Psoriatic nails: Study supports intramatrix triamcinolone therapy

International report – In a recent study, intramatrix injections of triamcinolone acetonide (TA) have proven safe and effective for treating psoriatic fingernails, says study co-author Kaur Savreet, M.D., a dermatologist who specializes in skin and sexually transmitted diseases, and a medical officer with the Government of Punjab, India, Department of Health.

Dr. Savreet says that, presently, physicians use varying concentrations of TA to treat psoriatic fingernails, but no standards for dosing or treatment regimens exist.

“There’s been little research done on this topic,” Dr. Savreet says.

The few studies that exist generally focus on TA concentrations of either 5 mg/ml (Bleeker JJ. Br J Dermatol. 1974 Jul;91(1):97-101) or 10 mg/ml (de Berker DC, Lawrence CM. Br J Dermatol. 1998 Jan;138(1):90-95), and none of these studies compare different concentrations, she says.

As a result, Dr. Savreet says, “Physicians are usually afraid of using intramatrix injections. Maybe some of them don’t know the technique,” and others might fear that intramatrix injections of steroids will cause nail fold atrophy.

The little and ring finger of a 36-year-old housewife are shown before (a) and six months after post-treatment (b,c) for discoloration and onycholysis. Subungual hyperkeratosis was also present. Photos: Kaur Savreet, M.D

” Physicians usually use topical medications in the form of creams or ointments, which aren’t very effective – there’s not much absorption through the nail,” Dr. Savreet says.

Therefore, she says, “We need to inject the drug into the nail bed or nail matrix for effective results.”

Study parameters

To compare and clinically validate the performance of various TA concentrations, Dr. Savreet and a colleague enrolled patients with a total of 90 psoriatic fingernails as a thesis project while Dr. Savreet was pursuing her M.D. credentials at the Government Medical College, Amritsar, India.

Investigators assessed each nail using the Nail Psoriasis Severity Index (Rich P, Scher RK. J Am Acad Dermatol. 2003 Aug;49(2):206-212) and divided the nails randomly into three groups of 30.

They treated patients in group A with TA 2.5 mg/ml, those in group B with 5 mg/ml and those in group C with 10 mg/ml. All patients received two intramatrix injections per nail, totaling 0.1 ml of solution at each sitting, Dr. Savreet tells Dermatology Times.

“I used three doses total, spaced six weeks apart. With the concentration of 10 mg/ml, I got good results,” she says.

Dr. Savreet also took clinical photographs every six weeks for up to six months. Using these photos, investigators assessed improvement in pitting, discoloration and other parameters using a four-grade scale (grade 1= up to 25 percent improvement; 4= greater than 75 percent improvement).

Results

As Dr. Savreet expected, the 10 mg/ml concentration performed best with respect to all study criteria.

Researchers observed the largest differential in the area of crumbling. Here, 91.66 percent of nails in this group (Group C) achieved more than 75 percent improvement, versus 50 percent in group B and zero in group A.

Regarding pitting, the proportion of nails in group C that achieved more than 75 percent improvement was 83.33 percent, versus 78.57 percent in group B and 26.6 percent in group A.

As for discoloration, 71.42 percent of nails in group C improved more than 75 percent, while only 44.44 percent of group B and 33.33 percent in group A improved.

Investigators observed similar results regarding onycholysis and subungual hyperkeratosis. The difference between the effect of the 10 mg/ml and other concentrations was statistically significant (p<0.001).

Adverse effects

“There were no side effects, except in two patients in whom hematoma occurred below the nail surface,” Dr. Savreet says.

The hematomas were painless and eventually grew out with the nail, Dr. Savreet says.

In the future, she says, researchers can perform similar studies with the newer biologic drugs for psoriasis. “There is still room for much study in this area,” Dr. Savreet says.

Disclosure: Dr. Savreet reports no relevant financial interests.

For more information: http://www.aad.org/

Related Keyword terms:

,finger discoloration from ring,nail atrophy,steroid-induced nail atrophy,triamcinolone for nails,triamcinolone nail