Nail psoriasis has a significant impact on patient quality of life (QOL) and function, and it is often misdiagnosed. Current treatment approaches for and data on nail psoriasis were discussed at the recent 2026 American Academy of Dermatology (AAD) Annual Meeting.

Following this presentation, featured expert Diego Ruiz Dasilva, MD, FAAD, was interviewed by Conference Reporter Associate Editor-in-Chief Rick Davis, MS, RPh. Clinical perspectives from Dr Ruiz Dasilva on these findings are presented here.

There are multiple reasons why nail psoriasis is such an important clinical condition, but 2 of the biggest ones are the impacts that the disease can have on the patient, both in terms of the impact on their QOL from an appearance and stigma perspective and the impact on their daily functioning. Some patients with psoriatic nail disease have difficulty using their hands to perform activities of daily living and/or activities they enjoy for fun, work, and leisure due to pain. Even in patients who do not have as much functional impairment, their QOL can suffer due to the stigma attached to having dystrophic, cracked, and crumbling nails, possibly with darkening, oil spots, splinter hemorrhages, and bleeding as well.

These cases are often misdiagnosed for years and are incorrectly treated as onychomycosis with a host of antifungals and antibacterials. Fungal nails and psoriatic nails can look very similar in terms of hyperkeratotic debris and discoloration. The only way that you can know for sure which is which is by performing a nail clipping assessment to confirm the presence of fungi in the nail and/or a nail unit biopsy in recalcitrant cases.

A combination of considerations dictates my use of treatments for nail psoriasis, but the first, most basic, well-accepted consideration is the number of affected nails. If 3 or fewer nails are affected, I consider using intralesional steroids in the nail bed and/or nail matrix. For these milder cases, you could also treat with topical steroids, topical vitamin D analogues, or topical retinoids, and patients may respond well to those treatments. However, once you are treating more than 3 affected nails, intralesional steroids can become cumbersome, less effective, and quite painful, and more advanced systemic agents are needed.

During the nail symposium at the 2026 AAD Annual Meeting, Shari Lipner, MD, PhD, FAAD, discussed the current data on many of the advanced systemic agents that are used to treat more severe nail psoriasis. These include oral options (ie, the PDE4 inhibitor apremilast, the TYK2 inhibitor deucravacitinib, and JAK inhibitors [eg, baricitinib, tofacitinib, and upadacitinib]), older biologics (ie, TNF inhibitors [eg, adalimumab, certolizumab pegol, etanercept, and infliximab]), and newer biologics (ie, the IL 12/23 inhibitor ustekinumab, IL-23 inhibitors [eg, guselkumab, risankizumab, and tildrakizumab], and—potentially the most effective drugs for nail psoriasis—IL-17 inhibitors [eg, bimekizumab, ixekizumab, and secukinumab] and the IL-17R blocker brodalumab).

In my mind, it does not seem like there is one treatment that is accepted as the “best” treatment for nail psoriasis. Any of these treatments can work well, so treatment selection depends on other aspects of the patient’s plaque psoriasis or concomitant conditions, such as psoriatic arthritis.

Patient preference also plays a huge role in treatment selection for nail psoriasis. I am a big proponent of shared decision making, so I want my patients to choose something that will be the most compatible with their lifestyle. How you frame the treatment options to patients is important as well. This helps guide patients to choose what I think will be best, but, at the end of the day, I like them to feel like they have a say in their treatment plan.

Another important point is counseling patients on the treatment timeline and expectations. Because nails grow slowly, I tell my patients that they may not notice any improvement in their nail psoriasis for a few months and that, even then, they need to wait until the nail grows out completely to fully appreciate this improvement in their disease. It is the new nail plate growing in that will ultimately show how well the disease is responding to treatment. When you explain this to patients, they understand that they should stay on the medication for approximately 6 months before determining whether it is working well for them.