This is ReachMD, and you’re listening to Psoriasis: What’s Beneath the Surface, sponsored by Lilly.
On this episode we’ll hear from Dr. Shari Lipner, Associate Professor of Clinical Dermatology at Weill Cornell Medicine in New York City. Dr. Lipner focuses on nail psoriasis and the various ways to treat this disease. Here’s Dr. Lipner now.
Dr. Shari Lipner:
Psoriasis is a chronic inflammatory skin disease, which classically presents with well-demarcated red flags with scale that involve the scalp, the elbows, the knees, and the presacral region, but really any part of the skin can be affected, including the palms, soles, and nails. nail psoriasis is psoriasis that affects the nails, and it classically presents with either nail matrix disease, nail bed disease, or both. Most patients have both nail matrix and nail bed disease. With the nail matrix, you typically see nail pits, you see crumbling of the nail, and you see red spots in the lunula. If there is disease of the nail bed, you see onycholysis, subungual hyperkeratosis, salmon patches, oil spots, and splinter hemorrhages.
Now, 80-90% of patients with cutaneous psoriasis will develop nail psoriasis sometime during their lifetime, and nail psoriasis affects up to 80% of patients with psoriatic arthritis. There is a small subset, about 5-10% of nail psoriasis patients, that have no skin involvement. Nail psoriasis can cause significant difficulty. Patients may present with pain, sensitivity of their nails, problems performing daily activities, and it also has a negative impact on quality of life.
Treatment of patients with nail psoriasis can be very challenging because the clinical trials that have been performed really focused on patients with cutaneous psoriasis, and the data that we have are really from subanalyses of these bigger studies. So, there’s very few clinical trials that specifically focus on nail psoriasis. However, there is some data, and there is a recent consensus paper that was published in the JAAD, which made recommendations for treatment of nail psoriasis in patients with little or no cutaneous psoriasis. this analysis largely divides these patients into patients that have three nails or less affected or greater than three nails affected.
Patients with few nail disease, should look to see whether their nail matrix or their nail bed is involved. For matrix disease, the treatment of choice is intralesional matrix injections. For patients with nail bed disease, you want to tell the patients to clip back the onycholytic part of the nail and then apply a strong topical steroid under occlusion, and that can be with or without vitamin D analogues.
Of course, if the patient has both matrix and bed disease, you can do a combination of intralesional matrix injections plus the clipping and the topical steroids. Patients with more than three nails involved, particularly if they have joint involvement or an impact negatively on their quality of life, really require systemic treatment. Intralesional matrix injections are really an underutilized treatment modality. They are very well-tolerated by patients, especially if the technique is done correctly, and patients can see great efficacy at first monthly treatment, and then the treatments can be spread out to once every two months or once every three months.
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