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LETTER TO THE EDITOR
Treatment of nail psoriasis with
calcipotriol/betamethasone
dipropionate foam versus pulse
dye laser: an unblinded,
intra-patient, left-to-right
prospective study
Editor,
Combination of topical vitamin D
3
analogues and corticos-
teroids is a valid therapeutic option for nail psoriasis.
1-3
Pulsed
dye laser (PDL) has also been employed with variable success.
4-9
This single-centre, intra-patient (left vs. right) prospective study
compared calcipotriol/betamethasone dipropionate (Cal/BD)
foam with PDL for nail psoriasis over 12 weeks. The study was
conducted following the principles of the Declaration of Helsinki
and approved by the institutional ethics committee. All subjects
provided written informed consent.
Enrolment criteria were (i) bilateral nail matrix/bed psoriasis
changes affecting ≤3 nails in each hand; and (ii) mild-to-mod-
erate skin psoriasis controlled with topical therapy. Exclusion
criteria were (i) presence of psoriatic arthritis; (ii) use of sys-
temic antipsoriatic agents within the prior 6 months; (iii) use of
any other medication that could affect psoriasis; and (iv) pres-
ence of onychomycosis. The one hand fingernails were randomly
treated with PDL with pulse duration 0.4 ms, fluence 6 J/cm
2
and spot size 7 mm with a 30% spot overlapping in four-week
intervals. The other hand nails were treated with Cal/BD foam
applied once daily on the proximal nail fold and hyponychium.
Effectiveness data were analysed by an intent-to-treat last obser-
vation carried forward imputation (ITT-LOCF) and presented
as frequencies (%) for categorical variables and means (SD) for
continuous ones after testing for normality (Shapiro–Wilk test).
A paired Student’s t-test was used to compare significance of dif-
ferences in mean values between groups. All analyses were per-
formed at the 5% level of significance using STATA/SE 11.0.
Of 20 enrolled patients (13 male and 7 female), 16 (80%)
completed the study. Three patients were lost at follow-up, and
one received cyclosporine due to relapse in skin psoriasis after
week 4. The mean (SD) age was 53.4 (9.2) years, while the mean
(SD) duration of skin and nail psoriasis was 7.3 (3.6) and 3.4
(1.3) years, respectively. A total of 110 fingernails, 44 with Cal/
BD foam and 66 with PDL, were treated.
The mean total NAPSI in the Cal/BD-treated nails was
reduced by 44%, from 7.85 at baseline to 4.4 at week 12
(P<0.000) (Fig. 1). A superior impact on nail bed signs was
noted: 61% reduction of the mean nail bed score from 3.55 at
baseline to 1.4 at week 12 (P<0.000) There was no statistically
significant difference regarding the total NAPSI (P=0.165) and
nail bed score in PDL-treated nails (Table 1). Adverse events, i.e.
mild skin irritation on the nail fold in 2 Cal/BD-treated cases
and erythema and/or petechiae in 5 PDL-treated cases, were
transient and resolved without treatment.
Cal/BD foam formulation combines anti-inflammatory, anti-
proliferative and keratinocyte differentiation properties to
Figure 1 A patient with nail psoriasis at baseline (a). The same patient with improvement in both nail matrix and nail bed signs after
12 weeks of treatment with Cal/BD foam (b).
©2020 European Academy of Dermatology and VenereologyJEADV 2020
JEADV
provide effective control of psoriasis while minimizing side-ef-
fects.
2,3,10
Although the mean reduction in total NAPSI at week
12 was lower than that previously reported by our group (44%
vs. 72%, respectively),
3
the current findings were obtained from
more severe cases compared to the prior study (mean baseline
NAPSI 7.85 vs. 5.8, respectively). Furthermore, the two studies
investigated different vehicles for Cal/BD (ointment vs. foam).
Cal/BD foam was well tolerated without steroid-induced AEs.
Long-term safety of this combination in gel and ointment for-
mulation has been well established.
10
Although the application parameters of the 595-nm PDL were
in part comparable with that of prior studies,
4-9
we observed a
disparity in effectiveness that could be attributed to fewer ses-
sions or non-use of concomitant therapy in our cohort.
In conclusion, even with limitations related to the small sam-
ple size, the monocentric design and the relatively short follow-
up period, this study demonstrated that Cal/BD foam showed
greater effectiveness in nail psoriasis treatment especially in nail
bed involvement, compared to PDL. Further validation is clearly
needed.
Acknowledgement
The patients in this manuscript have given written informed
consent to publication of their case details.
Funding sources
None declared.
S. Gregoriou, P. Sidiropoulou, A. Tsimpidakis,
N. Rompoti, T. Tsironi, P. Panagakis, D. Polydorou,
P. Kostakis, D. Rigopoulos
1st Department of Dermatology-Venereology, Faculty of Medicine,
National and Kapodistrian University of Athens, “A. Sygros”Hospital for
Skin and Venereal Diseases, Athens, Greece
*Correspondence: S. Gregoriou. E-mail: stamgreg@yahoo.gr
References
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tion, evaluation, and treatment of nail psoriasis in adult patients with no
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3 Rigopoulos D, Gregoriou S, Daniel Iii CR et al. Treatment of nail psoria-
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DOI: 10.1111/jdv.16426
Table 1 Change in Nail Psoriasis Severity Index (NAPSI) over the
study period (12 weeks)
NAPSI score Week 0 (baseline) Week 12 P-value
Cal/BD-treated nails
Total, mean (SD) 7.85 (4.1) 4.4 (2.8) <0.000
Nail bed, mean (SD) 3.55 (2.1) 1.4 (1) <0.000
PDL-treated nails
Total, mean (SD) 6.8 (3.1) 6.4 (3.3) 0.165
Nail bed, mean (SD) 3.2 (1.3) 3.2 (1.3) NA
Cal/BD, calcipotriene/betamethasone dipropionate; NA, not applicable;
NAPSI, Nail Psoriasis Severity Index; PDL, pulse dye laser; and SD,
standard deviation.
©2020 European Academy of Dermatology and VenereologyJEADV 2020
2Letter to the Editor
