Speakers at the 2025 Winter Clinical meeting in Hawaii offered guidance for dermatologists seeking to switch or augment therapies for their patients with psoriasis.
One session, “Wisdom and Therapeutic Advice in Psoriasis,” showcased perspectives from four clinicians, including April W. Armstrong, MD. Dr. Armstrong presented considerations for treating patients who do not have an adequate response after starting biologic therapy.
Approaching Stubborn Psoriasis
Dr. Armstrong advised clinicians to question why biologic therapy is not working, as a lack of a response may indicate that the patient has been misdiagnosed.
“These days, our biologics are so effective that if they don’t budge at all, I question the diagnosis,” Dr. Armstrong said. “If you are sure the patient has psoriasis and your standard dose of biologic is not working, you have a few different choices. You can either dose escalate (but that’s very difficult to get approved), or you can consider switching to another biologic.”
If a higher dose or switch is still insufficient to treat a patient’s psoriasis, dermatologists may consider combining biologics with topical treatments, intralesional triamcinolone (especially for stubborn plaques), oral therapies, or phototherapy.
“Once you get them to clear/almost clear, you can dial down the oral adjunct,” Dr. Armstrong said.
Considering Nail Injections?
Dr. Armstrong then shared guidance for clinicians who want to administer nail injections to patients with nail psoriasis that does not respond to systemic treatment.
According to a 2021 paper published in The Journal of Rheumatology, approximately half of patients with psoriasis experience nail involvement, and the lifetime prevalence of nail psoriasis can be as high as 90%. The authors also emphasized that nail psoriasis is associated with decreased QOL.
“Your patients are probably extremely afraid of [nail injections]. You may be very afraid as well,” Dr. Armstrong said. “Patient selection is important.”
Several factors may influence patient selection, including pain and discomfort associated with injections, the number of nails involved, the need for multiple injections, and disease severity.
“When you inject into the nail matrix, please remember that it only works best for nail matrix disease. If you have a patient who has a lot of onycholysis, which is mainly a nailbed disease, it won’t work well,” Dr. Armstrong said.
Injection concentrations of 5 mg/mL are preferred.
“You can dilute it with saline or lidocaine, but, as a reminder, no epinephrine,” Dr. Armstrong said.
Dr. Armstrong also advised clinicians to use as small a needle as possible. Depending on the number of injections administered, clinicians may consider ethyl chloride spray, pressure, or nerve blocks for pain management.
