By Pamela Korzeniowski, PA-C
Pamela Korzeniowski, PA-C, is a dermatology physician assistant with North Texas VA Dermatology and practices in Dallas and Fort Worth, Texas. She is a graduate of the University of Washington MEDEX Northwest PA program in Seattle, WA, and a current DMSc student at A. T. Still University. She is a founding member of the North Texas VA PA Committee which champions PA issues within the North Texas VA system and has served as the committee secretary since 2017. She enjoys bringing PAs together through teamwork on PA-led projects, and most of all spending time with her children and husband.
Disclosures: The author has disclosed no potential conflicts of interest, financial or otherwise, relating to the content of this article.
Treatment of severe nail psoriasis poses a particular challenge due to the anatomy of the nail, small surface area involved, and frequent irritation to fingertips from use of the hands.1,2 Nail psoriasis can be particularly devastating to affected patients as it is easily visible, leading to emotional distress, potential social ostracization and loss of work opportunities and loss of function with performing fine work with the hands.1,2 Being aware of which nail manifestations will present clinically depending on the nail structure affected by psoriasis, which first-line treatments are most efficacious, and when to consider systemic treatments can help guide treatment based on a patient’s preferences and other health conditions
Nail psoriasis, even when the primary clinical presentation in a psoriasis patient, is considered severe enough to think about systematic treatment, including acitretin, methotrexate, cyclosporin, small molecules, and biologics, when three or more nails are affected.1 Most patients with nail psoriasis will experience some improvement of their nail psoriasis with most systemics, however, the improvement is typically seen after 3 to 6 months or longer, and complete clearance may not occur even after more than one year of treatment.1,2 When three or fewer nails are affected, topicals, including calcipotriol, tacrolimus, tazarotene, high potency topical steroids, and injectable corticosteroid therapy can be offered first. These have been shown to have some efficacy for nail psoriasis, especially in mild cases.2 Topical steroids and injectable corticosteroid therapy seem to work better on nail matrix involvement, whereas calcipotriol has been shown to have better effect on nailbed psoriasis.2 Laser and phototherapy has been used with some success in nail psoriasis as well, but studies on these have been small and have shown inconsistent efficacy.2
Presentation. A 73-year-old Caucasian man presented to dermatology with a 2.5-year history of biopsy-confirmed plaque psoriasis (~5% total body surface area [TBSA] at time of diagnosis) well controlled with topical triamcinolone 0.1% ointment and nail psoriasis involving the bilateral thumbnails and the left third fingernail, previously well controlled with topical clobetasol ointment Mondays through Fridays and treatment with triamcinolone acetonide injectable suspension, USP (Kenalog® Bristol-Myers Squibb Company) every 4 to 6 weeks. He reported worsening nail psoriasis after a 10-month hiatus from the clinic. The patient had previously not been interested in systemics for his nail or plaque psoriasis as he was happy with the results seen with Kenalog® injections and topical steroids for the three affected nails, and his plaque psoriasis was mild and not bothersome to him.
Patient History. Two years prior to presentation, the patient had been treated for onychomycosis of bilateral thumbnails, left index finger, left third finger, and toenails with potassium hydroxide (KOH) prep made from scrapings taken of left thumbnail. Subungal debris was positive for hyphae and patient had yellowing, subungal debris, onycholysis of several fingernails and toenails as well as pitting and oil spots affecting most fingernails, which was clinically consistent with onychomycosis, in addition to suspected underlying nail psoriasis. He was treated with terbinafine 250mg daily by mouth for 12 weeks along with topical terbinafine for four weeks. After completion of this treatment, the patient’s toenails and the left index fingernail completely cleared other than pitting and oil spots which remained on all fingernails, while the left third fingernail and bilateral thumbnails persisted with crumbling, yellowing, subungal debris, and loss of proximal nailfold. Clinically, this was consistent with nail psoriasis status-post resolved concomitant onychomycosis. He was then started on topical clobetasol ointment twice daily to the three psoriatic nails Mondays through Fridays, along with intralesional Kenalog 10mg/cc 0.2cc per proximal nailfold (or more specifically 0.1cc to the ulnar and radial aspect of each proximal nailfold) every 4 to 6 weeks with excellent result within the first two months of treatment. Although he reported pain from the intralesional Kenalog treatments, the patient found that they worked better than the topical steroid alone, and so he continued to schedule injections every 4 to 6 weeks or longer depending on duration of clinical improvement. The patient was also continued with topical terbinafine cream to fingers daily as prophylaxis against recurrence of fungal superinfection, due to his gardening hobby which caused his hands to be exposed to soil and wet environments often.
Since his last visit 10 months prior, the patient had continued to use the clobetasol ointment twice daily on his affected nails Mondays through Fridays, the terbinafine cream to fingernails once daily, and for the plaque psoriasis the triamcinolone 0.1% ointment twice daily when needed; however, his nail psoriasis had gotten much worse in the past three months, now affecting seven fingernails, while his plaque psoriasis had also worsened. The patient was right hand-dominant, and the nail psoriasis was worse on his right hand, with the most severely affected nails being the thumbnails, making fine detail work with hands very difficult. He was no longer able to easily tie his shoelaces, button his shirts, use a zipper, or pick up a coin with his fingers. It had also made it embarrassing for him to be out in public due to the reactions he received when people would see his hands; he had taken to avoiding his favorite activities such as attending church with his wife. He denied sausage-like swelling (dactylitis) of his fingers or toes, unusual heel or plantar pain or swelling (enthesitis), or morning stiffness or pain of joints lasting more than 30 minutes. The patient requested Kenalog injections to all seven of the affected fingernails despite the discomfort of the procedure, along with anything else that might help.
Upon physical exam, the patient had a total of seven fingernails and two toenails with varying degrees of onycholysis, onychodystrophy (mild to severe), areas of yellow discoloration, crumbling, red dots at the lunula, several nails with small areas of hemorrhage splinters at distal third of the nail, subungal debris, pitting, and oil spots, consistent with both nail matrix and nail bed psoriasis (Table 1). He also had several fingers (bilateral thumbnails and right fourth fingernail) with mild to moderate psoriatic paronychia (edematous lateral nailfolds with overlying erythematous thin scaly plaques) and loss of the proximal nailfold (left thumbnail). See Figures 1-3. The patient reported mild to moderate tenderness to palpation at fingertips and periungal areas of affected nails, with exception of the two affected toenails, which were milder in comparison to the fingernails. His back, abdomen, buttocks, thighs, knees, and elbows were with erythematous silvery-scaled papules and plaques; the thickest plaques being at extensor elbows and knees (~15%TBSA plaque psoriasis). He did not have appreciable dactylitis, and the Achilles insertion sites were without swelling, redness, or tenderness. His face, scalp, genitalia, axillae, inguinal creases, palms, soles, interdigital spaces, and mucosal surfaces were spared.
At the patient’s request, we proceeded with intralesional Kenalog injections to the four worst fingernails (10mg Kenalog/cc, 0.2cc per proximal nailfold). Systemic options were discussed with the patient, and in anticipation of starting a systemic treatment, labs were ordered. Options discussed included methotrexate, acitretin, apremilast, tumor necrosis factor (TNF) inhibitors or interleukin (IL) inhibitors. The patient’s medical history was significant for newly diagnosed hypertrophic cardiomyopathy (HCM) with associated congestive heart failure (CHF) class II-III. He had no personal or family history of inflammatory bowel disease (IBD), and denied IBD-like symptoms, or history of gastritis or gastroesophageal reflux disorder (GERD). He admitted to having a depressed mood due to his nail psoriasis and the recent news that his wife had advanced colon cancer but denied suicidal ideation and denied history of significant depression or suicide attempt. He denied a history of known exposure to tuberculosis (TB), human immunodeficiency virus (HIV), intravenous (IV) drug use or an increased risk for hepatitis B or C exposure. The patient denied alcohol, tobacco, or illicit substance use; he also denied a history of liver or kidney disease. His complete blood count (CBC), comprehensive metabolic panel (CMP), and fasting lipid panel (FLP) including triglycerides were normal. Screens for HIV, hepatitis B, hepatitis C, and TB (T.SPOT.TB) returned negative. The patient lived 45 minutes away from the clinic and preferred less frequent visits for labs and follow up visits, though he was willing to get the Kenalog injections.
SELECTING THE RIGHT TREATMENT PLAN
With the patient’s nail psoriasis worsening, affecting greater than three nails, along with his plaque psoriasis now affecting more than 10% TBSA, starting a systemic was ideal. The patient did not drink alcohol, have liver disease or a history of hypertriglyceridemia. Since methotrexate and acitretin require frequent lab visits, these were not favored as first-line treatments per the patient’s preference. Apremilast was potentially a good choice for him as it would not require frequent labs, but with his current depressed mood, extra care would have been needed to monitor for worsening depression. Laser and phototherapy for nail psoriasis were not available treatments offered by the author’s dermatology office.
With his new history of class III heart failure, TNF inhibitors were decided against. As the patient did not have a personal history of IBD, an interleukin inhibitor was an option. IL inhibitors for treatment of nail psoriasis were further supported by recent research. In 2020, Wasel et al3 reported post-hoc data from a head-to-head trial of ixekizumab and ustekinumab (IXORA-S; ClinicalTrials. gov Identifier: NCT02561806), which examined the efficacy in nail psoriasis in patients with moderate-to-severe plaque psoriasis over 52 weeks. Although progressive improvement occurred with both treatments, ixekizumab showed earlier improvement compared with ustekinumab, and the improvement continued through 52 weeks regardless of baseline nail severity.3 Based on the patient’s medical history, his preferences, and findings of the IXORA-S study, we proceeded with ixekizumab.
Before initiation of treatment, we collaborated with the patient’s primary care provider (PCP) on his immunization status to ensure that his immunizations, especially any live or live attenuated virus vaccines such as zoster vaccine live, were up to date. While the patient’s PCP coordinated the immunizations required, we opted to add calcipotriol cream twice daily on Saturdays and Sundays to see if treatment would benefit the nail bed element of his nail psoriasis while continuing the clobetasol ointment 0.05% Monday through Friday. See Table 2. The patient did not feel comfortable administering his own injections due to concern he would not be able to handle the injector apparatus correctly with his current loss of ability to perform fine detail work with his hands, and so he opted to come into the clinic to have our staff give his ixekizumab injections (Week 0, then every 2 weeks for first 3 months).4 By the time of his third injection (4 weeks into ixekizumab treatment), the patient was very surprised and pleased to report he had no pain around the affected fingernails, the redness and scaling at the proximal nailfolds had improved, and his plaque psoriasis had already improved markedly. The plaques on his trunk, buttocks, and extremities faded to pink patches, while the thickest plaques on extensor elbows and knees had thinned. Given results from the IXORA-S study, we did not expect the nails themselves to improve considerably until the 4 to 6-month mark, but the pain and inflammation at the nails had improved quickly, leaving our patient relieved and encouraged with his rapid progress.
Signs of nail psoriasis, particularly crumbling, onycholysis, and discoloration, are not exclusive to psoriasis and can be observed in other common nail conditions such as onychomycosis. As there is so much similarity between some forms of nail psoriasis and tineaunguium, it is prudent to check a fungal culture or KOH prep before initially proceeding with topical or injectable steroids. Nail psoriasis can also present as chronic psoriatic paronychia, which can develop secondary bacterial infection; therefore, it is important to treat any bacterial infection if present before proceeding with topical or injectable steroids. Severe nail psoriasis is closely associated with development of psoriatic arthritis,2 making vigilance with screening questions regarding inflammatory arthritic symptoms, especially dactylitis and heel enthesitis, important. Collaborating with the patient’s primary care team on immunizations, management of depression and other chronic health conditions, and sharing of health history is key. In this case, knowledge of the patient’s newly diagnosed class III heart failure was critical information that impacted treatment decisions. By balancing the patient’s preferences, other health conditions, and the clinician’s knowledge of available treatment modalities along with the most recent supporting research, the patient and clinician were able to find a safe and effective treatment plan.
- Rigopoulos D, Stathopoulou A, Gregoriou S. Small molecules and biologics in the treatment of nail psoriasis. Skin Appendage Disord. 2020;6:134-141.
- Pasch M. Nail psoriasis: a review of treatment options. Drugs. 2016;76:675–
705. Published online 2016 Apr 4.
- Wasel N, Thaçi D, French LE, et al. Ixekizumab and ustekinumab efficacy in nail psoriasis in patients with moderate-to-severe psoriasis: 52-week results from a phase 3, head-to-head study (IXORA-S). Dermatol Ther (Heidelb). 2020;10(4):663-670.
- Taltz (ixekizumab). Drugs.com. https://www.drugs.com/taltz. Accessed January 11, 2021.