Case Reports: Off-label Tildrakizumab Effective in Nail Psoriasis

Off-label use of Ilumya (tildrakizumab) appears to improve treatment-resistant nail psoriasis, according to a 2-case report published in Australasian Journal of Dermatology.

Tildrakizumab is an interleukin-23 (IL-23) inhibitor approved for the treatment of moderate to severe plaque psoriasis. The authors explained that nail psoriasis can be found in the fingernails or toenails and has been shown to have a significant impact on patients’ quality of life. It is also “notoriously” difficult to treat, they added.

“Given the anatomical structure of the nail, good penetration of therapy is fundamental for successful treatment of the condition,” they wrote. “This frequently proves challenging with topical therapy, and systemic therapy is often required.”

Biologics like tildrakizumab have led to a marked improvement in the treatment of other kinds of psoriasis, and so the investigators decided to see if the plaque psoriasis treatment might work in 2 patients struggling with nail psoriasis.

They administered tildrakizumab to the 2 patients with the same dosing regimen used for chronic plaque psoriasis: 100 mg subcutaneously at day 0 and week 4, with maintenance dosing every 12 weeks thereafter.

The first patient was a 63-year-old female who had experienced nail psoriasis for 5 years, primarily on her toenails. She had a baseline modified nail psoriasis severity index (mNAPSI) score of 44. After 6 months of treatment, her score had dropped to 13, and after a year, it dropped further to 8, an 81.8% score reduction.

This patient also saw a dramatic drop in her Dermatology Life Quality Index (DLQI) score, which dropped from 16 at baseline to 4 at 6 months and to 3 at 12 months. The patient was still taking the drug at the 18-month follow-up mark.

The second patient was a 53-year-old male with a 15-year history of psoriasis in the nails and scalp. He also had psoriatic arthritis and had previously been treated with methotrexate and cyclosporine, without success.

This patient had a baseline mNAPSI score of 56. At 6 months, this had dropped to 12, and at the 1-year mark, he had a score of 7. His baseline DLQI score was 19; it fell to 8 at 6 months, remaining there following a year of treatment. The patient also remained on the therapy at 18 months.

No adverse events were noted in either patient.

The investigators noted that tildrakizumab works by binding to the p19 subunit of IL-23.

“IL-23 is raised in psoriasis, and the activation of the T helper 17 pathway promotes chronic inflammation and cytokine production resulting in keratinocyte activation and hyperproliferation characteristic of psoriasis,” the authors wrote. “The importance of the IL-23 and T helper 17 pathway in psoriasis has led to the development of IL-23 inhibitors.”

The authors noted that another published report has since described success with the same regimen, although different review timepoints were used and formal severity scoring was not outlined in the study. In spite of this, they said their experience and this new report “further support the suggestion that tildrakizumab is a potential effective and safe option for patients with nail psoriasis, particularly those with recalcitrant disease.”

Reference

Simpson K, Low ZM, Howard A, Kern JS. Successful management of treatment resistant nail psoriasis with tildrakizumab. Australas J Dermatol. Published online June 11, 2021. doi:10.1111/ajd.13642