The authors discuss their experience treating an adult patient with Upadacitinib for dystrophic nails, yielding excellent results.
Upadacitinib for Destructive Nail Dystrophy
By Margaret DiRuggiero, BSa; Emily Hall, DNPCb Douglas DiRuggiero, DMSc, PA-Cb; and John Chung, MDb
a. United States Air Force Academy, Colorado Springs, CO
b. Skin Cancer and Cosmetic Dermatology, Dalton & Rome, GA
A 29-year-old female with no remarkable medical history for skin diseases presented for evaluation of dystrophic nails on eight fingers (and the two great toenails, not pictured) that she reported having for 6 months (see Figures 1a and 1b).
Past medical history was significant only for COVID-19 infection 9 months prior to nail changes. Treatment with terbinafine 6 weeks prior to dermatology evaluation yielded no improvement. Nail biopsy revealed no fungal organisms on H&E and PAS stains. Biopsy of a mildly eczematous eruption on her left arm and right leg revealed mild psoriasiform dermatitis favoring chronic eczematous dermatitis. Upadacitinib (RINVOQ; Abbvie) 15 mg daily was initiated as monotherapy. A 50% nail improvement was noted at 8 weeks and nearly 90% improvement at 12 weeks (see Figure 2).
Nail changes are frequently seen in patients with cutaneous inflammatory diseases such as, but not limited to, chronic eczema, psoriasis, lichen planus, and alopecia areata. Usually, nail changes are seen in more severe forms of inflammatory conditions and may reflect a more refractory disease process.1 A very small body of evidence has observed full remission of nail dystrophy after the administration of tofacitinib 5 mg twice daily for 5 to 6 months.2 The use of oral JAK inhibitors remains an open area for further clinical investigation for destructive nail dystrophy. In this case, after 8 weeks of upadacitinib therapy, more than 50% improvement was noted and after an additional 4 weeks of therapy, the nails were nearly completely resolved.
References:
- Damsky W, King B. JAK inhibitors in dermatology: The promise of a new drug class. J AmAcad Dermatol. https://doi.org/10.1016/j.jaad.2016.12.005
- Ferreira SB, Scheinberg M, Steiner D, Steiner T, Bedin GL, Ferreira RB. Remarkable improvement of nail changes in alopecia areata universalis with 10 months of treatment with tofacitinib: A case report. Case Rep Dermatol 2016; 8: 262-266. https://doi.org/10.1159/000450848
Disclosures: Douglas DiRuggiero is a speaker/advisory board member for Amgen, Abbvie, Arcutis, Bristol-Myers-Squibb, Epi Health, Incyte, Lilly, Novartis, Regeneron, Sanofi, Sun Pharmaceuticals, and UCB. Margaret DiRuggiero, Emily Hall, and Dr. John Chung report no relevant financial interests.