Topical Tretinoin Effective in Nail Psoriasis

Nail involvement is a common feature of psoriasis commonly overlooked by physicians. It affects approximately 10-78% of psoriasis patients with 5-10% of patients having isolated nail psoriasis. Its significant association with arthritis, its resistance to treatment, and the psychological stress it causes in patients make it an important feature of psoriasis that needs attention and treatment. Recently, a case of nail psoriasis being successfully treated with topical tretinoin was reported in the Indian Dermatology Online Journal.

A 12‑year‑old girl presented with asymmetric fingernail involvement with distal nail disease in the form of subungual hyperkeratosis, distal onycholysis with proximal erythema, and shortening of nails. No skin or joint manifestations were present in the patient. With the suspicion of nail psoriasis, a nail bed biopsy was done which revealed subungual hyperkeratosis, focal parakeratosis with a neutrophilic infiltrate, and absence of any fungal elements confirming the diagnosis of nail psoriasis. The nail disease severity was evaluated using the NAPSI (Nail Psoriasis Severity Index) score, which was found to be 25.

Due to predominant distal nail bed disease, reluctance for injectable therapy, high cost, and poor availability of tazarotene, topical tretinoin 0.025% cream was prescribed. After approximately 3 months of regular application, an almost complete resolution of nail changes was seen with NAPSI at week 12 of the therapy dropping down to 5. The patient reported no major adverse effects. Then the frequency of the application was reduced to alternate nights and then to twice a week. There has been no exacerbation over a further 6 months of follow‑up.

Nail psoriasis has a tremendous impact on the quality of life. Management of isolated nail psoriasis depends on the severity of nail involvement and the impact of the disease on quality of life. The treatment options include:

• Topical medications
• Intralesional medications
• Systemic medications

Systemic therapy is recommended for multiple nail involvement, severe nail disease, or severe impact on quality of life. The most commonly used therapy has been topical corticosteroids, with or without vitamin D analogues.

Topical retinoids are a useful steroid‑free alternative in a wide range of dermatological diseases. The antiproliferative, differentiation normalizing, and anti‑inflammatory effects of retinoids are the reason for their use in psoriasis. Tretinoin is easily available and cost‑effective compared to tazarotene. Its preliminary use in our patient showed excellent response within 6 weeks, encouraging us to further extend the treatment duration. Though the use of tazarotene as a topical treatment for nail psoriasis is well known, that of topical tretinoin has not been reported.

To conclude, topical tretinoin cream can be a simple, cost‑effective, and easily available retinoid for the topical treatment of nail psoriasis, especially with distal nail disease.

Source

1. Grover C, Daulatabad D. Topical tretinoin in the treatment of nail psoriasis. Indian Dermatol Online J 2022;13:126-7.
2. Dogra A, Arora AK. Nail psoriasis: the journey so far. Indian J Dermatol. 2014 Jul;59(4):319-33. doi: 10.4103/0019-5154.135470.