Letter

Remission and time of resolution of nail psoriasis during infliximab therapy

Prevalence of nail psoriasis ranges from 7% to 56%, in psoriatic patients and significantly burdens quality of life. Nail psoriasis is often associated with psoriatic arthritis. Clinical features present due to inflammation of either the nail matrix or the nail bed and include pitting, leukonychia, red spots in the lunula, crumbling, onycholysis, splinter hemorrhages, subungual hyperkeratosis, and oil-drop salmon patches. Management of nail psoriasis should be individualized, and this depends on the number of nails affected, involvement of skin and/or joints, that might affect the choice of topical or systemic therapies.

The treatment of the psoriatic nails is strenuous and systemic therapies are associated with various side effects that lead to patient incompliance. Topical therapy seems to be mainstay approach that limits side effects and is patient compliant. The topical formulations include creams, gels, and ointments and nail lacquers. Of these nail lacquers appear to be promising, patient friendly formulation. However, the major challenge through topical route is inefficient permeation of drug through dense keratinized nail plate to reach target sites: nail matrix and nail bed. Chemical and physical enhancement techniques can be used for enhancing the drug permeation through nail plate. There has been quite a lot of research in this field in recent times. The current review focuses on various clinical reports on systemic, topical and peripheral therapies (intralesional, phototherapy and laser). It primarily focuses on topical nail lacquer formulation wherein an attempt has been made to summarize the factors affecting permeation of drug across the nail plate. Further, physical and chemical modes for permeation enhancement have been described. Finally the medicated nail lacquers as an effective and novel drug delivery system for treating nail psoriasis has been reviewed.

El término de psoriasis en localizaciones de difícil tratamiento se emplea para hacer referencia a la psoriasis localizada en el cuero cabelludo, las uñas, las palmas y las plantas y que requiere un manejo diferenciado. A menudo los pacientes presentan un importante impacto físico y emocional, unido a la dificultad para controlar adecuadamente sus lesiones con tratamientos tópicos, debido a una insuficiente penetración de los principios activos y la escasa cosmeticidad de los vehículos empleados. Esta circunstancia justifica que la psoriasis en estas localizaciones pueda ser considerada grave, a pesar de su extensión limitada. La experiencia con terapias biológicas en estas localizaciones es escasa, en general en el contexto de ensayos clínicos de formas extensas de psoriasis moderada y grave, junto con series limitadas o casos aislados. En el presente artículo se presenta la calidad de la evidencia científica para los 4 agentes biológicos disponibles en España (infliximab, etanercept, adalimumab y ustekinumab) siendo de nivel i en el caso de la psoriasis ungueal (nivel de recomendación A) y algo inferior en la psoriasis del cuero cabelludo y palmoplantar.

Psoriatic lesions affecting the scalp, nails, palms, and the soles of the feet are described as difficult-to-treat psoriasis and require specific management. Involvement of these sites often has a significant physical and emotional impact on the patient and the lesions are difficult to control with topical treatments owing to inadequate penetration of active ingredients and the poor cosmetic characteristics of the vehicles used. Consequently, when difficult-to-treat sites are involved, psoriasis can be considered severe even though the lesions are not extensive. Scant information is available about the use of biologic therapy in this setting, and published data generally comes from clinical trials of patients who also had moderate to severe extensive lesions or from small case series and isolated case reports. In this article we review the quality of the scientific evidence for the 4 biologic agents currently available in Spain (infliximab, etanercept, adalimumab, and ustekinumab) and report level i evidence for the use of biologics to treat nail psoriasis (level of recommendation A) and a somewhat lower level of evidence in the case of scalp involvement and palmoplantar psoriasis.