DOI Number

Nail Psoriasis: A Therapeutic Update

Hailey Land, RN, BScN,1,* Zahra Rehan, MD, MSc,2 Rachel Netahe Asiniwasis MD, MSHS3,*

1. Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada, hland@045@uottawa.ca

2. Cumming School of Medicine, University of Calgary, Alberta, Canada, zahra.rehan@ucalgary.ca

3. Division of Dermatology, University of Saskatchewan, Regina, Saskatchewan, Canada, rasiniwasis@gmail.com

*Corresponding author 

Hailey Land, 93 McArthur Drive, Penetanguishene, Ontario, Canada, L9M 1X3. Tel: 905-960-4038

Funding sources: None

Conflicts of Interest: None reported

Reprinted with permission © 2025 The Author(s). This is an open access article distributed under the terms of the Creative Commons Attribution Licence CC-BY 4.0, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Content has been edited to conform with the Canadian Press Publication Style Guide

KEY WORDS: psoriasis, nails, chronic skin disease

Abstract

Nail psoriasis presents a complex clinical challenge for clinicians due to its diverse manifestations, such as nail pitting, discoloration, and onycholysis. It also has a substantial impact on patients’ physical, functional, and psychosocial well-being. This narrative review synthesizes recent advancements in the management of nail psoriasis, including recently described reports of efficacy and safety of new and established treatments. A comprehensive literature search identified systematic reviews, randomized controlled trials, and observational studies published from 2013 to 2023. Topical treatments, including indigo naturalis, cyclosporine hydrogel, apremilast lacquer, tofacitinib ointment, and microneedle-delivered corticosteroids, were found to be effective with favorable safety profiles. Intralesional therapies such as triamcinolone and methotrexate remain viable first-line options for localized disease. Systemic agents—including apremilast, tofacitinib, and acitretin—demonstrated significant improvement in Nail Psoriasis Severity Index (NAPSI) scores, particularly in moderate to severe disease. Biologic therapies targeting IL-17 and IL-23 pathways, including ixekizumab, secukinumab, risankizumab, and adalimumab, consistently showed superior efficacy, even in patients unresponsive to prior treatments. Adjunctive procedural treatments—such as pulsed dye laser, Nd:YAG, fractional CO₂ laser, and methylene blue-mediated photodynamic therapy—offered additional benefit in select cases with minimal adverse effects. This review highlights the growing array of personalized treatment options for nail psoriasis and underscores the need for further research to optimize therapeutic algorithms and long-term patient outcomes.

Introduction

Nail psoriasis presents a unique challenge, requiring a practical and clinically relevant approach to diagnosis and management. This condition can significantly affect patients, manifesting through signs and symptoms such as pain and discomfort, nail pitting, discoloration, and onycholysis.1 Beyond the physical aspects, nail psoriasis can have profound psychosocial implications, often leading to diminished self-esteem, which in turn affects social interactions and overall quality of life.2 Understanding these impacts is crucial for healthcare providers as they seek to offer comprehensive care.

The treatment landscape for nail psoriasis has evolved considerably, with a range of options now available to address both established and emerging needs. In addition to conventional therapies such as topical corticosteroids and intralesional injections, a range of novel systemic agents and procedural approaches have emerged. These include phosphodiesterase-4 inhibitors, Janus kinase (JAK) inhibitors, biologic agents targeting IL-17 and IL-23 pathways, and adjunctive options like laser therapy and photodynamic treatments.3,4,5 However, due to the variable severity and multifaceted presentation of nail psoriasis, selecting the most appropriate therapeutic strategy remains a clinical dilemma.

This narrative review aims to provide a concise yet comprehensive synthesis of recent advances in the treatment of nail psoriasis, drawing on primary studies published between 2013 and 2023. It addresses the following key research questions: What new therapeutic modalities have emerged for nail psoriasis in the past decade, and what is their reported efficacy and safety? What are the latest clinical outcomes reported in the literature, and how can they inform treatment decision-making? By focusing on both evidence-based and pragmatic considerations, this review is not intended to be prescriptive but rather seeks to equip busy clinicians with up-to-date knowledge of current on and off-label therapeutic options to optimize patient care.

Methods

Study design

This work is a narrative review designed to synthesize and evaluate reports of recent advancements in the treatment of nail psoriasis. Unlike a systematic review or meta-analysis, the goal of this review is to provide a clinically relevant, practical summary of treatment modalities introduced or evaluated in the past decade, with a focus on reported efficacy, safety, and real-world applicability for clinicians managing adult patients with nail psoriasis.

Data sources and search strategy

A comprehensive literature search was conducted using MEDLINE, Cochrane and Embase databases to identify eligible studies published between 2013 and 2023. The search strategy utilized Boolean operators and wildcards to capture both traditional and novel therapeutic approaches. The following search strings were used:

1. (“nail psoriasis” AND “management”) OR (“nail psoriasis” AND therap*) OR (“nail psoriasis” AND “treatment”) OR (“nail psoriasis” AND “intervention”) with the Systematic Review filter, which returned 40 results.

2. ((“nail psoriasis” AND “novel management”) OR (“nail psoriasis” AND “novel therap*”) OR (“nail psoriasis” AND “novel treatment”) OR (“nail psoriasis” AND “novel intervention”)) OR ((“nail psoriasis” AND “new therap*”) OR (“nail psoriasis” AND “new treatment”) OR (“nail psoriasis” AND “new intervention”)) which returned 209 results.

Inclusion and exclusion criteria

Studies were included if they were published in English between 2013 and 2023 and involved adult patients with nail psoriasis. Eligible studies evaluated a therapeutic intervention—whether topical, intralesional, systemic, or procedural—and reported clinical outcomes using validated measures such as the Nail Psoriasis Severity Index (NAPSI) or related scoring systems.6 Studies were excluded if they were published before 2013, focused exclusively on pediatric populations or were non-clinical in nature, including editorials or narrative pieces that did not present original data.

Study selection and data extraction

All identified studies were initially screened by title and abstract to assess eligibility. Full-text articles that met the inclusion criteria were then reviewed in detail. Data was systematically extracted into a standardized framework, capturing key study characteristics including study design (e.g., randomized controlled trial, prospective, observational, or case report), sample size, intervention and comparator (if applicable), duration of treatment, primary and secondary outcomes, and reported adverse events. Each study was classified under one of four treatment categories: topical therapies, intralesional therapies, systemic treatments, or procedural/laser therapies. Extracted data were synthesized qualitatively to provide an overview of the evolving treatment landscape and to inform evidence-based clinical decision-making.

Results

Sample sizes

Sample sizes among the reviewed studies varied significantly. The smallest studies were single-patient case reports that highlighted individual therapeutic responses and safety considerations, while larger RCTs involved cohorts ranging from 25 participants up to 1196 participants.

Interventions

The reviewed interventions encompassed topical formulations (see Table 1: microneedle-delivered corticosteroids, topical apremilast lacquer, tofacitinib ointment, cyclosporine hydrogel, and indigo naturalis extract), intralesional treatments (see Table 2: methotrexate injections), systemic medications (see Table 3: oral apremilast, tofacitinib, acitretin, ixekizumab, secukinumab, risankizumab, and adalimumab), and laser and photodynamic treatments (see Table 4: fractional CO2 laser, pulsed dye laser [PDL], Nd:YAG laser, and methylene blue-mediated photodynamic therapy [MB-PDT]).

Duration of treatment

Treatment durations varied among studies, with some interventions evaluated for as brief as two weeks, whereas others continued up to 52 weeks.

Primary and secondary outcomes

The primary outcomes consistently involved validated clinical scores for nail psoriasis severity, particularly the Nail Psoriasis Severity Index (NAPSI), modified NAPSI (mNAPSI), single-hand NAPSI (shNAPSI), and modified target NAPSI (mtNAPSI). Secondary outcomes frequently included quality-of-life indices, patient and physician global assessments, Psoriasis Area and Severity Index (PASI), Dermatology Life Quality Index (DLQI), Nail Psoriasis Quality of Life Scale (NPQ10), and adverse event monitoring.

Adverse events

Adverse events reported across studies are as described in Table 1. Overall, they were predominantly mild to moderate, such as local irritation (such as transient pain, erythema, peeling, numbness), nasopharyngitis, headaches, and mild gastrointestinal symptoms. Severe adverse events were uncommon, though systemic therapies were associated with slightly higher rates of systemic events such as infection.

Summary of results

Table 1 includes a summary review of reported therapeutic efficacy and adverse events for both traditional and novel interventions (Table 1). Overall, topical and intralesional therapies consistently showed localized efficacy, systemic agents offered substantial improvements in moderate-to-severe cases, biologics therapies demonstrated sustained efficacy, and laser therapies presented effective adjunctive or alternative options. Improvement in NAPSI scores, often reaching statistical significance compared to controls, underscored the effectiveness of these treatments across a range of severities and patient groups.

Topical therapies for nail psoriasis

In a randomized controlled trial 31 patients were treated with indigo naturalis extract in oil, showing statistically significant improvement in nail psoriasis severity scores compared to olive oil controls.7 No pain, erythema, or pruritus was reported throughout the 24-week treatment period, indicating excellent tolerability. Another study assessed microneedle patch delivery of topical triamcinolone in an RCT involving 25 patients.8 Results showed that this method was at least as effective as a combination of calcipotriol and betamethasone, with transient adverse effects including mild pain, peeling skin, numbness, and discomfort related to the application device. Two prospective studies further explored novel topical approaches. One studied a cyclosporine hydrogel ointment in three patients, reporting a significant and rapid clinical response with no adverse events.9 The second evaluated a nail lacquer formulation of apremilast in six patients, which demonstrated approximately double the drug penetration compared to the control lacquer without enhancers.10 No adverse effects were reported in either study. An observational study tested 2% topical tofacitinib ointment on three patients, showing a reduction in NAPSI scores from 30.3 to 4.3 over a 12-week period on the treated hand, compared to a non-treated control hand.11 No adverse events were observed, supporting the potential of topical JAK inhibitors in this population. Across all five studies, topical therapies were generally well tolerated, with most reporting no adverse events or only mild, transient symptoms. These findings reinforce the safety and potential efficacy of topical agents, including novel delivery systems, in the treatment of nail psoriasis.

Intralesional therapies for nail psoriasis

Intralesional therapies offer targeted treatment for nail psoriasis, focusing on direct delivery to the affected areas. A case report explored the use of intralesional methotrexate, administered once a month for 12 weeks into the proximal nail fold.12 The study found a significant reduction in the NAPSI score from a baseline of 56, with total healing and resolution of nail psoriasis observed. Importantly, no side effects were reported, suggesting that intralesional methotrexate may be a viable option for localized nail psoriasis without significant adverse events.

Systemic therapies for nail psoriasis

Three studies evaluated the efficacy of apremilast for nail psoriasis. In a case report, apremilast led to substantial clinical improvement, reducing the NAPSI score from 44 to 4 within 16 weeks.13 One patient experienced two isolated episodes of vomiting early in treatment, but overall tolerability was high. A larger observational study involving 15 patients confirmed rapid and sustained improvement with apremilast 30 mg twice daily, showing a reduction in NAPSI scores from 53.2 to 9.9 over 24 weeks, with no adverse events reported.14 Tofacitinib was evaluated in a randomized controlled trial involving 1,196 patients.15 Both 5 mg and 10 mg twice-daily dosing regimens demonstrated significant improvements in nail psoriasis compared to placebo, with 44.2% of patients at the 10 mg dose achieving at least 75% NAPSI improvement. Adverse events were generally mild and infrequent, including infections and low rates of malignancy.

Risankizumab was investigated in two studies. A randomized controlled trial of 647 patients reported significant improvement in nail psoriasis severity from baseline compared to placebo.16 Frequently reported adverse events included upper respiratory tract infections, nasopharyngitis, headaches, and elevated liver enzymes, but no serious adverse events were deemed treatment-related. The second study further evaluated risankizumab in a small cohort of nine patients who had previously failed IL-17 inhibitors, reporting meaningful improvements in nail involvement without serious adverse events.17 Mild adverse events included nasopharyngitis, upper respiratory tract infections, and headaches.

Secukinumab and ixekizumab, both IL-17A inhibitors, demonstrated robust clinical efficacy. In a randomized controlled trial, secukinumab (150 mg and 300 mg) significantly improved NAPSI scores in 186 patients, with the 300 mg dose showing a 45.3% improvement.18 Nasopharyngitis and upper respiratory tract infections were the most common adverse events. A study that evaluated ixekizumab in 809 patients and found significant NAPSI improvements of 35.2% and 36.7% at biweekly and monthly dosing, respectively, compared to 20% with etanercept.19 No adverse events were reported in this trial. Additionally, a head-to-head trial comparing ixekizumab and adalimumab reported higher complete clearance rates with ixekizumab (75.7% vs. 51.2%), with infections being the most common adverse event across both groups.20

Adalimumab was assessed in two studies. A randomized controlled trial of 188 patients demonstrated that adalimumab 40 mg was effective in reducing NAPSI scores in moderate-to-severe nail psoriasis.21 Common adverse events included nasopharyngitis and upper respiratory tract infections, with a slightly elevated rate of serious infections in the treatment group. Another study evaluated adalimumab in 19 patients who had previously received other biologics (etanercept, infliximab, or efalizumab).22 The switch to adalimumab yielded notable improvement, supporting its use in patients with previous biologic therapy failure. No serious adverse events were reported; the most frequent were acute tonsillitis and nasopharyngitis.

A single case report assessed acitretin 25 mg/day in combination with 5% urea nail lacquer.23 The patient experienced significant clinical improvement in nail psoriasis. The only reported adverse event was cheilitis, a known mucocutaneous side effect of systemic retinoids.

Laser and procedural therapies for nail psoriasis

Pulsed Dye and Nd:YAG Laser Therapy Laser-based treatments have emerged as effective adjunctive therapies for nail psoriasis. A RCT involving 14 participants evaluated the efficacy and safety of pulsed dye laser (PDL) monotherapy compared to combined therapy of PDL and Nd:YAG laser.24 The interventions involved three monthly sessions using PDL (6 J/cm², 7 mm, 0.45 ms) on both hands, with additional Nd:YAG laser (10 J/cm², 6 mm, 15 ms) application specifically on the right hand. The study revealed no statistically significant difference was found between combined laser therapy and PDL alone (p=0.081), with both methods achieving an approximate 20% overall improvement in NAPSI scores. Reported adverse events included transient purpura and tenderness, which resolved without intervention.

Fractional CO2 Laser Therapy Fractional CO2 laser therapy was evaluated in a RCT trial involving 30 patients.25 Patients received six monthly sessions of fractional CO2 laser treatment alone or in combination with daily topical betamethasone/calcipotriol ointment. Both treatment groups showed similar improvements in NAPSI scores, indicating no additional benefit from combining topical corticosteroids with laser therapy. Fractional CO2 laser therapy alone demonstrated effectiveness and safety, with no adverse events recorded.

Methylene-Blue Mediated Photodynamic Therapy (MB-PDT) In an observational study, the safety and effectiveness of methylene-blue mediated photodynamic therapy (MB-PDT), using intense pulsed light (IPL) as the activation source, were assessed among 20 patients.26 Participants received six bi-weekly sessions, applying MB-PDT to the right hand and IPL alone to the left hand as a comparator. Both treatments improved nail psoriasis; however, MB-PDT significantly reduced NAPSI scores (from baseline 12.35 to 4.55 post-treatment), establishing its superior efficacy compared to IPL alone. Although minor adverse events, including pain during treatment and temporary nail discolouration, were noted, no severe complications occurred. These findings suggest MB-PDT as a promising therapeutic option for nail psoriasis.

Conclusion

Nail psoriasis continues to present diagnostic and therapeutic challenges for clinicians due to its diverse manifestations and its substantial impact on patients’ physical and psychosocial well-being. In recent years, there has been a notable evolution in the treatment landscape, with an increasing array of targeted and personalized therapies. Topical treatments such as indigo naturalis, cyclosporine hydrogel, microneedle corticosteroids, and topical tofacitinib have shown promising outcomes in localized disease with favourable safety profiles.7,8,9,11 Intralesional therapies, including triamcinolone and methotrexate, remain first-line options for isolated nail involvement, offering localized efficacy with minimal systemic risk.12

Oral systemic agents, including apremilast, tofacitinib, and acitretin, demonstrated measurable reductions in NAPSI scores, particularly in moderate-to-severe disease or when comorbidities are present.13,15,23 Biologic therapies targeting IL-17 and IL-23, such as ixekizumab, secukinumab, and risankizumab, offer high levels of nail clearance and durable clinical responses, even among patients previously unresponsive to treatment.16,17,18,19

Emerging procedural interventions, such as pulsed dye laser, fractional CO2 laser, and methylene blue-mediated photodynamic therapy, serve as adjunctive or alternative options, particularly for refractory or localized cases.24,25,26 The growing body of evidence confirms that targeted treatments for nail psoriasis have consistently demonstrated favorable safety and significant efficacy, underscoring their central role in personalized patient care strategies.27 Systemic therapies, backed by recent meta-analytical evidence, offer robust efficacy and tolerability, further strengthening their recommended use in moderate-to-severe cases of nail psoriasis.28

Limitations of this review include its narrative nature, inclusion of off-label therapies, small sample sizes in some reports, and lack of direct comparisons. Overall, this review highlights a robust and expanding therapeutic arsenal for nail psoriasis. As new modalities emerge, individualized treatment approaches that consider disease severity, comorbidities, safety, and patient preference will be essential. Ongoing research—including head-to-head trials and long-term safety studies—is needed to better define optimal treatment algorithms and improve quality of life for affected patients.

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