Effectiveness of Systemic Treatment Agents on Psoriatic Nails: A Comparative Study

September 2013 | Volume 12 | Issue 9 | Original Article | 1039 | Copyright © September 2013

Evren Odyakmaz Demirsoy MD,a Rebiay Kıran MD,a Selma Salman MD,a Çiğdem Çağlayan MD,b
Aysun Şikar Aktürk MD,a Dilek Bayramgurler MD,a and Nilgün Bilen MDa

aDepartment of Dermatology, Kocaeli University, Kocaeli, Turkey
bDepartment of Public Health, Kocaeli University, Kocaeli, Turkey

BACKGROUND: Nails, one of the most visible sites of body, are frequently involved in psoriasis and accepted as the most difficult site for topical treatment because of their anatomical structure. Healing of the psoriatic nails usually occurs when systemic therapy is initiated to treat severe skin psoriasis or joint involvement, but sometimes systemic therapy is essential for severe nail psoriasis, although Psoriasis Area and Severity Index (PASI) score is low or none of the joints are affected. In this case, knowing which systemic agent is most potent on nail findings is important.
AIM: We aimed to evaluate the effect of systemic antipsoriatic agents on nail findings.
METHODS: Eighty-seven psoriatis patients with fingernail involvement who required systemic treatment but had not used any systemic treatment in the previous 12 weeks were included in this study. Different systemic treatment agents were given to patients, considering factors such as age, sex, and joint involvement, but not nail involvement. The control group was recruited from psoriatis patients with nail involvement who were not receiving any systemic treatment. Baseline and week 16 Nail Psoriasis Severity Index (NAPSI) and PASI were detected in all groups. At the end of the study, effects of the agents on both PASI and NAPSI were compared statistically.
RESULTS: Patients were divided into 5 groups to receive either: 1) methotrexate, 2) narrow-band ultraviolet B phototherapy, 3) biological agents, 4) acitretin, or 5) no treatment (control group). None of the conventional treatment agents caused any significant difference on NAPSI at the end of week 16 compared with control group, although PASI decreased significantly. Rate of NAPSI changes were more prominent in the biological treatment group, and a statistically significant difference was detected when compared with the control group.

J Drugs Dermatol. 2013;12(9):1039-1043.


Psoriasis is a common, chronic inflammatory disease that can affect skin, nails, and joints. Nail involvement ranges between 10% to 90% and may be a harbinger for joint involvement.1,2 Nail psoriasis is accompanied with skin findings but may rarely occur in the absence of cutaneous disease. Nail involvement may cause functional impairment of manual dexterity, pain, and psychological stress and can significantly reduce patient quality of life.1-3 Patients with nail psoriasis usually complain about an altered sense of touch, impaired ability to grab small objects, and restriction in daily activities.2,4 The clinical manifestations of nail psoriasis are classified into 2 groups based on the anatomical sites of the nail: nail matrix and nail bed. Leukonychia, red spots, pitting, and crumbling stem from the nail matrix, while oil drops, splinter hemorrhages, subungual hyperkeratosis, and onycholysis stem from the nail bed.4 Nails occupy one of the most visible sites of human body and also, unfortunately, represent one of the most difficult sites for topical treatment because of their anatomically tough structure. Specific treatment of nail psoriasis is usually neglected, as treatment of severe skin disease or arthritis is supposed to cure all symptoms,4 but sometimes systemic therapy is a necessity for severe nail involvement despite low Psoriasis Area and Severity Index (PASI) score or absence of joint involvement. In this case, it will be important to know which systemic agent is most effective on nail findings. There are only a few comparative reports to show the effects of the systemic antipsoriatic agents on nail involvement. We aim to compare the effects of common systemic antipsoriatic agents on each nail finding and on nail involvement.


This prospective study was carried out from November 2010 to April 2012 after ethical approval was obtained from Kocaeli University ethics committee. Patients who presented to our outpatient clinic and were diagnosed with any type of skin psoriasis with nail involvement and had not received any systemic