Psoriatic disease is a condition characterised by the development of a progressive chronic inflammatory process caused by various immunological pathways, among which the IL-23/Th17 axis plays a key role. Therefore, the efficacy of IL-23 p19 inhibitors is currently being actively studied. To date, quite a large number of therapeutic options among genetically engineered biological drugs (GEBDs) exist for the treatment of psoriasis, but in real clinical practice patients may lose efficacy or suffer from adverse events, resulting in the need to switch to other classes of GEBDs. Guselkumab is a fully human IgG1λ monoclonal antibody that binds selectively to the p19 subunit of interleukin 23 (IL-23) with high specificity and affinity. The implementation of the drug into clinical practice has improved the efficacy, safety and survival rate of genetically engineered biological therapy for psoriasis. Finding optimal approaches to the treatment of psoriatic disease by analysing data from clinical trials and actual practice is the real challenge for practicing clinicians. However, a current problem is the lack of sufficient information on the use of guselkumab in real clinical practice when it is initiated subsequent to administration of other classes of GEBDs – anti-TNF-α, anti-IL-17 and/or anti-IL-12/23. This article provides a review of the existing literature, as well as our own clinical observations of non-bionaive patients with successful therapy switching to the IL-23 inhibitor guselkumab. Understanding the basic aspects of GEBD therapy for psoriasis will help to achieve successful control of the disease and improve the quality of life of patients in general.
Psoriasis is a chronic immune-mediated inflammatory disease in which the pathological process quite often involves the nail apparatus. Psoriatic onychodystrophy is considered a serious psychological and social problem, as nail lesions are not only a cosmetic defect, they can also complicate daily activities, including employment, ability to work and generally impair the quality of life of patients. In addition, numerous studies and clinical practice show that nail lesions in psoriasis are also associated with a more severe course of the skin process, and are rather torpid to therapy. Moreover, psoriatic onychodystrophy is considered as a form of enthesitis, which is in fact an important predictor of the development of psoriatic arthritis. Various topical, systemic and physiotherapeutic options have been recommended in the therapy of psoriasis with nail plate damage, but the effectiveness of these therapeutic methods is in most cases insufficient and the search for highly effective treatment is of great clinical importance at present. Taking into consideration the critical importance of interleukin (IL)-17 in the pathogenesis of psoriasis, its inhibitors allow to achieve a stable remission of cutaneous and joint processes, thus, it is promising in the therapy of psoriatic onychodystrophy. The article presents the literature data on epidemiology, clinical picture of nail changes in psoriasis, the review of effective pathogenetic methods of psoriatic onychodystrophy therapy and personal clinical observations of patients with severe psoriasis with nail plate damage treated with Russian interleukin 17A inhibitor – Netakimab. These observations allow to draw a conclusion about high efficacy of netakimab in the therapy of patients with psoriasis including the presence of such hardtop-treat localizations as nail lesions.
Introduction. The severity of the psoriatic process is associated with the involvement of the scalp, genitals, fold zones and nails in the process. The selection of effective therapy for psoriasis of difficult localizations is an urgent task of modern dermatology.Aim. To evaluate the effectiveness of treatment of moderate psoriasis and nail psoriasis with an IL-17A inhibitor in combination with a combined betamethasone dipropionate + salicylic acid ointment.Material and methods. A 12-week prospective study included data from 60 patients who were under observation at the Moscow Scientific and Practical Center of Dermatovenereology and Cosmetology in 2020-2021. Group 1 included 30 patients who received only the biological drug IL-17 inhibitor. Group 2 included 30 patients who received an IL-17 inhibitor in combination with topical therapy with an ointment of 0.05% betamethasone dipropionate and 3% salicylic acid (Rederm). The ointment was applied twice a day in two courses of 3 weeks with a break of 6 weeks between courses. When comparing indicators between groups, Student’s t-test was used for normal samples and the Mann- Whitney test for non- Gaussian samples.Results. When comparing PASI and NAPSI in patients of group 2 who received an IL-17 inhibitor in combination with external therapy with an ointment of 0.05% betamethasone dipropionate and 3% salicylic acid 2 times a day for two courses of 3 weeks with a break of 6 weeks between courses, the index values statistically significantly decreased after 12 weeks of therapy (p = 0.003) compared to group 1 (p = 0.015).Conclusions. The study showed that patients who received an IL-17 inhibitor in combination with a combined betamethasone dipropionate + salicycylic acid ointment achieved a significantly greater effect compared to patients who received only biologics. In addition, the combination with Rederm ointment has shown greater efficacy in the treatment of psoriatic onychodystrophy, which is difficult to treat even with biologics.
Psoriatic onychodystrophy affects up to 50% of patients with psoriasis and up to 80% of patients with psoriatic arthritis, with an estimated lifetime risk of nail plate changes in this patient population of up to 90%. Nail psoriasis is characterised by a variety of morphological changes resulting from the inflammation in the nail matrix or nail bed, leading to functional impairment and negative impact on patient’s quality of life. Psoriatic onychodystrophy is a distinct therapeutic problem, as its localization is torpid to the current treatment. The limited penetration of topical agents through the nail plate together with the poor adherence to treatment make them typically ineffective. Systemic therapy is often regarded by dermatologists as inappropriate for patients with limited cutaneous lesions. Many systemic drugs, especially biologics, are effective in treating nail psoriasis, but with delayed and less pronounced effects compared to the improvement of skin manifestations. Efficacy for nail changes should be evaluated after 3–6 months of therapy. Recent studies demonstrate that the best effect is achieved after 1 year of treatment. This article presents the main clinical features of psoriatic onychodystrophy and provides information about the interleukin 17A (IL-17A) inhibitor drug netakimab as a promising therapeutic agent for patients with nail psoriasis. It also describes our own clinical experience of using netakimab in the therapy of patients with psoriasis coupled with onychodystrophy. Our experience of using netakimab in two cases of resistant psoriasis accompanied by nail lesions demonstrates its high efficacy in treatment of patients with both plaque psoriasis and psoriasis with “difficult”, hard-to-treat locations, such as nail plate lesions.
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