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Rapid Response of Nail Psoriasis to Etanercept To the Editor: Nail psoriasis is a chronic disease affecting the appearance of the nails and causing severe distress to patients. Several methods of successful treatment for cutaneous psoriasis have been reported, and evidence-based therapies for psoriatic nail disease do exist1, although there is lack of a standardized treatment regimen. Biological agents have established effectiveness in the treatment of psoriasis; however, reports regarding their efficacy on psoriatic nails remain limited2. We describe a case of rapid improvement of nail psoriasis in a patient receiving etanercept for plaque-type psoriasis. A 35-year-old man with recalcitrant plaque psoriasis resistant to acitretin and cyclosporine was placed on a regimen of etanercept 50 mg per week in April 2006. All his 10 fingernails had also displayed psoriatic lesions resistant to previous treatments, while no symptoms of psoriatic arthritis were noted. The affected nails presented oil-drop discoloration, nailbed hyperkeratosis, onycholysis, and pitting (Figure 1). Toenails did not show any significant lesions.
After 3 weeks' administration of etanercept, a marked improvement was noted (Figure 2), and a complete cure was seen during the sixth month of etanercept therapy (Figure 3). Cutaneous psoriasis also showed a significant improvement. The medication was discontinued after 7 months of treatment; the patient remains free of psoriatic lesions on nails.
Etanercept has been shown to be safe and to have longterm efficacy for treatment of moderate to severe psoriasis resistant to other modes3. It acts by binding tumor necrosis factor-a (TNF-a), which becomes biologically inactive; and therefore many proinflammatory pathways responsible for the initiation, maintenance, and recurrence of skin lesions in psoriasis are suppressed3. Nail abnormalities are seen in about 50% of patients with psoriasis, with a wide spectrum of severity4. Medical management of nail psoriasis can be divided into the areas of topical, intralesional, radiation, and systemic and combination therapies5. The choice of treatment depends on the clinical presentation and specific patient factors. When nail psoriasis is the only manifestation, with no evidence of psoriatic arthritis, topical treatment as single therapy or in combination with systemic drugs is the most appropriate choice5. Systemic treatment is indicated when psoriatic nail disease is severe, or when topical treatment fails, or when extensive skin lesions and/or joint lesions coexist3. In our case, etanercept showed remarkable and rapid effectiveness in the treatment of psoriatic nail disease. Our result is in agreement with other unpublished data2. Thus etanercept may represent a safe, well tolerated alternative therapeutic option for treatment of psoriatic nail disease. Further studies are needed to establish the effectiveness and the therapeutic regimens of etanercept for treatment of nail psoriasis. EFSTATHIOS RALLIS, MD; EVGENIA STAVROPOULOU, MD, Department of Dermatology, Army General Hospital, Athens; DIMITRIS RIGOPOULOS, MD, University of Athens, A. Sygros Hospital, Athens; CONSTANTINOS VERROS, MD, Tripolis, Greece. Address reprint requests to Dr. E. Rallis, 11 Pafsaniou Street, Athens, Greece GR-11635. E-mail: efrall@otenet.gr 2. de Rie M, Giannetti S, Walker J, et al. Nail psoriasis improves after 12 weeks of etanercept therapy in patients with moderate to severe psoriasis. Proceedings, 16th Congress of the European Academy of Dermatology and Venereology, Vienna, Austria, May 16-20 2007; Poster 1117:193. 3. Tyring S, Gordon KB, Poulin Y, et al. Long-term safety and efficacy of 50 mg of etanercept twice weekly in patients with psoriasis. Arch Dermatol 2007;143:719-26. 4. Lawry M. Biological therapy and nail psoriasis. Dermatol Ther 2007;20:60-7. 5. Jiaravuthisan M, Sasseville D, Vender RB, et al. Psoriasis of the nail: Anatomy, pathology, clinical presentation, and a review of the literature on therapy. J Am Acad Dermatol 2007;57:1-27. |
