Severe Nail Psoriasis and Early Psoriatic Arthritis: Illustrative Cases Confirming That Severity of Disease Is Not Solely Dependent on the Extent of Body Surface Area.

Nail psoriasis is a chronic inflammatory manifestation frequently associated with cutaneous psoriasis and psoriatic arthritis (PsA). Fingernails and/or toenails may be affected by psoriasis. The management of nail psoriasis can be challenging due to marked variability in clinical presentation, its chronicity, its frequent refractory nature despite a variety of therapies, and the slow rate of nail plate growth over several months. Unfortunately, the common clinical misdiagnosis as onychomycosis often leads to delay in an accurate diagnosis of nail psoriasis as well as exposure of the patient to topical and/or oral antifungal therapies that are not effective for psoriasis. Traditional treatment options for nail psoriasis often require extended courses of therapy to achieve significant results. Both of these cases were characterized by limited or absent psoriatic skin involvement, with extensive symptomatic psoriatic fingernail dystrophy and presence of PsA. This article describes the use of bimekizumab, a dual interleukin (IL)-17A and IL-17F inhibitor, for the rapid resolution of severe psoriasis in 2 patients with extensively dystrophic fingernail psoriasis and concomitant PsA, both causing marked interference with daily physical functioning and significant psychosocial impairment. Both patients rapidly achieved marked improvement of all signs and symptoms of severe psoriasis involving all affected fingernails and joints, within at least 1 to 3 months. These results add real-world evidence that further highlights the potential for accelerated improvement with specific biologic therapies effective for plaque psoriasis, with both cases supporting the rapid onset and high magnitude of efficacy for symptomatic severe psoriasis presenting with extensive dystrophy of all fingernails and PsA.