LAUSR

BACKGROUND Nearly up to 50% of patients with skin psoriasis have concomitant nail involvement. The comparative effectiveness in nail psoriasis (NP) among the available biologics is still an area of contention due to the limited data on nails. We conducted a systematic review and network meta-analysis (NMA) to compare the efficacy of biologics in achieving complete resolution of NP. METHODS We comprehensively identified studies in Pubmed, EMBASE and Scopus. The eligibility criteria included randomized controlled trial (RCTs) or cohort studies in psoriasis or psoriatic arthritis with at least 2 arms of active comparator of biologic reporting al least one efficacy outcome of interest, i.e. NAPSI= 0, mNAPSI= 0, f-PGA= 0. RESULTS Forteen studies comprising 7 treatments met the inclusion criteria, and were included in the NMA. The NMA showed the odds of complete NP resolution were superior with ixekizumab (RR: 1.4, 95%CI= 0.73-3.1) compared to the treatment of reference (adalimumab). Brodalumab (RR: 0.92, 95%CI= 0.14-7.4), guselkumab (RR: 0.81, 95%CI= 0.40-1.8), infliximab (RR: 0.90, 95%CI= 0.19-4.6) and ustekinumab (RR: 0.33, 95%CI= 0.083-1.6) demonstrated worse therapeutic effect compared with adalimumab. According to the surface under the cumulative ranking curve (SUCRA), ixekizumab 80 mg every 4 weeks had the highest probability of being the best treatment. CONCLUSION The IL-17A inhibitor ixekizumab has the highest rate of complete nail clearance and it can be considered the best ranked therapy with the present evidence. This study has relevant implications in the daily practice as it facilitates the decision to choose among the wide variety of available biologics when facing patients in whom clearance of nail symptoms is the first concern.