Recommendations for Nail Psoriasis in Adults With No or Mild Skin Psoriasis

Psoriatic arthritis and psoratic nails.
A consensus group offers practical recommendations to treat nail psoriasis in patients with no skin psoriasis or with mild skin lesions with no indication for a systemic treatment.

A dermatologist and nail expert panel consensus was conducted to provide practical recommendations for the management of nail psoriasis in adult patients with no or mild cutaneous psoriasis. According to the consensus findings, a definite threshold for the initiation of systemic treatment in patients with nail psoriasis was not endorsed. Results from the panel were published in the Journal of the American Academy of Dermatology.

It is well recognized that the severity of nail involvement in patients with psoriasis does not always correspond with the intensity of cutaneous disease. The investigators created a consensus group that sought to offer recommendations to define, evaluate, and treat nail psoriasis in patients without skin psoriasis or with mild skin lesions with no indication for systemic treatment. The collaborative process was performed by an international panel of dermatologists with special expertise in nail disorders. All statements were agreed upon with the use of formal consensus methodology.

The expert panel — composed of 18 dermatologists from the United States, Europe, Asia, and Africa — was invited to participate in the survey under the supervision of a steering committee. The panel participants, all of whom had extensive experience in the diagnosis and/or management of nail and cutaneous psoriasis in clinical practice and/or clinical trials, were willing to develop additional questions and to attend a live consensus meeting.

The expert panel aimed to establish a consensus with respect to the definition of nail psoriasis, the severity of nail psoriasis, and patients’ response to therapy. They included treatment recommendations according to  the severity of nail psoriasis, along with matrix or nail bed involvement. “Few-nail” disease was defined as nail psoriasis that affects ≤3 nails.

Related Articles

The consensus was that in patients with matrix involvement only, intralesional steroid injections were determined to be the treatment of choice. In patients with nail psoriasis limited to the nail bed, the use of topical steroids alone or in combination with topical vitamin D analogues was recommended. Regarding the systemic treatment of nail psoriasis, acitretin, methotrexate, cyclosporine, biologic, and small molecules can be used.

The investigators concluded that treatment of patients with nail psoriasis that involves more than “a few nails” should be considered according to patients’ needs and the effect of therapy on quality of life. According to the panel, economic and health insurance reimbursement factors are also anticipated to affect treatment selection and the availability of new agents in the future.

Follow @DermAdvisor


Rigopoulos D, Baran R, Chiheb S, et al. Recommendations for the definition, evaluation, and treatment of nail psoriasis in adult patients with no or mild skin psoriasis: a dermatologist and nail expert group consensus [published online February 4, 2019]. J Am Acad Dermatol.  doi:10.1016/j.jaad.2019.01.072