Randomized clinical study comparing Compeed® cold sore patch to acyclovir cream 5% in the treatment of herpes simplex labialis

Background Hydrocolloid technology has been proven effective in treating dermal wounds. A previous study showed that a newly developed thin hydrocolloid patch [Compeed® cold sore patch (CSP)] provided multiple wound‐healing benefits across all stages of a herpes simplex labialis (HSL) outbreak. Methods An assessment of CSP efficacy and safety was conducted in an international, multicentre, assessor‐blinded study, which enrolled 728 subjects with a history of recurrent HSL. Of these, 351 experienced an HSL outbreak and were randomized to use CSP (n = 179) or acyclovir cream 5% (n = 172) at the onset of symptoms until the lesion healed, for a maximum of 10 days. The primary end point was the subject's global assessment of therapy (SGAT; 0–10 scale; 0 = no response, 10 = excellent response). Multiple secondary end points included clinician‐assessed healing time and subject assessment of lesion protection, noticeability and social embarrassment. Results CSP and acyclovir were highly effective (mean SGAT = 7.89 and 8.00, respectively), with no significant difference observed (P = 0.65). The difference in healing times between products was not significant (median, 7.57 days with CSP vs. 7.03 days with acyclovir, P = 0.37). Both treatments were well tolerated. Conclusion CSP using hydrocolloid technology provides an efficacious and safe alternative to topical antivirals in treating HSL as a wound while affording additional immediate benefits of wound protection, discretion and relief of social embarrassment.     

Good vibrations: Itch induction by whole body vibration exercise without the need of a pruritogen

Mechanically induced itch is an important cofactor in many patients with chronic itch. However, studying mechanical itch in a controlled environment is challenging because it is difficult to evoke. We investigated the use of whole body vibration (WBV) exercise, a training method used for musculoskeletal rehabilitation, to experimentally evoke mechanical itch. Mild to severe itch ascending from the soles to the groins was evoked in 16 of 20 healthy participants. We observed a characteristic on/off itch crescendo pattern reflecting the alternating intervals of vibration and no vibration. Wheals or an angioedema was absent, and serum mast cell tryptase was not increased by the exercise. Participants described the evoked sensation primarily as “itching” with some nociceptive components. Itch intensity correlated with the intensity of a concomitant erythema (R = 0.45, P = 0.043) and with the rise in skin temperature (R = 0.54, P = 0.017). Hence, WBV can be used as an easily applicable, noninvasive, investigator‐ and user‐friendly framework for studying mechanical itch. Moreover, WBV allows to “switch itch on and off” rapidly and to simultaneously study interactions between itch, skin blood flow and skin temperature.     

Electrical stimulation increases blood flow and haemoglobin levels in acute cutaneous wounds without affecting wound closure time: evidenced by non‐invasive assessment of temporal biopsy wounds in human volunteers

Recent studies highlighted the beneficial effects of a novel electrical stimulation waveform, the degenerate wave (DW), on skin fibroblasts and symptomatic skin scarring. However, no study to date has investigated the role of DW on acute cutaneous wounds. Therefore, we evaluated this in a trial using a temporal punch biopsy model. Twenty healthy volunteers had a biopsy performed on day 0 (left arm) and day 14 (right arm). On day 14, DW was applied. Participants were randomised into two groups. Objective non‐invasive assessments were performed on days 0, 7, 14, 60 and 90 using spectrophotometric intracutaneous analysis and full‐field laser perfusion imaging. There were statistically significant increases in mean flux on day 14 (P = 0.027) in the post‐DW arm. Haemoglobin levels increased on day 7 for the post‐DW arm compared to without DW (P = 0.088). Differences in melanin levels were higher post‐DW on the left arm between randomised groups on day 90 (P = 0.033). Haemoglobin levels in the vascular ring increased significantly from day 7 to 90 (P < 0.001 for post‐DW and without DW arms). This study, for the first time, shows that DW increases blood flow and haemoglobin levels in acute healing wounds without affecting wound closure time and may have potential application in enhancing acute cutaneous healing.     

On the relationship between VDR,RORα and RORγ receptors expression and HIF1‐α levels in human melanomas

We analysed the correlation between the expression of HIF‐1α (hypoxia‐inducible factor 1 alpha), the nuclear receptors: VDR (vitamin D receptor), RORα (retinoic acid receptor‐related orphan receptor alpha), and RORγ and CYP24A1 (cytochrome P450 family 24 subfamily A member 1) and CYP27B1 (cytochrome P450 family 27 subfamily B member 1), enzymes involved in vitamin D metabolism. In primary and metastatic melanomas, VDR negatively correlated with nuclear HIF‐1α expression (r = ?.2273, P = .0302; r = ?.5081, P = .0011). Furthermore, the highest HIF‐1α expression was observed in pT3‐pT4 VDR‐negative melanomas. A comparative analysis of immunostained HIF‐1α and CYP27B1 and CYP24A1 showed lack of correlation between these parameters both in primary tumors and melanoma metastases. In contrast, RORα expression correlated positively with nuclear HIF‐1α expression in primary and metastatic lesions (r = .2438, P = .0175; r = .3662, P = .0166). Comparable levels of HIF‐1α expression pattern was observed in localized and advanced melanomas. RORγ in primary melanomas correlated also positively with nuclear HIF‐1α expression (r = .2743, P = .0129). HIF‐1α expression was the lowest in localized RORγ‐negative melanomas. In addition, HIF‐1α expression correlated with RORγ‐positive lymphocytes in melanoma metastases. We further found that in metastatic lymph nodes FoxP3 immunostaining correlated positively with HIF‐1α and RORγ expression in melanoma cells (r = .3667; P = .0327; r = .4208, P = .0129). In summary, our study indicates that the expression of VDR, RORα and RORγ in melanomas is related to hypoxia and/or HIF1‐α activity, which also affects FoxP3 expression in metastatic melanoma. Therefore, the hypoxia can affect tumor biology by changing nuclear receptors expression and molecular pathways regulated by nuclear receptors and immune responses.     

Association of rs3783641 single‐nucleotide polymorphism in GTP cyclohydrolase 1 gene with post‐herpetic neuralgia

Post‐herpetic neuralgia (PHN) is a well‐established clinical problem with potential severe personal and socioeconomic implications. GTP cyclohydrolase 1 (GCH1) gene, which encodes the rate‐limiting enzyme in tetrahydrobiopterin synthesis, has been strongly implicated to be associated with neuropathic pain in previous animal and human studies. The rs3783641 (T > A) single‐nucleotide polymorphism (SNP) in the GCH1 gene is functional. Here we examine the association between rs3783641 and PHN. A total of 292 subjects including 103 PHN patients, 87 herpes zoster (HZ) patients and 102 healthy controls were enrolled in this study. The rs3783641 polymorphisms were detected via the high‐resolution melting curve (HRM) method. There were statistical differences between PHN group and the other two groups in genotype distribution (P = 0.029 and 0.017, respectively) and allele frequency (P = 0.032 and 0.005, respectively) of rs3783641. The proportion of subjects with AA genotype in the PHN group was significantly lower compared to HZ group and control group (P = 0.026 and 0.016, respectively). The frequency of A allele was lower in the PHN group than in control group (P = 0.005), and the frequency of T allele in the PHN group was higher than in HZ group and control group (P = 0.001 and 0.003, respectively). The results of this study suggest that the rs3783641 SNP in the GCH1 gene is associated with PHN, and the AA genotype showed a protective effect in PHN.     

UVB‐ and NGF‐induced cutaneous sensitization in humans selectively augments cowhage‐ and histamine‐induced pain and evokes mechanical hyperknesis

Exaggerated itch responses to pruritic chemical provocations and mechanical stimuli are evident in patients with chronic itch, for example, in atopic dermatitis. Currently used human models of itch do not account for such itch sensitization features, and the mechanisms underlying clinical itch sensitization are unknown. This study utilized two established human models of cutaneous nociceptive sensitization to explore how pre‐established inflammatory hyperalgesia (ultraviolet‐B‐irradiation; “UVB”) and non‐inflammatory neurotrophic pain sensitization (nerve growth factor; “NGF”) alter sensitivity to chemical and mechanically evoked itch. Twenty healthy volunteers participated in the UVB experiment. Six volar forearm areas (2 cm diameter) were UVB irradiated with ≤2 × minimal erythemal dose, and two non‐irradiated areas were used as controls. Sixteen healthy volunteers participated in the NGF experiment and had 2 μg intradermally injected (4 × 50 μL in 2 cm diameter areas) into both volar forearms. Isotonic saline was applied as control. Pain sensitivity measurements (mechanical and heat pain thresholds) were conducted to validate the models. Subsequently, itch was evoked using histamine and cowhage spicules in the sensitized skin areas, and itch/pain was rated using visual analogue scales. Mechanical hyperknesis (increased itch to punctuate stimuli) was probed with von Frey filaments before/after each itch provocation. Both UVB‐ and NGF models induced robust primary mechanical hyperalgesia (P < .01) and hyperknesis (P < .05). Neither of the models augmented itch in response to chemical itch provocations but significant increases specifically for pain ratings were observed for both histamine and cowhage (P < .05). This suggests that these models are of limited value as proxies for itch sensitization to pruritogens observed, e.g., in inflammatory dermatoses.     

Long‐pulsed dye laser vs. intense pulsed light for the treatment of facial telangiectasias: a randomized controlled trial

Objective This study aims to compare the efficacy and adverse effects of long‐pulsed dye laser (LPDL) and intense pulsed light (IPL) in the treatment of facial telangiectasias. Methods We used intra‐individual, randomized, controlled trial with split‐face treatments and single‐blind outcome evaluations in this study. Forty patients with symmetrically located facial telangiectasias received a series of three LPDL (V‐beam, 595 nm, Candela Laser Corp.) and three IPL treatments (Ellipse Flex, PR and VL2 applicators, Danish Dermatologic Development) at 6‐week intervals. Patients were evaluated 3 months after the final treatment. Outcome measures were clinical efficacy (five‐point ordinal scale), pain (10‐point numerical scale), adverse effects, patient satisfaction (10‐point numerical scale) and preferred treatment. Results Thirty‐nine of 40 patients completed the study. All but 2 patients obtained a reduction in facial telangiectasias from both IPL and LPDL treatments. Both treatments were effective with good or excellent response in 30 of 39 patients. The LPDL was superior in the overall reduction of telangiectasias by blinded photographic evaluations: Excellent clearance (75% to 100% vessel clearance) was found in 18 patients treated with LPDL (46%) and in 11 patients treated with IPL (28%) (P = 0.01). Patients experienced less pain from LPDL [4 (2–6)] than IPL treatments [7 (3–9)] (P < 0.001). No adverse effects (hypo‐/hyperpigmentation or scarring) were seen from any of the treatments. Patients were satisfied with both LPDL [8 (2–10)] and IPL treatments [7 (2–10)] (P = 0.05). Twenty‐five patients preferred the LPDL (64%), 8 patients preferred IPL (21%) and 6 patients had no preference (15%) (P < 0.001). Conclusion This study was based on two specific types of laser and IPL equipment, which effectively clear telangiectasias; however, the most beneficial outcome was from the LPDL.     

US Prescription trends of antihistamines for atopic dermatitis, 2011‐2016

Antihistamine use for primary treatment of atopic dermatitis (AD) is not recommended, but current guidelines state that sedating antihistamines are favored over non‐sedating antihistamines for relief of burdensome pruritus. We analyzed the National Ambulatory Medical Care Survey data to compare use of antihistamines between dermatologists and non‐dermatologists. Overall, dermatologists are more likely to prescribe sedating than non‐sedating antihistamines when compared to non‐dermatologists (P < .001, δ_abs = 0.45). Patients under 21 years old (P = .03, δ_abs = 0.10) and Black patients (P < .001, δ_abs = 0.19) were also more likely to receive sedating antihistamines than non‐sedating antihistamines. These findings highlight the differential prescribing practices for atopic dermatitis among physicians.     

CDKN2A and MC1R variants influence dermoscopic and confocal features of benign melanocytic lesions in multiple melanoma patients

Non‐invasive diagnostic tools are effective in the histomorphological study of melanocytic lesions. The role of melanoma susceptibility genes on melanocytic nevi histopathological features is not clear. The current study aimed to correlate genetic alterations and histomorphological features of melanocytic nevi. Clinical, dermoscopic and confocal features of 34 multiple melanoma patients and 34 controls were compared. Among patients with melanoma, carriers of CDKN2A mutations and/or MC1R variants, and wild‐type genes were also compared. In patients with melanoma, a lighter phototype (P = 0.051), a higher number of nevi (P < 0.01) and clinically atypical nevi (P < 0.01) were observed. At dermoscopy, these nevi showed a complex pattern (P = 0.011), atypical network (P = 0.018) and irregular pigmentation (P = 0.037); at confocal, an irregular meshwork pattern (P = 0.026) with atypical nests (P = 0.016) and an inflammatory infiltrate (P = 0.048) were observed. Among patients with melanoma genetically tested, CDKN2A G101W mutation carriers were more frequently younger (P = 0.023), with clinically atypical nevi (P = 0.050), with cytological atypia (P = 0.033) at confocal. G101W mutation and MC1R variants carriers showed hypopigmented nevi (P = 0.002) and, at confocal, roundish cells infiltrating the junction (P = 0.019). These data suggest an influence of CDKN2A mutation and MC1R variants in the development of dysplastic melanocytic lesions. Non‐invasive histomorphological evaluation, together with genetic studies, improves melanoma risk identification and early diagnosis, for a patient‐tailored management.     

Clinical clues for differential diagnosis between verruca plana and verruca plana‐like seborrheic keratosis

Sometimes the clinical differentiation between verruca plana (VP) and VP‐like seborrheic keratosis (SK) could be challenged. However, there have been no studies on this issue to date. The aim of this study was to elucidate clinical and dermoscopic differences between these two diseases, and also to suggest a diagnostic algorithm of VP and VP‐like SK without skin biopsy. The patients who had lesions clinically considered as VP or VP‐like SK were the target of our study. We took clinical and dermoscopic photos with informed consent and conducted a questionnaire. All patients had their diagnoses confirmed by biopsy. Thirty‐three patients were enrolled in our study. Seventeen patients were finally diagnosed with VP (51.5%) and 16 patients with VP‐like SK (48.5%). In clinical findings, VP‐like SK showed significantly more scattered distribution than VP (P = 0.039), which exhibited more clustered or grouped distribution (P = 0.039). In dermoscopic findings, brain‐like appearance was more commonly observed in VP‐like SK (P = 0.003) whereas VP showed more red dots or globular vessels (P = 0.017) and even‐colored light brown to yellow patch (P < 0.001). Sex, onset age, the size of each lesion, location, color and shape showed no significant differences between them (P > 0.05). Based on our results, we suggest a diagnostic algorithm using Koebner's phenomenon, dermoscopic findings, distribution of each lesion and biopsy for multiple VP‐like lesions in adults, and we think it will be a very useful diagnostic tool in daily clinical dermatological practice.     

Mask-related adverse skin reactions in orientals during COVID-19: Prevalence,social-psychological impacts and risk factors for acne exacerbation

Background

COVID-19 pandemic has caused mask-related skin problems on health-care professions, yet very few studies have investigated the prevalence in oriental general population.

Objective

To investigate the prevalence of mask-related adverse skin reactions in Orientals, to explore psychological influence, to identify risk factors for mask-related acne exacerbation.

Methods

We performed a survey through social media. Participant demographics, skin condition before and after COVID-19, and the influence of adverse skin on social-psychological conditions were collected. We compared characteristics between individuals with or without acne exacerbation, and we performed a logistic regression to identify risk factors.

Results

Six hundred and six participants (62.3%) responded the survey and 23.3% complained their facial acnes become exacerbated since COVID-19. The social-psychological impact of acnes is more prevalent in women. Risk factors for mask-related acne exacerbation were occupation as health-care workers (OR = 1.861, p = 0.027), prolonged wearing of N95 masks (OR = 3.167, p = 0.001), and touching of acnes (OR = 2.65, p = 0.002). Sex, pre-existed acnes, and prolonged wearing time per day are also associated with acne exacerbation.

Conclusions

Mask-related adverse skin reactions are common in Orientals, and could lead to negative social-psychological effects.     

Hemicellulose dressing versus rayon dressing in the re-epithelialization of split-thickness skin graft donor sites: a multicenter study

The aim of this study was to compare the effectiveness of a hemicellulose dressing with that of rayon dressing in the healing of split-thickness skin graft donor sites. Twenty-eight patients were selected from five different hospitals and randomized into two groups: hemicellulose dressing group and rayon dressing group. All patients underwent split-thickness skin grafting for various reasons, and the skin graft donor site wounds were covered with hemicellulose dressing (n = 14) or rayon dressing (n = 14). The donor site was assessed on postoperative days 1, 7, 14, 21, and 28 for hyperemia, pruritus, pain, exudate level, and adherence of the wound dressing. At the 60-day follow-up visit, the donor site was assessed again for pruritus and pain. Touch-pressure, thermal, and pain sensibility tests were performed preoperatively and on postoperative day 60 together with the assessment of color and texture of the re-epithelialized area. In all patients, re-epithelialization was completed between 14 and 21 days after surgery. There were no significant differences between the two groups with regard to pain, hyperemia, pruritus, exudate, and final appearance (color and texture) of the skin graft donor site. The rayon dressing provided significantly better adherence than the hemicellulose dressing, and both dressings showed similar results with regard to the parameters evaluated when used in the treatment of split-thickness skin graft donor sites.     

Rebounding triad (severe itching,dryness and burning) after facial corticosteroid discontinuation defines a specific class of corticosteroid‐dependent dermatitis

In patients with dermatitis, the sudden discontinuation of topical corticosteroid (TC) use after long‐term treatment could cause flaring symptoms (named “rebounding responses”). Diagnostic criteria for facial corticosteroid‐dependent dermatitis (FCDD) are vague and uncertain. We aim to define a category of patients with clinical rebounding triad including severe itching, dryness and burning. Patients with FCDD (n = 268) were evaluated to determine distinctive rebounding triad manifestations after TC cessation. Data on history of facial TC use and rebounding presentations were collected. A group of chronic dermatitis patients (n = 83) with rebounding triad after TC discontinuation were enrolled and added to patients with FCDD presenting triad symptoms. Patients without triad were compared with triad‐positive patients. Eighty‐five patients who displayed triad manifestations after TC cessation showed longer (93.1 ± 53.6 vs 9.6 ± 5.5 weeks, P < 0.001) and more frequent (7.7 ± 4.5 vs 2.3 ± 1.6 times/week, P < 0.001) use of TC. Similar results were observed after adding 83 dermatitis patients who experienced triad after TC cessation. Multivariate analysis showed that mean duration of TC use (odds ratio [OR] = 1.83, 95% confidence interval (95% CI) = 1.042–3.218, P = 0.035) and mean frequency of TC use (OR = 2.802, 95% CI = 1.135–6.918, P = 0.025) were independent predictors of rebounding triad after TC cessation. Duration and frequency of TC use were the main factors predicting rebounding triad.     

In situ assessment of PI3K and PTEN alterations in mycosis fungoides: correlation with clinicopathological features

Deregulated signalling through phosphatidylinositol 3‐kinase (PI3K) pathway plays a critical role in tumour initiation and progression. We have already shown that AKT is activated in skin lesions in Mycosis Fungoides (MF) and we herein further investigate the frequency and clinical significance of PTEN and PI3K at the protein and at the DNA level as well as the presence of AKT1 mutations in skin lesions from 50 patients with MF clinical stages I‐IV in relation to clinicopathological features. Increased p‐AKT expression correlated with poor prognosis in plaques (P = 0.0198), whereas p‐AKT was an independent predictor of poor survival in the entire cohort (P = 0.017, HR = 1.012). PTEN cytoplasmic expression was found low or absent in all 77.3% of cases and inversely correlated with advanced clinical stages (P = 0.0744). Molecular analysis showed no AKT1 mutation, no PI3KCA copy number gain, only 1 case with PI3KCA mutation in exon 9 and 3 cases with PTEN mutations (7%) in exons 7, 8 and 5. The latter correlated with disease (P = 0.0253) and progression (P < 0.0001) free survival in tumour stage. Although activation of PI3K/AKT signalling pathway due to PTEN alterations is rarely attributed to abnormalities in PTEN, PI3K, and AKT1 genes, PTEN mutations exert a negative effect on patients’ prognosis with tumours.     

Serum vascular endothelial growth factor receptor 3 as a potential biomarker in psoriasis

To discover novel biomarkers of psoriasis, a target‐specific antibody array screening of serum samples from psoriasis patients was initially performed. The results revealed that vascular endothelial growth factor receptor 3 (VEGFR‐3) was significantly elevated in the sera of psoriasis patients, compared to healthy controls. Next, ELISA validation studies in a larger cohort of psoriasis patients (N = 73) were conducted, which confirmed that serum VEGFR‐3 was indeed significantly increased in patients with psoriasis compared to healthy controls (P < 0.001). Furthermore, receiver operating characteristic curve analysis demonstrated that serum VEGFR‐3 exhibited potential in distinguishing healthy controls from psoriasis patients: area under the curve = 0.85, P < 0.001. In addition, serum levels of VEGFR‐3 were correlated with Psoriasis Area Severity Index scores (R = 0.32, P = 0.008) in psoriasis patients. Interestingly, serum VEGFR‐3 levels were significantly elevated in psoriatic arthritis compared to non‐psoriatic arthritis (P = 0.026). A pilot longitudinal study demonstrated that serum levels of VEGFR‐3 could reflect disease progression in psoriasis. Collectively, serum VEGFR‐3 may have a clinical value in monitoring disease activity of psoriasis.     

A prospective comparative study on the effectiveness of two different non-adherent polyurethane dressings on split-thickness skin graft donor sites

AimTo analyze differences in re-epithelization, exudate absorbency, ease and pain on dressing removal between ALLEVYN? Non-Adhesive and Betaplast? N.MethodologyPatients admitted to the general ward undergoing split skin grafting were recruited. Allevyn and Betaplast were applied on the donor site. Exudate absorption was assessed daily using an absorbency grading chart. Dressing change was done on post-operative day five. Ease of dressing removal and pain score using the Wong-Baker Pain Scale was assessed. The percentage of re-epithelization for each dressing was assessed.Results30 patients were recruited. There was a statistically significant difference in exudate absorption on post-operative day 3 (z = ?2.006, p = 0.045, T = 236) and post-operative day 4 (z = ?2.026, p = 0.0143, T = 188), pain score (z = ?2.861, p = 0.004, T = 180), ease of removal (z = ?2.668, p = 0.008, T = 126) and re-epithelization (z = ?2.566, p = 0.009, T = 336) between Betaplast and Allevyn.ConclusionBetaplast may have faster re-epithelization, better exudate absorption, and is easier to remove while minimizing discomfort as compared to Allevyn.     

Topical 2% ketoconazole cream monotherapy significantly improves adult female acne: A double‐blind,randomized placebo‐controlled trial

The emergence of bacterial resistance is a global crisis. Prolonged use of antibiotics especially in acne is one issue of concern among dermatologists. Ketoconazole (KTZ) cream, a topical antifungal with anti‐inflammatory and antiandrogenic actions, can decrease lipase activity of Cutibacterium acnes in vitro. We evaluated the efficacy and safety of KTZ cream in mild adult female acne (AFA) by conducting a randomized, double‐blind, placebo‐controlled trial using KTZ 2% and placebo cream twice daily for 10 weeks. We assessed the improvement of clinical severity, measured by AFA score graded by investigators and participants, and the change of acne count. Forty‐one participants enrolled in our study. The proportion of participants with acne improvement from baseline (42.9% vs 9.5%, P = 0.015) and the success rate (45.0% vs 14.3%, P = 0.043) in the KTZ group were significantly higher than that of the placebo group. The most common adverse events were dryness and itching. The percentage change of acne count decreased significantly compared with baseline but did not differ statistically between the two groups (P = 0.268). We concluded that the KTZ monotherapy showed a plausible effect in improving AFA with excellent safety profile. It should be considered as a viable option for mild AFA treatment.     

Role of nail bed methotrexate injections in isolated nail psoriasis: conventional drug via an unconventional route

Nail psoriasis can be a debilitating condition; however, in patients with isolated nail involvement, the use of toxic systemic therapies such as methotrexate may not be justified. We report on 4 patients (30 involved nails between them), who were treated with injections of methotrexate (0.1 mL of a 25 mg/mL solution) into the nail bed at 3‐weekly intervals. Mean baseline Nail Psoriasis Severity Index (NAPSI) was 4.77 (range 2–8, cumulative score 143; n = 30); dropping successively at each visit to 2.43 (range 0–4, cumulative score 73; n = 30) at 15 weeks. The decline in mean NAPSI from 4.87 to 2.17 was statistically significant (P < 0.001; Friedman analysis). Reported adverse effects were pain, injection site pigmentation and nail bed haemorrhage. Administration of specific targeted therapy to the nail bed may help manage nail psoriasis effectively.