Table 3 – Conventional/Oral Systematic Treatment Options for Nail Psoriasis3

Treatment Comments

Methotrexate

– Widely used


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– Administered orally or subcutaneously

– AEs: hepatotoxicity, ulcerative stomatitis, lymphopenia, nauseas, low WBC, nausea

Cyclosporine

– Some evidence shows comparable efficacy to biologics

– Only used in severe cases for 6-12 months due to AEs

– AEs: reversible renal dysfunction, reversible hypertension, fatigue, headache, paresthesia, hypertrichosis, gingival hyperplasia, GI disorders

Prolonged used: renal failure, malignancies

Retinoides:
– Acitretin

– Moderate efficacy but can be used for years

– AEs: cheilitis, dry mouth, skin exfoliation

Apremilast

– Well tolerated

Other agents

– Fumaric acid esters, sulfasalazine, and leflunomide studied

– Not recommended (lack of evidence and insufficient data)

Table 4 – Biologic Treatment Options for Nail Psoriasis3

Treatment Comments

Anti-TNF agents:
– Infliximab
– Adalimumab
– Etanercept
– Golimumab
– Certolizumab pegol

– Infliximab: fastest-acting biologic, may have decreased efficacy over time, increased risk of onychomycosis and anaphylactic reactions

– Etanercept: may have less antibody formation

– Certolizumab pegol: less frequent dosing versus other anti-TNFα agents

– AEs: opportunistic infections, demyelinating diseases, congestive heart failure, formation of autologous antibodies

– Contraindications: chronic infection, moderate to severe heart failure, pregnancy, nursing

– Use caution in patients with hematological changes, demyelination processes, recent neoplasms

– Evaluate patient for TB prior to initiating therapy

Anti-IL-12/23 agents:
– Ustekinumab

– Similar AEs and contraindictions as anti-TNFa agents

Anti-IL-17 agents:
– Secukinumab
– Ixekizumab

– Secukinumab: evidence for use in nail psoriasis is limited, may exacerbate Crohn’s disease, may cause anaphylaxis

– AEs: upper respiratory tract infection, headache

– Use with caution in patients with a history of chronic infection

– Evaluate patient for TB prior to initiating therapy