Psoriasis is a chronic condition characterized by erythematous plaques on the skin.1 There are several types of psoriasis, however up to 80% of patients with this condition experience psoriatic nail involvement. Not only is nail psoriasis cosmetically unappealing, it is also associated with pain and obstruction of daily activities, thus significantly decreasing a patient’s quality of life (QOL).2

Nail psoriasis can have several different clinical presentations based on the area of the nail that is affected.1,3 Table 1 compares the clinical manifestations seen in nail matrix versus nail bed psoriasis, which are important to identify as they can dictate the best treatment option for a patient.3 In addition to clinical presentation, the choice of treatment also depends on patient-related factors, such as age, concomitant co-morbidities, and patient preferences.

Unfortunately, due to the lack of abundant statistical evidence about therapeutic options, the likelihood of relapses, and a delayed response to therapy, nail psoriasis can be difficult to treat.3 Fortunately, however, various topical agents, intralesional steroids, and systemic treatments have proven to be efficacious for nail psoriasis. A suggested treatment algorithm is shown in Figure 1

Patients with mild nail psoriasis without signs of psoriatic arthritis (PsA) or severe plaque psoriasis (PP) are recommended to initiate topical therapy.3 Although the topical agents are slower-acting than systemic therapies, there is also a decreased risk of systemic adverse events (AEs) with these agents. Evidence indicates that the topical calcineurin inhibitors may be one of the most effective and tolerable topical treatment options for both nail matrix and nail bed psoriasis. Topical therapies are described in Table 2.

Systemic therapy is indicated in patients experiencing severe nail psoriasis, major impacts on QOL, and concomitant psoriatic diseases.3 Several comparative studies have been conducted to determine when oral versus biologic systemic therapy should be initiated, however the results have been difficult to interpret. It was concluded, however, that oral agents used to treat nail psoriasis are less efficacious and slower-acting compared to biologic therapies. Cyclosporine was the one exception to this conclusion, as it proved to be more efficacious and faster-acting than other oral therapies. Oral therapies are detailed in Table 3.