SKIN

September 2021 Volume 5 Issue 5

BRIEF ARTICLE

Calcipotriene 0.005%/Betamethasone Dipropionate 0.064% Foam
as a Treatment for Nail Psoriasis: A Case Series

Shifa Akhtar1, BS, Mariana Perez1, BA, Jessica Sharma1, BS, Agnese Canazza2, Martin
Zaiac1,2, MD

1 Florida International University, Herbert Wertheim College of Medicine, Miami, FL
2 Greater Miami Skin and Laser Center, Mount Sinai Medical Center, Miami Beach, FL

An estimated 80-90% of psoriasis patients
develop nail involvement, leading to
decreased quality of life secondary to pain,
activity restriction, and an increased risk of
anxiety and depression.1 Historically, topical
treatments for nail psoriasis have been
considered less effective due to limited
penetration through the psoriatic nail plate
and prolonged duration of use leading to poor
patient adherence.2 While systemic
approaches with newer biologic agents have
demonstrated efficacy in the treatment of
moderate to severe nail psoriasis, patients
with disease limited to the nail may be
reluctant to use systemic biologic agents as
opposed to topical agents. Though combined
approaches with topical vitamin D analogues

and steroids as creams and ointments have
been well-documented as effective
treatments for mild psoriasis of the nail, there
is minimal literature regarding the use and
efficacy of calcipotriene/betamethasone
dipropionate in a foam vehicle.3,4
Calcipotriene 0.005%/betamethasone
dipropionate 0.064% (Cal/BD) aerosol foam
is indicated for the treatment of plaque
psoriasis; we report our experience utilizing it
as a treatment for psoriasis of the nail.

Three patients were evaluated in the
dermatology clinic for psoriasis of the nail and
treated with Cal/BD aerosol foam, resulting in
positive clinical outcomes.

ABSTRACT

Combination topical corticosteroids and vitamin D analog treatments for nail psoriasis are widely used
in cream and ointment vehicles, but patients may prefer a foam vehicle due to ease of application and
favorable cosmetic appearance. Calcipotriene 0.005%/betamethasone dipropionate 0.064% (Cal/BD)
aerosol foam is an FDA approved therapy for plaque psoriasis, but may also be an effective treatment
for nail psoriasis in a novel aerosol foam. We present a case series of 3 patients with mild to moderate
nail psoriasis who responded positively to treatment with Cal/BD aerosol foam applied 1-2 times daily
to affected nails for at least 6 weeks. Reduction of nail plate surface abnormalities and inflammation of
the nail folds were assessed with clinical evaluation and dermoscopy, and documented with serial
photography. While further research on the efficacy and safety of Cal/BD aerosol foam as a treatment
for nail psoriasis is needed, this report suggests its potential as a combination topical vitamin D
analogue and high potency steroid in a foam vehicle.

INTRODUCTION

CASE SERIES

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Case 1:

A 42-year-old male presented with adult-
onset, mild changes in nail appearance and
texture. Physical exam showed pitting in the
left small fingernail, right thumbnail, and right
index fingernail plates. A diagnosis of
psoriasis of the nail was established, and
global/microscopic pictures (executed with
FotoFinder medicam dermoscopy) were
obtained to document the nail changes at
baseline (Fig 1, A). The patient was
subsequently prescribed daily Cal/BD
aerosol foam. On five- and ten-month follow-
up exams, dermoscopy demonstrated a
decrease in nail pits and an improvement of
nail plate surface abnormalities (Fig 1, B, C).

Figure 1. Case 1 A) Before treatment B) Progressive
improvement after five C) and ten months of treatment

Case 2:

A 60-year-old female, diagnosed by her
previous physician with onychomycosis of
the thumb and toenails and treated with
terbinafine and efinaconazole for three
months, presented to our clinic due to a lack
of improvement. Exam demonstrated
dystrophic nails involving multiple nail plates.
Unilateral curvature of the nail plate,
onycholysis, and keratosis of the nail bed
were all present (Fig 2, A). Dermoscopy
demonstrated nail pitting, erythematous
borders, and splinter hemorrhages in the
distal nail bed (Fig 2, B, C, D). Terbinafine
and efinaconazole were discontinued, and

the patient was started on daily Cal/BD
aerosol foam for treatment of nail psoriasis.
At six-week follow-up, she noted improved
nail appearance but continued to complain of
mild to moderate onychodystrophy and
discomfort (Fig 2, E). Dermoscopy
demonstrated a decrease in psoriatic pits,
nail scaling, and erythematous borders (Fig
2, F, G, H). Cal/BD aerosol foam was
increased to a twice daily application regimen
with enhanced success.

Figure 2 Case 2 A, B, C, D) Before treatment
E, F, G, H) Marked improvement after six weeks of
treatment

Case 3:

A 47-year-old female with a history of plaque
psoriasis presented to our clinic with mild to
moderate discoloration and pitting of the right
thumbnail and left small fingernail plates for
the past year. Physical exam demonstrated
pitting and crumbling of the right thumbnail

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September 2021 Volume 5 Issue 5

and left small fingernail plates (Fig 3, A).
Dermoscopy of the right thumbnail plate
showed leukonychia, irregular thickening,
salmon patches, and hyperkeratosis of the
cuticle (Fig 3 B, C). The patient was followed
by Rheumatology and pending initiation of a
new biologic agent at the time of the visit,
having discontinued apremilast due to
gastrointestinal side effects. She was given
Cal/BD aerosol foam to be applied topically
to the affected nails twice daily. At four-month
follow-up, the patient was being treated with
adalimumab and Cal/BD aerosol foam and
noted improvement in nail appearance (Fig 3,
D). Dermoscopy demonstrated reduced
inflammation in the posterior nail folds as well
as decreased nail pitting in the re-growing
nails (Fig 3, E, F).

Figure 3. A, B, C) Before treatment D, E, F)
Improvement after four months of treatment

For the treatment of mild nail psoriasis,
topical/intralesional corticosteroid
monotherapy, topical vitamin D analog
monotherapy, or combination therapy is
commonly recommended. Vitamin D is
understood to exhibit immunomodulatory and

antiproliferative effects, while corticosteroids
exhibit anti-inflammatory effects, thus
working synergistically when combined.5 The
use of different vehicles aside from ointment
in the topical treatment of nail psoriasis have
been explored. Eight percent clobetasol-17-
propionate in a colorless nail lacquer vehicle
has produced favorable results, with one
study of 15 patients demonstrating a
reduction in nail alterations and in the
modified Psoriasis Severity Index by 78%
compared to baseline.6 There are also case
reports of refractory nail psoriasis treated
successfully with Cal/BD gel, with authors
hypothesizing that the low viscosity of the
lipophilic gel may reach the subungual gap
and the gap beneath the proximal nail folds in
affected nails.7

While topical therapies combining a
corticosteroid and vitamin D analog are
established treatments for nail psoriasis,
there is scarce literature regarding the use of
Cal/BD aerosol foam. Traditionally, ointments
were the vehicle of choice, but the rising
popularity of different formulations including
creams, lotions, nail lacquers, and foams has
provided more options for patients and
clinicians. While patient adherence to
treatment is essential in the successful
management of psoriasis, around 40% of
psoriasis patients report poor adherence to
topical regimens and report that both
psoriasis and its treatment interfere with their
quality of life.8 Notably, patients prefer foam
vehicle solutions over creams, gels, and
ointments for psoriasis treatment.9 Therefore,
substitution of the traditional ointment with a
foam vehicle may improve adherence and
subsequently result in greater positive patient
outcomes, but further investigation is
needed. The efficacy and safety of Cal/BD
foam for plaque psoriasis has been
established, with randomized control trials
demonstrating tolerability and increased
remission time.10 A preliminary study of

DISCUSSION

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September 2021 Volume 5 Issue 5

Cal/BD in foam formulation for the treatment
of nail psoriasis demonstrated it was well-
tolerated and lacked steroid-related adverse
reactions, but larger clinical trials are
underway to better establish its efficacy and
tolerability for this indication.11

Our case series demonstrates the potential of
Cal/BD aerosol foam as a treatment for nail
psoriasis. This can be a desirable option for
patients with contraindications to systemic
therapy or a preference for topical therapy in
a foam vehicle. Further investigation with an
adequate sample of patients should be
undertaken to better determine its side
effects and efficacy.

Conflict of Interest Disclosures: None

Funding: None

Corresponding Author:
Shifa Akhtar, BS
Florida International University
Herbert Wertheim College of Medicine
11200 SW 8th St, AHC-2
Miami, FL, 33199 USA
Phone: (305) 348-0570
Email: sakht008@med.fiu.edu

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11. Gregoriou S, Sidiropoulou P, Tsimpidakis A, et al.
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CONCLUSION