controlled trials of psoriasis treatment with
adalimumab, alefacept, briakinumab, etanercept, golimumab, or ustekinumab were retrieved from Pubmed and Web of
Science and abstracts scanned for references to nails or general physical symptoms. If nails were not
specifically mentioned, the manuscripts were scanned for the words: NAPSI or nail, and only those containing
references to the nail score used for further analysis. Only data from fingernails were included in the review,
because of their greater impact on patients and the lower prevalence of onychomycosis on the fingernails. In
addition fingernails grow faster than toenails, thereby making any therapeutic effect evident earlier.
is a human monoclonal antibody against TNF-α, and has been studied in several randomized controlled trials
in patients with psoriasis or psoriatic arthritis, although only one RCT reports data on nail psoriasis.
Adalimumab is most commonly administered subcutaneously with a loading dose of 80 mg followed by 40 mg every
other week (e.o.w.) thereafter.
Open trials have been published. In a trial of 21 psoriasis patients, Rigopoulos et al. reported
significant improvements in NAPSI scores over a 24-week observation period.12 Patients with cutaneous psoriasis only improved their score from
10.57±3.21 at baseline to 1.57±0.20 at week 24, while patients with predominant