The “Psoriasis Study of Health Outcomes” (PSoHO) is an international, prospective, non-interventional cohort study. In the meantime, new interim analyses have been published of study participants who had nail infestation and underwent treatment with an interleukin (IL)-17A inhibitor. The results underline the great potential of IL-17A-i in psoriasis with nail infestation.
Typical psoriatic nail changes include subungual hyperkeratosis, onycholysis and stippled/oily nails (Fig. 1). Up to over half of patients with skin psoriasis and up to 80% of those with psoriatic arthritis (PsA) have nail involvement [1]. Patients often experience considerable additional suffering due to nail infestation, so it is not surprising that it is one of the upgrade criteria** [2]. The extent of nail psoriasis can be assessed using the Modified Nail Psoriasis Severity Index (mNAPSI), which is an easily reproducible scale for assessing nail infestation (box) [3].
** Upgrade criteria for moderate to severe psoriasis in the S3 guideline: “Pronounced disease of visible areas, pronounced disease of the scalp, disease of the genital area, disease of the palms of the hands and soles of the feet, onycholysis or onychodystrophy of at least two fingernails, itching and associated scratching, presence of treatment-resistant plaques”
The PsoHo study included adults with moderate to severe psoriasis who had been treated with biologics for ≥6 months. The treatment response to anti-IL-17A antibodies (secukinumab and ixekizumab) is compared with that to other biologics$ for the assessment of progression [4,5]. At the start of the study, nail infestation was classified as present (mNAPSI ≥1) or absent (mNAPSI=0) using the modified Nail Psoriasis Severity Index (mNAPSI). The proportion of patients who achieved a 50% or 100% reduction in mNAPSI after 12 months (mNAPSI50 or mNAPSI100)&.
$ Brodalumab, adalimumab, certolizumab, etanercept, infliximab, ustekinumab, guselkumab, risankizumab, tildrakizumab
The baseline data were analyzed using ANOVA or Fisher’s Exact Test and the data in month 12 were analyzed descriptively with imputation of non-responders.
| Modified Nail Psoriasis Severity Index (mNAPSI) |
| To determine the mNAPSI of the fingernails, the specific lesions of the nail matrix (spots, leukonychia, red dots in the area of the lunula and nail dystrophy) and the nail bed (onycholysis/oil spots, subungual hyperkeratosis and splinter hemorrhages) are recorded individually for each nail. |
| For the lesions spotting, nail dystrophy and onycholysis/oil spots, the severity is assessed on the basis of the number or percentage of infestation using a scale from 0 to 3. All other nail symptoms are rated 0 (not present) or 1 (present). |
| The mNAPSI can therefore assume values between 0 and 130 for all ten fingernails. Lower values reflect a lower level of expression. |
| to [1,2] |
Of the patients with nail psoriasis (n=263), 46.8% were receiving an anti-IL-17A antibody (ixekizumab: n=94, secukinumab: n=29) and 53.2% were being treated with other biologics at the start of the study [5]. Participants with nail psoriasis had more severe skin disease (PASI: 16.4 vs. 14.2, p=0.013) and the proportion of patients with PsA was higher compared to patients without nail psoriasis (29.7% vs. 14.0%, p<0.001). Patients with nail infestation had a mean mNAPSI of 24.8 (SD 21.9). A proportion of 47.9% (n=126) had moderate to severe nail psoriasis (mNAPSI≥20). The most frequently reported characteristics of nail psoriasis were onycholysis/oil spots (78.3%) and pitting of the nail plate (77.9%). After 12 months, 85.4% and 55.3% of patients treated with anti-IL-17A achieved mNAPSI50 and mNAPSI100, respectively. In patients treated with other biologics, this proportion was 72.1% and 42.9% respectively. Similar results were observed in patients with a baseline mNAPSI ≥20.
Congress: Dermatology compact & practical
Literature:
- Bardazzi F, et al: Nail Psoriasis: An Updated Review and Expert Opinion on Available Treatments, Including Biologics. Acta Derm Venereol 2019; 99(6): 516-523.
- Nast A, et al: German S3 guideline on the treatment of psoriasis vulgaris, adapted from EuroGuiDerm – Part 1: Treatment goals and treatment recommendations. JDDG 2021; 19(6): 934-951.
- Cassell SE, et al: The modified Nail Psoriasis Severity Index: validation of an instrument to assess psoriatic nail involvement in patients with psoriatic arthritis. J Rheumatol 2007; 34(1): 123-129.
- Pinter A, et al: Comparative effectiveness of biologics in clinical practice: week 12 primary outcomes from an international observational psoriasis study of health outcomes (PSoHO). J Eur Acad Dermatol Venereol 2022; 36(11): 2087-2100.
- Egeberg A, et al: Baseline Characteristics and Interim Month 12 mNAPSI Results in Patients with Moderate-to-Severe Plaque Psoriasis and Concomitant Nail Psoriasis Treated with Biologics in the Psoriasis Study of Health Outcomes (PSoHO), KoPra 2024, P034. JDDG 2024; 22, Issue S1: 1-40.
- Krajewska-Wlodarczyk M, Owczarczyk-Saczonek A: Int J Environ Res Publich Health 2022; 19: 5611. www.mdpi.com/1660-4601/19/9/5611/htm,(last accessed 13.05.2024).
DERMATOLOGIE PRAXIS 2024; 34(3): 32 (published on 14.6.24, ahead of print)
