Skin Efficacy Linked to Nail Response in Guselkumab Treatment

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In patients receiving guselkumab, achieving NAPSI 0/1 at week 24 and week 48 was associated with lower baseline NAPSI and week 16 PASI.

At week 16, higher skin efficacy was linked to better nail responses in patients with psoriasis receiving guselkumab who may be at a high risk of developing psoriatic arthritis (PsA), according to a study published in Arthritis Research and Therapy.1 Additionally, nail response was maintained longer compared with skin response following treatment withdrawal.

Nail psoriasis is a common, albeit undertreated, manifestation of the condition which is reported to affect between 50 - 90% of patients with psoriasis. It has been linked to an increased risk of developing PsA and can be an early sign of joint disease. The symptom, which can involve the nail bed and nail matrix, causes functional impairment, discomfort, and psychological stress.2

“The presence of nail psoriasis has been found to be associated with the development of PsA in both retrospective and prospective cohorts,” wrote lead investigator William Tillett, PhD, consultant rheumatologist at the Royal National Hospital for Rheumatic Diseases, Bath, UK, and colleagues. “Although current data on the extent to which treatment-related improvements in nail psoriasis reduce patients’ risk of PsA development are very limited, these cohort data suggest that early and targeted treatment of nail psoriasis is important.”

To evaluate the trajectory of nail psoriasis in patients receiving either guselkumab or adalimumab treatment, followed by withdrawal, investigators conducted a post hoc analysis of the phase 3, multicenter, randomized, double-blind VOYAGE 2 trial. Eligible patients had moderate-to-severe plaque psoriasis and baseline nail involvement. The Psoriasis Area and Severity Index (PASI) and Nail Psoriasis Severity Index (NAPSI) were assessed through week 48 and multiple logistic regression determined factors associated with NAPSI 0/1 at week 24 and 48 following treatment with guselkumab. A separate analysis stratified patients by prior experience with biologics.

Overall, 470 receiving guselkumab and 228 patients treated with adalimumab remained on treatment through week 28. Of these patients, 272 patients in the guselkumab cohort and 132 patients in the adalimumab cohort had nail psoriasis at baseline. In patients receiving guselkumab, achieving NAPSI 0/1 at week 24 was linked to lower baseline NAPSI and week 16 PASI (NAPSI, odds ratio [OR] .685 [95% confidence interval [CI]: .586, .802]; week 16 PASI, .469 [.281, .782]). A similar pattern was observed at week 48 (NAPSI, .784 [.674, .914]; week 16 PASI, .557 [.331, .937]). NAPSI response was not affected by previous biologic experience.

Mean NAPSI was maintained in the guselkumab cohort following treatment withdrawal at week 28 (week 24: 1.7, week 48: 1.9), although it was slightly increased in the adalimumab cohort (week 24: 1.4, week 48: 2.3). The mean PASI increased across both groups.

Investigators noted a number of limitations, including the post hoc and retrospective study design, as well as the use of mostly descriptive statistics. The PASI at week 16 may have been influenced by baseline variables, which may have potentially hindered interpretation. Additionally, patients in the adalimumab and guselkumab arms stopped treatment at different times (23 weeks vs 20 weeks, respectively). Differences in the response to individual components of nail psoriasis, such as pitting or leukonychia, were not evaluated. Lastly, the proportion of patients who would have eventually developed PsA without treatment could not be determined.

“In conclusion, these findings have the potential to inform clinical decisions in psoriasis management, such as the importance of assessing probability of nail response with continued therapy, based on their skin response,” investigators concluded. “Future studies should investigate whether improvements in nail response, such as those seen in this analysis, reduce patients’ risk of later PsA development.”


  1. Tillett W, Egeberg A, Sonkoly E, et al. Nail psoriasis dynamics during biologic treatment and withdrawal in patients with psoriasis who may be at high risk of developing psoriatic arthritis: a post hoc analysis of the VOYAGE 2 randomized trial. Arthritis Res Ther. 2023;25(1):169. Published 2023 Sep 15. doi:10.1186/s13075-023-03138-z
  2. Baran R. The burden of nail psoriasis: an introduction. Dermatology. 2010;221(Suppl 1):1–5.