Severe 20-nail psoriasis successfully treated by low dose methotrexate

Area of Science:

• Dermatology
• Rheumatology
• Pharmacology

Background:

• Severe psoriatic nail disease often presents with extensive nail matrix dystrophy.
• Current treatments including topical steroids, photochemotherapy, and oral retinoids can be unsatisfactory for severe cases.

Observation:

• An 11-year-old girl experienced rapid onset of painful, severe nail dystrophy affecting all 20 nails.
• Physical examination revealed characteristic psoriatic nail changes and associated oral findings (geographic and fissured tongue).
• Initial treatment with topical corticosteroids and calcipotriol failed to halt disease progression.

Findings:

• Low-dose oral methotrexate (5 mg weekly) was initiated for the severe psoriatic nail dystrophy.
• Significant improvement was observed within 4 weeks, with normal nail plate regrowth.
• Complete resolution of nail dystrophy was achieved after 9 months for fingernails and 13 months for toenails.

Implications:

• Weekly low-dose methotrexate may be a viable and effective treatment for severe psoriatic nail dystrophy.
• This treatment option should be considered for patients with severe nail psoriasis unresponsive to conventional therapies, provided no contraindications exist.
• Further research into low-dose methotrexate for psoriatic nail disease is warranted.