Fractional CO2 Laser-Assisted Delivery Versus Intralesional Injection of Methotrexate in Psoriatic Nails

Abstract

BACKGROUNDNail psoriasis has a major negative impact on physical and psychological aspects of the patient's life. Treatment is often unsatisfactory because of difficult penetration of the drug into the nail.OBJECTIVETo evaluate and compare the efficacy of laser-assisted delivery of methotrexate versus its intralesional injection in fingernail psoriasis.MATERIALS AND METHODSTwenty-eight patients with fingernail psoriasis were divided into 2 groups of 14 patients each. Group A was treated with intralesional injection of methotrexate while Group B received fractional CO2 laser followed by topical application of methotrexate. The treatment was given at a 2-week interval for 6 sessions. The improvement of nail psoriasis was assessed by clinical and dermoscopic evaluation.RESULTSAt the end of treatment, both laser-assisted delivery and intralesional injection of methotrexate were associated with statistically significant improvement of psoriatic signs. No statistically significant difference was found between the 2 groups regarding total nail psoriasis severity Index (p = .18), matrix score (p = .38), bed score (p = .23), and dermoscopic score (p = .78). However, the pain and subungual hematoma were significantly less in the laser group (p < .001 and p = .03, respectively).CONCLUSIONFractional CO2 laser-assisted delivery of methotrexate can be an effective and well-tolerated alternative to intralesional injection in nail psoriasis.

Fractional CO2 Laser versus Fractional CO2 Laser Plus Betamethasone/Calcipotriol Ointment in the Treatment of Nail Psoriasis

“…13 Fractional CO 2 laser-assisted drug delivery of methotrexate or triamcinolone were previously studied versus their intralesional injection for nail psoriasis, and both studies reported significant improvement. 14,15 Moreover, fractional CO 2 laser with tazarotene 0.1% gel showed better NAPSI score improvement after treatment than tazarotene monotherapy. 16 It is essential for appropriate assessment of nail improvement, to allow ample time for the nail plates to grow from the matrix and be visibly appreciable by the observer; thus, our last clinical observation was 9 months after the initial intervention.…”

“…13 Fractional CO 2 laser-assisted drug delivery of methotrexate or triamcinolone were previously studied versus their intralesional injection for nail psoriasis, and both studies reported significant improvement. 14,15 Moreover, fractional CO 2 laser with tazarotene 0.1% gel showed better NAPSI score improvement after treatment than tazarotene monotherapy. 16…”

The Anti-Psoriatic Efficacy and Safety Profile of Topical and Intralesional Methotrexate: A Literature Review

“… - Local AE: Pain at injection site (10%), acute paronychia (5%) - Systemic AE: No Starace et al (2022) 53 Prospective study 12 (20) Nail matrix 0.1 ml of MTX 25 mg/ml 0.1 ml of 10 mg/ml triamcinolone acetonide 4 injections with an interval of 6 weeks. 24 weeks Nail psoriasis responded well to both treatment but more stability was noted at follow-up period in MTX group - Local AE: Subungual hematoma - Systemic AE: N/A Alakad et al (2022) 52 RCT 28 (123) Nail matrix and nail bed 0.02 ml of MTX 25 mg/ml Fractional CO 2 laser followed by topical application of 0.1 mL of MTX 25 mg/mL Biweeky for 6 treatment sessions 3 weeks Both treatments were associated with statistically significant improvement of nail psoriasis score. No statistically significant difference between both treatments was found.…”

“…Eleven studies examined the use of intralesional MTX for psoriasis (Table 4). 15,[44][45][46][47][48][49][50][51][52][53] One study of its efficacy for psoriasis skin lesions found no significant improvements. By contrast, all 10 studies investigating its efficacy for nail psoriasis demonstrated significant improvements in the nail matrix and nail bed.…”

“…51 The efficacy of intralesional MTX for nail psoriasis was compared with fractional laser assisted drug delivery in one study. 52 Fractional carbon dioxide (CO 2 ) laser plus topical application of 0.1 mL of MTX 25 mg/mL and intralesional MTX (25 mg/mL) were given biweekly for 6 weeks in 28 patients with nail psoriasis. They found that Fractional CO 2 laser plus topical MTX displayed a comparable improvement to intralesional MTX but the laser group was associated with less side effects (pain and subungual hematoma).…”