Ablative CO₂-Assisted Laser for Topical Drug Delivery in Nail Psoriasis: A Systematic Review

Abstract

Background

Nail psoriasis poses challenges for effective treatment, and topical drug delivery through the nail plate is limited. A novel approach to address this challenge involves the use of ablative fractional laser as a pretreatment strategy to enhance topical drug delivery for nail psoriasis.

Summary

This systematic review, conducted in accordance with PRISMA guidelines, involved an extensive literature search across PubMed/MEDLINE, EMBASE, and the Cochrane Library up to July 2023. The primary focus was on exploring studies that investigated the application of ablative laser technology to augment drug delivery for nail psoriasis.

Key Messages

(1) The review included seven randomized controlled trials, all examining the combination of fractional CO₂ laser with topical treatments. These trials demonstrated varying degrees of improvement in nail psoriasis. (2) Patients undergoing laser treatment reported experiencing moderate levels of pain, effectively managed through the application of topical anesthesia. (3) Commonly observed side effects included erythema, swelling, and crusting, with the Koebner phenomenon being a rare occurrence. (4) Notably, patient satisfaction levels with the combined approach of laser and topical treatments were consistently high. In conclusion, the utilization of ablative CO₂-assisted laser pretreatment, when used in conjunction with topical therapy, appears to be both effective and well-tolerated for the treatment of nail psoriasis. However, the establishment of optimal parameters and treatment intervals for fractional laser therapy remains an area for further research. Standardized studies are imperative to identify the most effective strategy for enhancing topical drug delivery in the context of nail psoriasis treatment.

Introduction

Nail psoriasis occurs in approximately 50% of patients affected by psoriasis vulgaris and 80% of patients with psoriatic arthritis [1]. This condition has a detrimental effect on the quality of life, manifesting as cosmetic disfigurement that can result in social stigmatization and pain that may significantly disrupt daily activities [2]. The clinical diagnosis of nail psoriasis relies on the identification of characteristic signs, including pitting, onycholysis, subungual hyperkeratosis, oil spots, and crumbling.

Nail psoriasis treatment is challenging, often leading to unpredictable outcomes and frequent relapses. The effectiveness of topical products is hindered by inadequate permeation through the nail plate. On the other hand, conventional systemic therapies typically exhibit partial efficacy and require prolonged treatment duration, with an increased risk of systemic toxicities and low patient compliance [3, 4]. To overcome the issue of limited drug delivery to the nail tissue, intralesional injection has been utilized for many years in the treatment of nail psoriasis. Triamcinolone acetonide and methotrexate (MTX) have demonstrated favorable outcomes when administered in this manner [5, 6]. Despite its effectiveness, intralesional injection induces considerable pain, necessitating the use of pain management techniques before treatment. Moreover, this approach is associated with potential adverse effects, including subungual hematomas and injection site atrophy in the case of triamcinolone [5].

A novel approach in the field of topical treatment for nail diseases involves the utilization of an ablative fractional laser as a pretreatment strategy to enhance the absorption of topically applied medications. Laser treatment creates multiple perforations, enhancing drug delivery of topical treatments into the nail bed or matrix. Referred to as laser-assisted drug delivery, laser pretreatment of the nail offers additional advantages owing to its minimal invasiveness, potentially improving patient compliance. Fractional lasers have been utilized in conjunction with topical agents for the management of onychomycosis, as well as traumatic onychodystrophy, resulting in significant improvement of the dystrophic nails [7, 8].

An in vitro study using nail models has confirmed that fractional lasers can enhance the delivery of high-molecular-weight molecules, including MTX, through the nail plate. A 2,940 nm fractional ablative laser treatment of bovine hoof membrane, serving as an in vitro model for human nails, resulted in successful micro-poration and increased drug delivery, flux, and permeability coefficient compared to the untreated group [9]. In this systematic literature review, we comprehensively analyzed all relevant articles concerning the use of ablative laser pretreatment for enhancing topical drug delivery in nail psoriasis.

Material and Methods

Research Strategy and Exclusion Criteria

The systematic review adheres to the guidelines set by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Articles published up to July 2023 were considered. The literature search was conducted on July 8th, 2023, using the bibliographic databases PubMed/MEDLINE, EMBASE, and Cochrane Library. The search terms used were “laser” AND (“nail psoriasis” OR “psoriatic nail”). Only articles focusing on the use of ablative laser as a drug delivery enhancer for the treatment of nail psoriasis were considered.

After duplicate removal, articles were excluded based on titles and abstracts with the following criteria: (1) articles not focused on humans; (2) articles not focused on fractional laser treatment followed by topical drug application, and (3) abstracts or full-text not available.

Articles remaining after the initial screening underwent a full-text review for inclusion. The detailed search strategy is shown in Figure 1.

Fig. 1.

PRISMA 2020 flow diagram showing the search strategy in this systematic review.

Data Extraction and Analysis

Two independent physicians (J.T., A.S.) conducted the review of abstracts and data extraction. The data extracted consisted of the author’s information, publication year, study design, number of patients receiving treatment, demographics of the treated population, comorbidities, baseline disease severity assessed by Nail Psoriasis Severity Index (NAPSI) (or variants of NAPSI score), disease duration, outcomes, any reported adverse events, local anesthesia, pain measures (assessed by VAS) and patient’s satisfaction, posttreatment management, number of sessions, interval between sessions and topical treatment. In cases where there were differences of opinion between the reviewers regarding study selection and quality, a third opinion was provided by SP till a definitive agreement was reached among the searching physicians. Duplicate studies and articles reporting results from the same cohort of patients were excluded from data analysis.

Results

Our study included 7 randomized controlled trials assessing the effectiveness of ablative fractional CO₂-assisted laser delivery versus no treatment, fractional laser monotherapy, topical therapy monotherapy, and injection therapy with triamcinolone acetonide or MTX. Four of the included studies had intra-patient designs. A total of 142 patients were included. The distribution of patients among the different treatment groups is as follows: calcipotriol/betamethasone dipropionate (Cal/BD) foam was administered to 11 patients, Cal/BD ointment to 40 patients, Cal/BD gel to 22 patients, triamcinolone acetonide to 18 patients, Tazarotene 0.1% gel to 27 patients, and Topical MTX to 24 patients. Patients had a mean age of 32 years and were mostly female (65%).

Baseline NAPSI scores (NAPSI, mNAPSI (Modified NAPSI), and tNAPSI (Target NAPSI)) differed among the studies. The baseline severities of nail psoriasis according to specific scoring systems are listed in Table 1. Some authors provided the NAPSI score according to the nail involvement, distinguishing between the nail matrix and nail bed psoriatic manifestations.

Table 1.

Patient characteristics and outcome measures

	Year of publication	Study type	Comparison of fractional laser treatment with control group	Number of patients randomized to fractional laser	Age (mean)	Sex (M, F) (%)	Baseline NAPSI (mean)	Outcome Δ NAPSI (CR)	Disease duration in years (mean)	Comorbidities	Patient’s reported outcome
Ortner et al. [10]	2022	RCT (intra-patient) versus Cal/BD foam only	Equally effective (treatment group achieved a higher reduction of NAPSI but the difference was not statistically significant)	11	52	73, 27	Total 40	Total −78%; (NA)	NA	Skin psoriasis 100%, psoriatic arthritis 18,18%	mDLQI −60%
Sharkawy et al. [11]	2023	RCT (intra-patient) versus fractional laser only	Equally effective	30	37.27	53.3, 46.7	Total 3.9, matrix 1.7, bed 2.2 [tNAPSI]	Total −35.89%, matrix −23.53%, bed −45.54%; (complete to almost normal 33.33%)	11.23	Skin psoriasis 83.3%	Poor 6.7%, below average 10%, good 20%, very good 33.3%, excellent 30%
Nassar et al. [2]	2022	RCT versus intralesional triamcinolone acetonide	Equally effective	18	25	83.3, 16.7	Total 13.5, matrix 2, bed 8	Total −62.96%, matrix −100%, bed −37.5%; (NA)	1	Skin psoriasis 22.2%, psoriatic arthritis 11.1%; diabetes mellitus 5.6%; hypertension 5.6%	Unsatisfied 5.56%, satisfied 27.8%, highly satisfied 66.7%
Abd Elazim et al. [12]	2022	RCT (intra-patient) versus tazarotene gel only	More effective	27	45.19	81.48, 18.52	Total 24.74, matrix 12.63, bed 12.11 [mNAPSI]	Total −48.15%, matrix −61.57%, bed −33.73% (NA)	4.83	Skin psoriasis 92.59%	7.33 mean patient global assessment
Alakad et al. [13]	2022	RCT versus intralesional MTX	Equally effective	14	28.5	71.4, 28.6	Total 16, matrix 5.5, bed 7	Total −50%, matrix −81.82%, bed −21.43% (NA)	1	Skin psoriasis 42.9%, psoriatic arthritis 28.6%, diabetes mellitus 7.1%, hypertension 7.1%	7.1% unsatisfied, 28.6% satisfied, 64.3% highly satisfied
Shehadeh et al. [14]a	2021	RCT (intra-patient) versus no treatment	More effective	22	42	68.18, 31.82	Total 21.41, matrix 11.17, bed 10.11	Total −34.04%, matrix −26.1%, bed −42% (NA)	5	Skin psoriasis NA, diabetes mellitus: 9.09% hyperlipidemia: 9.09% hypertension: 13.64% hypothyroidism: 4.55% gastro-esophageal reflux: 4.55%	Slightly satisfied 12%, moderately satisfied 69%, greatly satisfied 19%
Afify et al. [15]b	2023	RCT versus topical Cal/BD	Equally effective	10	40	35, 65	Total 8, matrix 9, bed 4 [tNAPSI]	Total −87.5%, matrix −88.89%, bed −100% (NA)	5	Skin psoriasis 100%	Not at all satisfied 25%, partially satisfied 5%, satisfied 30%, completely satisfied 40%
Afify et al. [15]b	2023	RCT versus topical MTX	Equally effective	10	40	35, 65	Total 5, matrix 5, bed 3.5 [tNAPSI]	Total −60%, matrix −60%, bed −100% (NA)	5	Skin psoriasis 100%	Not at all satisfied 30%, partially satisfied 5%, satisfied 25%, completely satisfied 40%

RCT, randomized controlled trial; NAPSI, Nail Psoriasis Severity Index; mNAPSI, modified NAPSI; tNAPSI, target NAPSI; CR, complete response; mDLQI, modified Dermatology Life Quality Index; VAS, visual analog scale; OCT, optical coherence tomography; Cal/BD, calcipotriol/betamethasone dipropionate.

^aIn this study, pulsed-dye laser was used in addition to fractional CO2 laser and topical drug application.

^bAA Afify et al. conducted a study with two treatment arms: in one arm, they topically administered Cal/BD, and in the other arm, MTX was administered.

The primary outcome measure, Δ NAPSI, i.e., the percentage change in NAPSI score, was assessed in all studies. Fractional laser pretreatment demonstrated varying degrees of improvement. The included studies reported reductions in total NAPSI scores ranging from 34% to 87.5%, along with matrix and bed reductions ranging from 26.1% to 100% (see Table 1). Ortner et al. reported a total NAPSI reduction of 78% using Cal/BD foam, while El Sharkawy et al. reported a reduction of 35.8% in total NAPSI score using Cal/BD ointment, with matrix and bed reductions of 23.53% and 45.54%, respectively. Only the study conducted by El Sharkawy and colleagues reported the complete response as outcome (defined as the normal appearance of the nail unit after treatment).

The mean disease duration across the studies ranged from 1 to 11.2 years. Comorbidities reported in the studies included skin psoriasis (61.1% of the total) and psoriatic arthritis (37.5%). Other comorbidities, including diabetes mellitus, hypertension, hyperlipidemia, hypothyroidism, and gastro-esophageal reflux have been reported inconsistently. Among the various studies, a clear correlation between disease duration or the presence of comorbidities and clinical response has not been identified.

Patient-reported outcomes were assessed using different scales. Ortner et al. utilized the modified Dermatology Life Quality Index (mDLQI) and reported a 60% reduction. Other studies reported patient satisfaction graded as: not at all satisfied, partially (or slightly) satisfied, satisfied (or moderately satisfied), and completely (or greatly) satisfied. El Sharkawy et al. reported a high level of treatment satisfaction, with 66.7% of patients expressing high satisfaction. Alternatively, Afify et al. observed a lower satisfaction rate, with 40% of patients who reported complete satisfaction. Furthermore, Shehaded’s study revealed that 19% of patients experienced a great level of satisfaction, while 69% reported a moderate level of satisfaction.

Pain levels during the procedure were evaluated using the visual analog scale (VAS) in several studies. Both Ortner et al. and El Sharkawy et al. reported a mean VAS score of 3 (out of 10), indicating moderate pain. Nassar et al. noted that 38.9% of patients experienced no pain at all, while the remaining patients reported mild to moderate pain.

Local anesthesia in the form of topical anesthetic was used in 6 out of 7 studies to manage pain during the procedure. Various side effects associated with fractional laser treatment were reported across the studies. Erythema was the most commonly observed side effect, reported with a percentage ranging from 7.4% to 75% of patients. Swelling and crusting were also common, with a reported percentage of 28% and 27%, respectively, in the study by Ortner and colleagues. Other side effects included distal skin peeling (20%), onychoschizia (9%), bleeding (7.4%) hyperpigmentation (7%), and proximal skin peeling (5%). The complete list of the reported side effects among the various studies is reported in Table 2.

Table 2.

Treatment characteristics

	Intra-procedural pain (mean VAS)	Local anesthesia	Side effects	Posttreatment management and brief description of the procedure	Laser parameters	Number of sessions	Time interval between sessions	Topical treatment
Ortner et al. [10]	3	Topical anesthetic	Erythema (75%), swelling (28%), crusting (27%), distal skin peeling (20%), onychoschizia (9%), hyperpigmentation (7%), proximal skin peeling (5%), erosion (2%), flaking (2%), signs of nail fold infection (1%), fissures (1%), acute paronychia (9.09%), onychocryptosis (9.09%), persistent post-laser erythema (9.09%), transient application site pain (9.09%), proximal interphalangeal joint pain (9.09%), transient reduction in grip strength (9.09%)	Participants applied Cal/BD foam once daily at nighttime (week 1 to week 24). Patients were instructed to apply the foam directly on the included nails and distribute it to cover the nail plate, the nail folds, and the surrounding skin. After applying the product in a thin, even layer, patients were instructed to keep test sites uncovered for at least 15 min	Laser parameters for nail plate were individualized based on OCT-measurement; nail folds were treated at 40 mJ/mb	Nail plates: 1 session, lateral and proximal nail folds: 3 sessions	NA for nail plate, 6 weeks for nail folds	Cal/BD foam applied daily
Sharkawy et al. [11]	3.3	Topical anesthetic	New-onset nail pitting (10%)	Cal/BD ointment was applied right after laser treatment	20 W power, 2000-μs dwell time, 5 stacks, 500-μm spacing	6	4 weeks	Cal/BD ointment applied right after treatment and once daily
Nassar et al. [2]	No pain 38.9%, mild pain 50%, moderate pain 11%, severe pain 0%	Topical anesthetic	Koebnerization (5.6%), paronychia (11.1%)	Triamcinolone acetonide application right after laser. After 15 min, each patient was made to wear plastic disposable gloves	10 W power, 500-μs dwell time, 4 stack, 550-μm spacing	6	2 weeks	Topical triamcinolone acetonide right after treatment; no topical treatment in-between sessions
Abd Elazim et al. [12]	4.7	Topical anesthetic	Bleeding (7.41%), periungual erythema (7.41%)	After cooling with ice packs, topical tazarotene gel was applied on the nails and periungual skin of the laser-treated hand under occlusion for 1–2 h	140 mJ pulse energy, 150 spots/cm2 density, 1 depth level	3	4 weeks	Tazarotene 0.1% gel applied right after treatment and once daily
Alakad et al. [13]	No pain 78.5%, mild pain 21.5%	Topical anesthetic	No adverse effect noticed	Laser treatment was followed by topical application of 0.1 mL methotrexate (25 mg/mL) per digit. The patients were then instructed to wear plastic gloves and to avoid washing their hands for 2 h	10 W power, 500-μs dwell time, 3 stack, 600-μm spacing	6	2 weeks	Topical MTX 0.1 mL (25 mg/mL) right after treatment, no topical treatment in-between sessions
Shehadeh et al. [14]a	5.66	None	Local irritation, pain, erythema, and purpura spontaneously resolving within days. No percentage reported	The proximal and lateral nail folds were treated with a 595-nm PDL while the nail plate was treated with fractional CO2 laser. Postprocedure care included cold compressions and the use of broad-spectrum sunscreen	The Co2 laser’s energy was determined by the tolerability of the patients	3	4 weeks	Cal/BD gel applied daily (treatment continued for 4 weeks after the last treatment)
Afify et al. [15]b	NA	Topical anesthetic	Transient yellow nail discoloration 100%	After Co2 laser, 0.1 mL MTX applied for every affected nail, then a plastic strip was applied for 30 min	180 mj/cm2 energy, pulse width 4.006 ms, spot size 3 mm × 3 mm, density 0.5 mm	4	2 weeks	Topical MTX 0.1 mL (25 mg/mL) right after treatment, no topical treatment in-between sessions
Afify et al. [15]b	NA	Topical anesthetic	NA	After Co2 laser, Cal/BD gel was applied without occlusion	180 mj/cm2 energy, pulse width 4.006 ms, spot size 3 mm × 3 mm, density 0.5 mm	4	2 weeks	Cal/BD ointment applied right after treatment; no treatment between sessions

RCT, randomized controlled trial; NAPSI, Nail Psoriasis Severity Index, mNAPSI, modified NAPSI; tNAPSI, target NAPSI; CR, complete response; mDLQI, modified Dermatology Life Quality Index; VAS, visual analog scale; OCT, optical coherence tomography; Cal/BD, calcipotriol/betamethasone dipropionate.

^aIn this study, pulsed-dye laser was used in addition to fractional CO² laser and topical drug application.

^bAA Afify et al. conducted a study with two treatment arms: in one arm, they topically administered Cal/BD, and in the other arm, MTX was administered.

The occurrence of new psoriatic lesions in areas subjected to physical stress from the laser treatment (Koebner phenomenon) was reported in only two studies. Specifically, El Sharkawy et al. reported new-onset nail pitting in 10% of patients, while Nassar et al. observed Koebnerization as an adverse effect in 5.6% of patients.

Therapies combined with laser pretreatment varied among the studies. In general, the topical treatment most frequently employed was Cal/BD. Ortner et al. utilized Cal/BD foam once daily for a duration of 24 weeks, whereas El Sharkawy et al. applied Cal/BD ointment immediately after treatment and once daily throughout the treatment period. Shehadeh and colleagues administered Cal/BD gel daily during the treatment period, and treatment was continued for an additional 4 weeks following the final treatment. Other topical approaches were used in other studies, including triamcinolone acetonide, tazarotene gel, and MTX.

The setting of laser parameters employed also varied. Ortner et al. customized the laser parameters based on optical coherence tomography measurements for the nail plate, whereas the nail folds were treated at 40 mJ/mb. El Sharkawy et al. used a 20 W power, 2000-μs dwell time, 5 stacks, and 500-μm spacing; Nassar et al. used a laser with 10 W power, 500-μs dwell time, 4 stacks, and 550-μm spacing. Afify and coworkers adopted a 180 mj/cm² energy, pulse width of 4.006 ms, spot size of 3 mm × 3 mm, and density of 0.5 mm; finally, Shehadeh adapted the laser setting to patients’ tolerability.

The number of treatment sessions and the time intervals between sessions varied. The weighted average for the number of sessions and time intervals between sessions was found to be approximately 3 sessions and 2.7 weeks, respectively. Ortner et al. conducted one session for the nail plates and three sessions for the lateral and proximal nail folds, with a 6-week interval for the nail folds. El Sharkawy et al. performed six treatment sessions with a 4-week interval, while Nassar et al., Abd Elazim et al., and Alakad et al. all conducted six sessions with a 2- or 4-week interval. Shehadeh et al. performed three sessions with a 2-week interval, and Afify et al. conducted four sessions with a 2-week interval between sessions.

Discussion

In the scientific literature, there is a paucity of data that would allow the establishment of universally applicable guidelines for the treatment of nail psoriasis. The effectiveness of topical treatments has been questioned due to the limited ability to penetrate the psoriatic nail plate, the need for prolonged usage, and subsequent poor patient compliance. Furthermore, a substantial portion of the available studies are not specifically designed to address nail psoriasis. Instead, randomized clinical studies often focus on subpopulations with nail involvement within larger populations affected by cutaneous psoriasis or psoriatic arthritis.

Recent recommendations regarding the management of few-nail disease (fewer than 3 nails) have highlighted the role of topical therapy in addition to intralesional steroids. Specifically, topical agents including topical steroids, combinations of topical vitamin D analogs with steroids, topical retinoids, and topical 0.1% tacrolimus have demonstrated good efficacy in treating both nail matrix and nail bed psoriasis [16].

Fractional laser treatment has been investigated as a potential method to enhance the penetration of topical medications into the psoriatic nail plate. In their in vitro permeation study, H. Nguyen et al. successfully demonstrated that fractional laser treatment improves transungual flow and permeability coefficient of MTX, a high-molecular-weight molecule, compared to non-pretreated models [9].

However, the available scientific literature on this topic is limited. While some studies have reported positive outcomes with the use of fractional lasers in enhancing drug delivery and improving clinical outcomes in nail psoriasis, there is a lack of standardized protocols and guidelines. Furthermore, the optimal parameters of fractional laser treatment, such as energy levels and treatment intervals remain to be determined.

The results of our systematic literature review support the role of fractional laser treatment in the management of psoriasis while using topical medications. A total of 7 RCTs have been identified to date, out of which 4 were conducted as intra-patient studies [2, 10–15]. Despite the use of different topical medications and varying laser parameters across the studies, all of them have demonstrated a certain degree of reduction in NAPSI (although varying among the different studies). Four studies have demonstrated non-inferiority to the control treatment, which encompassed a range of interventions including no treatment, fractional laser monotherapy, topical therapy monotherapy, and injection therapy with triamcinolone acetonide or MTX. Furthermore, 2 studies have shown superiority over the control treatment. Notably, AA Afify et al. conducted a study comparing fractional laser treatment in conjunction with two distinct topical therapies (MTX and Cal/BD), demonstrating significant efficacy for both treatment modalities. These data suggest that the combination of fractional laser treatment and topical therapies demonstrates promising outcomes in addressing psoriatic nail involvement. However, it is important to acknowledge the limitations that hinder direct comparisons among different treatment modalities. The limited sample sizes and heterogeneity of the study populations pose challenges in drawing definitive conclusions regarding treatment efficacy. The presented data do not allow for a definitive determination of the superior topical agent or optimal laser parameters and session intervals for the treatment. To establish more robust evidence and identify the optimal therapeutic approach, future investigations should encompass larger cohorts and employ standardized protocols.

Based on the available data, the treatment was generally well-tolerated. In 6 out of the 7 studies, the use of topical anesthesia was sufficient to achieve low levels of pain during the treatments. In the study performed by Alakad et al. [13], no anesthesia was used, yet the reported pain was either absent or minimal, indicating the potential favorable tolerability of laser treatment as a pretreatment modality for the topical treatment. Furthermore, when compared to intralesional therapy with triamcinolone acetonide or MTX, the laser technique resulted in significantly lower pain levels. This notable difference in pain levels translated into higher overall patient satisfaction with the laser and topical approach compared to intralesional therapy.

Interestingly, the Koebner phenomenon, where new psoriatic lesions develop in response to physical trauma, was rarely observed following laser treatment. Only Sharkawy et al. and Nassar et al. reported the occurrence of Koebnerization, with respective incidences of 10% and 5.6%. However, these authors also reported an overall decrease in NAPSI scores and high patient satisfaction. These results suggest that the combination of laser treatment and topical intervention not only provides effective outcomes but also contributes to a more favorable patient experience, characterized by reduced pain and increased satisfaction.

Conclusions

The findings of this systematic analysis might help to define the role of fractional laser in combination with topical therapy to enhance outcomes in nail psoriasis without the need for systemic treatment. The currently available data in the scientific literature support the role of fractional laser pretreatment in nail psoriasis, both in terms of clinical efficacy and patient satisfaction, with minimal side effects and low discomfort. However, the limited sample size of the selected studies, heterogeneity in the characteristics of the study populations, and variability in both laser parameters and topical drug selection preclude definitive conclusions regarding the optimal approach. Standardized studies with larger sample sizes are needed to provide more conclusive information on the characteristics of the most effective approach.

Limitations of the Study

One of the primary limitations of this study revolves around the lack of standardization in both the laser settings and topical treatments employed across the included studies. Significant variations were observed in the parameters of fractional laser treatment, including energy levels and treatment intervals, making direct comparisons challenging. Similarly, the diversity in the selection and administration of topical therapies introduced complexities in assessing their individual contributions. Additionally, the heterogeneity observed within the study populations, characterized by variations in patient demographics, disease severity, and comorbidities, poses a challenge when drawing definitive conclusions regarding treatment efficacy. Furthermore, we must acknowledge the relatively small sample sizes present in the included studies, which may limit the generalizability of our findings to a broader population. These factors collectively underscore the need for larger cohorts and standardized protocols in future investigations. Despite these limitations, our review underscores the potential of fractional laser treatment in combination with topical therapies as a promising approach for addressing psoriatic nail involvement.

Statement of Ethics

An ethics statement is not applicable because this study is based exclusively on published literature.

Conflict of Interest Statement

The authors declare no conflicts of interest.

Funding Sources

This study received no funding.

Author Contributions

J.T. and A.S. were responsible for conducting the research, including the literature review, data collection, and data analysis. L.N. and S.P. provided supervision and guidance throughout the study process and contributed to the editing and refinement of the manuscript.

Funding Statement

This study received no funding.

Data Availability Statement

All data analyzed during this study are included in this article. Further inquiries can be directed to the corresponding author upon request.