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Alefacept treatment of psoriatic nail disease: How severe should nail psoriasis be?

2006; Elsevier BV; Volume: 54; Issue: 4 Linguagem: Inglês

10.1016/j.jaad.2005.11.1064

1097-6787

John E. M. Körver, P.C.M. van de Kerkhof, Marcel C. Pasch,

Psoriasis: Treatment and Pathogenesis

To the Editor: We support the attention drawn by Cassetty et al1Cassetty C.T. Alexis A.F. Shupack J.L. Strober B.E. Alefacept in the treatment of psoriatic nail disease: a small case series.J Am Acad Dermatol. 2005; 52 ([letter]): 1011-1012Abstract Full Text Full Text PDF Scopus (31) Google Scholar in the June 2005 issue of the Journal to their experiences with alefacept in the treatment of psoriatic nail disease. Nail involvement indeed is a frequent event in the course of psoriasis and it causes serious distress. A survey from our clinic about disability associated with nail psoriasis showed that 93% of 1728 patients consider it a major problem; in 58% it interferes with their daily activities; and 52% of patients describe pain as a symptom.2de Jong E.M. Seeger B.A. Gulinck M.K. Boezeman J.B. van de Kerkhof P.C. Psoriasis of the nails associated with disability in a large number of patients: results of a recent interview with 1,728 patients.Dermatology. 1996; 193: 300-303Crossref PubMed Scopus (250) Google Scholar Relative effective systemic treatments for nail psoriasis are cyclosporine, methotrexate, and acitretin. All these drugs have a serious toxicity potential.3Feliciani C. Zampetti A. Forleo P. Cerritelli L. Amerio P. Proietto G. et al.Nail psoriasis: combined therapy with systemic cyclosporin and topical calcipotriol.J Cutan Med Surg. 2004; 8: 122-125Crossref PubMed Google Scholar, 4de Berker D. Management of nail psoriasis.Clin Exp Dermatol. 2000; 25: 357-362Crossref PubMed Scopus (84) Google Scholar, 5Mahrle G. Schulze H.J. Farber L. Weidinger G. Steigleder G.K. Low-dose short-term cyclosporine versus etretinate in psoriasis: improvement of skin, nail, and joint involvement.J Am Acad Dermatol. 1995; 32: 78-88Abstract Full Text PDF PubMed Scopus (147) Google Scholar Great progress in the treatment of severe psoriasis of the skin was made last year by the introduction of biologicals. Unfortunately, little is known of the effects of these drugs on nail psoriasis; therefore we read the report of Cassetty et al with great interest. Cassetty et al reported significant improvement, a reduction of the Nail Psoriasis Severity Index (NAPSI) of more than 30%, in 3 of 6 patients treated with alefacept monotherapy. However, 4 of these 6 patients had a pretreatment NAPSI score below 7. The NAPSI scoring system for psoriatic nail changes uses scores ranging from 0 to 80. Each nail is divided into 4 quadrants and each quadrant is scored for nail psoriasis with a maximum score of 8 for each nail.6Rich P. Scher R.K. Nail Psoriasis Severity Index: a useful tool for evaluation of nail psoriasis.J Am Acad Dermatol. 2003; 49: 206-212Abstract Full Text Full Text PDF PubMed Scopus (395) Google Scholar A NAPSI score below 7, as in most of the patients presented in the article by Cassetty et al, means that the patient had almost no clinical signs of nail psoriasis. For example, a patient who had 6 pits in 6 nails before treatment and 4 pits in 4 nails after treatment was considered as having a significant improvement in their psoriatic nail disease. We do not think that the patients presented in the letter of Cassetty et al are representative of the psoriasis patients with nail disease. Little is known about nail changes during alefacept therapy, but conclusions should not be drawn from series in which appearance or disappearance of 2 or 3 pits will result in “significant” improvement or deterioration. Effects should be investigated on patients with relevant nail psoriasis, that is, higher NAPSI scores. Because nail disease in psoriasis causes pain and restrictions in daily activities in the majority of patients2de Jong E.M. Seeger B.A. Gulinck M.K. Boezeman J.B. van de Kerkhof P.C. Psoriasis of the nails associated with disability in a large number of patients: results of a recent interview with 1,728 patients.Dermatology. 1996; 193: 300-303Crossref PubMed Scopus (250) Google Scholar and improvement in these subjective complaints is, from a patient's point of view, more important than objective improvements, it is also important to score these quality of life–related topics. In addition, it is likely that these subjective complaints arise mainly when a certain degree of clinical, psoriatic nail disease is present. This places even more stress on the importance of including patients with a significant degree of nail psoriasis to study the effects of treatments on nail psoriasis. Unfortunately, the retrospective construct of the study described in the letter of Cassetty et al did not allow readers to get any insight in these topics. In our opinion, it indeed is important to investigate the effect of biologicals on nail psoriasis. However, we recommend studies with more severe nail psoriasis to obtain more meaningful results. An example is the study published by Bianchi et al7Bianchi L. Bergamin A. de Felice C. Capriotti E. Chimenti S. Remission and time of resolution of nail psoriasis during infliximab therapy.J Am Acad Dermatol. 2005; 52: 736-737Abstract Full Text Full Text PDF PubMed Scopus (54) Google Scholar on infliximab that reported complete remission in nail psoriasis in 25 patients with a minimal NAPSI score of 15 at the start of therapy. Furthermore, patient satisfaction and quality-of-life topics also need to be included in studies on the effect of biologicals on nail psoriasis.