Navigating Nail Psoriasis: Treatment Strategies for Patient-Centered Care

Announcer:
You’re listening to Clinician’s Roundtable on ReachMD. On this episode, Dr. Shari Lipner will discuss treatment options for nail unit psoriasis. Dr. Lipner is an Associate Professor of Clinical Dermatology and Director of the Nail Center at Weill Cornell Medicine, and she spoke on this topic at the 2025 AAD Annual Meeting. Let’s hear from her now.

Dr. Lipner:
So we have a ton of data on how to treat psoriasis patients, but the data on treatment of nail psoriasis is really scarce, and most of the data that we have are really from post hoc psoriasis trials. A group of nail experts got together and wrote a consensus paper on nail psoriasis in JAAD in 2019, and it really delineates treatment of nail psoriasis into number of nails involved as a rough estimate. So if patients have three nails or fewer and they have matrix involvement, the treatment of choice is intralesional steroids and if they have bed involvements, it’s topical corticosteroids as well as other adjuncts. Now if they have greater than four nails involved or they have fewer than four nails involved but they also have skin psoriasis, joint involvement or a great impact on their quality of life, this is the time to pull out either systemic therapies and targeted therapies.

We’re not using a ton of classic therapies like cyclosporine/methotrexate these days because we have the targeted options, the TNFs, the IL-17s, IL-23s, the small molecules, and this can really make a difference for our patients because they’re targeted, and oftentimes we can practically clear their nail psoriasis.

It’s very important to manage patient expectations regarding the long-term treatment and prognosis of nail unit psoriasis. Patients always want a quick fix; they want a cure. You have to explain to them that you’re treating a disease that’s similar to, let’s say, diabetes or hypertension where we can’t just give an antibiotic and wipe it out and so there’s going to be constant management of these patients. And so I think if you set those expectations, the patients really start to understand that they’re going to need to be on some sort of therapy.

The other thing that differentiates nails from skin is that nails grow very slowly, and so oftentimes we’ll give a treatment for cutaneous psoriasis and their skin is better within weeks. It’s different for nail unit psoriasis because the nails grow very slowly. It takes almost six months to replace an entire fingernail, and so we have to really look at treatment differently, and we have to explain to patients, “Hey, if I give you a treatment, try not to look at the nail for months. Don’t look at it every day. It’s not going to change on everyday basis. We have to take a look at it in three months or six months.” And I think when you tell them that, they get it and they get that it’s going to take a while to see improvement in their nails.

Announcer:
That was Dr. Shari Lipner discussing treatment options for nail unit psoriasis. To access this and other episodes in our series, visit Clinician’s Roundtable on ReachMD.com, where you can Be Part of the Knowledge. Thanks for listening!