Safety of current systemic therapies for nail psoriasis

ABSTRACT

Introduction

A discussion of safety of systemic treatments for nail psoriasis is lacking, particularly in reference to approval of new therapies assessed for nail outcomes. A review of safety profiles for agents commonly utilized for treatment of nail psoriasis is warranted to help inform treatment choices. The PubMed database was searched on 5 April 20235 April 2023, with articles discussing safety of nail psoriasis systemic therapies identified and reviewed.

Areas covered

Systemic treatments for nail psoriasis include biologic therapies (tumor necrosis factor-alpha inhibitors, interleukin-17 inhibitors, interleukin-23 inhibitors, interleukin-12/23 inhibitors), small molecule inhibitors (apremilast, tofacitinib), and oral systemic immunomodulators (methotrexate, cyclosporine, acitretin), each with unique safety profiles and considerations. Herein, we discuss adverse events, contraindications, drug–drug interactions, screening/monitoring guidelines, as well as utilization for special populations, including pregnant, older, and pediatric patients.

Expert opinion

The advent of targeted therapies, including biologic treatments and small molecule inhibitors, has revolutionized outcomes for nail psoriasis patients, but warrant review and monitoring for potential adverse events. Oral systemic immunomodulators have demonstrated moderate efficacy for nail psoriasis treatment, but are notable for frequent contraindications and drug–drug interactions. Further study of these agents and their use in special populations is needed to elucidate safety profiles for long-term use.

KEYWORDS:

• biological therapy
• nail
• nail psoriasis
• psoriasis
• psoriatic arthritis
• safety
• targeted therapy

Article highlights

• Biologic therapies have demonstrated efficacy for nail outcomes, but carry increased risks of infections, most commonly upper respiratory tract infections and nasopharyngitis. Interleukin-23 inhibitors are associated with the lowest risk of safety events, compared to other biologics for nail psoriasis. Malignancy risk with biologic agents in patients with nail psoriasis is likely minimal, but caution is still warranted.

• Small molecule inhibitors, including apremilast and tofacitinib, are effective therapies for nail psoriasis, but are associated with gastrointestinal symptoms and increased risk of herpes zoster infections, respectively.

• Oral systemic immunomodulators have demonstrated moderate efficacy for nail psoriasis, but are notable for frequent contraindications and drug-drug interactions.Tumor necrosis factor-alpha inhibitors, particularly certolizumab and etanercept, are the preferred medication class for nail psoriasis treatment in pregnant women. Etanercept, ixekizumab, secukinumab, and ustekinumab are approved for pediatric patients. Guidelines for older patients are lacking, but biologic therapies and small molecule inhibitors have demonstrated efficacy and safety in this population.

Author contribution statement

SR Lipner contributed to conception and design of the work. JK Hwang contributed to acquisition and analysis of data. Authors JK Hwang and SR Lipner contributed to drafting and editing of the manuscript.

Declaration of Interest

SR Lipner is a consultant for Hoth Therapeutics, Ortho-Dermatologics, Belle Torus Corporation, and Moberg Pharmaceuticals. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Correction Statement

This article has been republished with minor changes. These changes do not impact the academic content of the article.

Additional information

Funding

This paper was not funded.