Table 2.

Treatment algorithm for nail psoriasis

Hitherto untreated mild NP (three nails, NAPSI <16)	Topical steroid class III–IV Steroid plus calcipotriol
No improvement	Injections (steroids, methotrexate)
No improvement	Systemic antipsoriatics (MTX, CyA [FAE])	More than three nails, NAPSI >16. Unsuccessfully pretreated	Systemic antipsoriatics (MTX, CyA [FAE])
No improvement	Biologicals: TNF-α inhibitor	No improvement	Biologicals: TNF-α inhibitor
		If TNF-α inhibitors no longer active or show a paradox worsening	IL-12/23 or IL-17 inhibitor
		If IL-12/23 or IL-17 inhibitors no longer active	Selective p19 inhibitor (IL-23)

Abbreviations: CyA, cyclosporin A; FAE, fumaric acid ester; MTX, methotrexate; NP, nail psoriasis; NAPSI, nail psoriasis severity index.