Psoriatic nails: Persistent condition presents treatment dilemma

Key Points

With all of the possible systemic treatments for psoriasis, it's those patients with psoriasis restricted to nails that present a bigger challenge to successful treatment.

Mark Lebwohl, M.D., professor and chairman of dermatology, Mount Sinai School of Medicine, New York, says there aren't any "perfect" options for treating psoriasis restricted to the nail bed or matrix.

Dr. Lebwohl says when psoriasis is restricted to the nails, it creates a dilemma for doctor and patient.

If the changes are minor, like nail-pitting, patients can often just cover that cosmetically with nail polish. If changes are more than minor, there are topical therapies, such as corticosteroids, tazarotene and vitamin D analogues, but Dr. Lebwohl says they generally are not effective.

More effective are injections of corticosteroids near the nail bed or nail matrix. Dr. Lebwohl says those work better than topical therapies, but they have other drawbacks.

Fungus

Another problem that occurs with psoriatic nails is that a high proportion of those patients can have a fungal infection in the nails as well.

"That means that the fungus can be the primary problem, or the two problems co-exist and the patient can benefit from treating the fungus. That makes it worthwhile getting nail cultures. I've had a significant proportion of patients with psoriatic nails also have fungus in their nails," Dr. Lebwohl says.

'Treatment void'

Although avulsion is sometimes touted as a possible treatment for psoriatic nails, Dr. Lebwohl does not like that option.

Neither does he strongly recommend PUVA. Although it can help some nails, PUVA cannot be counted on to be effective, he explains.

"Right now, there really is still a treatment void for psoriatic nails. Systemic treatments can work, but could be considered overkill when the psoriasis is restricted to the nails, and nothing else works effectively without other major drawbacks," he says.

Disclosure: Dr. Lebwohl has been a consultant for most pharmaceutical companies that manufacture psoriasis products.