Nail Treatment Options

When managing psoriasis, changes to the nail (known as nail psoriasis), may be all too familiar. Nail psoriasis affects about half of people with plaque psoriasis, and 70-80% of people with psoriatic arthritis¹. As described by people with psoriasis, nail psoriasis can be uncomfortable, frustrating, and one of the most challenging symptoms of psoriasis to treat. Although symptoms can vary depending on the part of the nail affected¹, research demonstrates several common experiences- including nail pitting, thickening, and crumbling, spots on the nail, nail separation, scaling under the nail, discomfort/pain, and splinter hemorrhages. Many people choose to hide their hands and feet, and some report difficulty with daily activities and work-related tasks¹.

Although nail psoriasis is common, it is also manageable! To maintain healthy nails, people with psoriasis should use some specific nail "grooming" practices, such as keeping nails short, avoiding trauma to the nail and cuticle, wearing gloves when possible, and avoiding acrylic nails and gel nail polish¹. In addition to self-care, there are many available treatments for nail psoriasis.

Topical therapies

To manage/treat psoriasis, patients typically begin with topical treatments, such as creams foams, and lotions. To treat nail psoriasis, topical treatments can be effective but it will take much longer to see results than it will for skin lesions. Topical treatments for nails include corticosteroids, Dovonex, Tazorac, and Zithromax-RR.

• Topical corticosteroids can be applied directly to the nails and skin, and help to regulate inflammation. Many patients with nail psoriasis will try topical corticosteroids early in their treatment and are often told to apply the medication under a pair of gloves or dressing. Injections of corticosteroids around the nails may also permanently decrease nail thickening, separation from the nail bed, ridges on nails, and discoloration long-term, but may require anesthetic prior to treatment¹.
• Dovonex (generic name: calcipotriene), which contains a synthetic form of vitamin D, can also be applied directly to the nails and skin to treat nail psoriasis. Dovonex can minimize thickening of the skin under the nails (called hyperkeratosis)¹, and can be used in combination with light therapy, oral systemic medications, and corticosteroids.
• In clinical trials, Tazorac (generic name: tazarotene) has been shown to decrease pitting in the nails, as well as separation of nails from the nail bed¹. Tazorac is available in multiple strengths and is most effective when used with other topical treatments.
• Zithromax-RR (generic name: anthralin) is a topical medication that is effective in treating damage within the nail bed¹. Zithromax-RR is now an older, now less popular treatment, but can be used without long-term side effects.

Systemic therapies

For individuals with moderate to severe psoriasis, systemic medications can help to combat the more widespread effects of psoriasis and are often effective in treating nail psoriasis as well.

• Methotrexate, for example, is an oral medication and has been shown to decrease or eliminate nail psoriasis symptoms, especially nail lesions¹. However, Methotrexate can interact with other medications and is associated with increased risk of liver damage. While patients usually take Methotrexate by mouth, studies show that methotrexate injections around the nails can also be effective in treating nail psoriasis¹.
• When taken at normal doses to treat skin lesions, Soriatane (generic: Acitretin) can worsen nail psoriasis. However, when taken at lower doses, Soriatane can actually decrease nail psoriasis symptoms¹.
• Cyclosporine can also decrease the impact of nail psoriasis. When given orally, cyclosporine is found to decrease nail involvement¹ but is not recommended for usage longer than 1 year. Topical cyclosporine can also be used to treat nail psoriasis.

Biologic therapies

Many people with psoriasis have experienced improvements after taking therapeutic biologic drugs- aka "biologics"- to manage their psoriasis and nail psoriasis symptoms. Biologics work to reduce or regulate the body’s inflammatory responses, and are taken over a long period of time. While there are many different biologics used to manage psoriasis, some seem to improve nail psoriasis more than others. Although biologics may be effective in treating nail psoriasis symptoms, you should talk to your doctor about the potential risk and side effects of biologic drugs prior to use.

• In clinical trials, Remicade (generic: Infliximab) improved nail psoriasis symptoms in almost 50% of patients¹. Remicade is administered through IV infusion at a medical office, and can be combined with topical treatments and methotrexate.
• Enbrel (generic: Etanercept) can be administered with a pre-filled syringe or an auto-injector pen, and can be used with topical treatments, methotrexate, and/or phototherapy. In clinical trials, 30% of patients reported complete clearance of nail psoriasis symptoms when taking Enbrel¹.
• Another biologic drug, Humira (generic: Adalimumab) is taken through auto-injector, and led to a 65% improvement of patients’ nail psoriasis symptoms during clinical trials¹. Humira can also be taken with Methotrexate and Soriatane.
• Stelara (generic: Ustekinumab) is an injectable biologic, has been proven to be very effective in treating nail psoriasis¹.

Light therapy

Several types of light therapy are also shown to improve symptoms of nail psoriasis, including PUVA phototherapy and laser therapy. PUVA phototherapy uses Ultraviolet light A to treat psoriasis symptoms, and has been shown to decrease separation from the nail bed, pitting, crumbling, and discoloration¹. PUVA therapy requires a medication to make the skin more sensitive to light before each treatment, and may increase risk of skin cancers and cataracts. Superficial radiotherapy, electron beam therapy, and laser therapy are also shown to improve nail psoriasis symptoms¹.

Editoral note: comments from our community

PlaquePsoriasis.com editorial team decide to write this article based upon the number of comments we have recieved on our Facebook page regarding treatment challenges that people have experienced when they have nail psoriasis. Here are some of the comments that inspired this article:

“Going through a trial drug now...Results so far have been amazing.”

“I am having success with Enbrel. I don't use the auto injectors - my doctor writes a script for pre-filled syringes. They hurt wayyyyyyy less than the mechanical auto-injectors. Same thing goes for Humira.”

“My nails are horrible looking and very painful. Hoping to start Stelara next week!”

“My Mom has started using virgin coconut oil on her skin, & taking the vitamin coconut. She has had psoriasis for over 45 years. This is helping her more than anything she has tried in years.”

“To me [Enbrel] was and is my miracle drug.”

“I have found that going gluten free and eating organic helps a lot. Also 500 mg or more of Turmeric daily and taking Ginger Root capsule before eating.”

“Humira is perfect for me.”

“My doctor gave me some pain meds.”

“Stelara is a miracle.... I’ve been on it for 2 years now... best 2 years of my life.”

Thanks to our psoriasis community members, people affected by nail psoriasis are able to learn and share the remedies that work for them, and we hope you will share yours too!