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Letters to the Editor - Letter in Response to Previously Published Articles
2019:85:1;81-82
doi: 10.4103/ijdvl.IJDVL_632_18
PMID: 30457124

Intramatricial injections for nail psoriasis: An open-label comparative study of triamcinolone, methotrexate, and cyclosporine

Surya Ravindran, Sebastian Criton
 Department of Dermatology, Amala Institute of Medical Sciences, Thrissur, Kerala, India

Correspondence Address:
Surya Ravindran
Department of Dermatology, Amala Institute of Medical Sciences, Amala Nagar, Thrissur - 680 555, Kerala
India
Published: 20-Nov-2018
How to cite this article:
Ravindran S, Criton S. Intramatricial injections for nail psoriasis: An open-label comparative study of triamcinolone, methotrexate, and cyclosporine. Indian J Dermatol Venereol Leprol 2019;85:81-82
Copyright: (C)2019 Indian Journal of Dermatology, Venereology, and Leprology

Sir,

This letter pertains to the article by Mittal and Mahajan in the July–August 2018 issue of the IJDVL. It is with great interest and appreciation that we have read this experimental paper on “Intramatricial injections for nail psoriasis: An open-label comparative study of triamcinolone, methotrexate, and cyclosporine.”[1] The concept of using a direct intramatricial delivery of antipsoriatic agents in nail psoriasis is indeed promising. However, there are some points we would like to highlight with regard to this study:

  1. This study may have overlooked the fact that the formulations of antipsoriatic agents injected intramatricially in this study are not depot agents and the effect is not likely to last 24 weeks. With regards to drug kinetics, the elimination half-life of cyclosporine is 5–18 h.[2] Cyclosporine is extensively metabolized by the cytochrome P-450 3A4 (CYP3A4) enzyme system in the liver and is primarily excreted by way of the bile through feces, with only 6% of the dose (parent drug and metabolites) excreted in urine.[2] Further, the usually reported mean values for the elimination half-life and the total body clearance of methotrexate is 5–8 h.[3] Hence if the intramatricial drug worked like a depot agent and its action lasted for 24 weeks after two injections, it would be contradictory as to why we need to give systemic cyclosporine daily and methotrexate weekly to achieve desired therapeutic efficacy in psoriasis vulgaris.[2]
  2. Reverse Koebner phenomenon, even though rare, was first described in a psoriasis patient. It is defined as the nonappearance or disappearance of the lesions of particular dermatoses at the site of injury.[4],[5],[6] Even though there are no reports of reverse Koebner phenomenon in nail psoriasis, we would like to clarify if the results in this study can be attributed to the same.
  3. Beau's lines are transverse depressions in the nail plate that occur after a stressful event that temporarily interrupts nail formation.[7] The literature available on mechanism of action of antipsoriatic agents on nail psoriasis is relatively sparse. However, if there is an antiproliferative effect and immediate improvement as reported in this study, would the chances of finding Beau's lines as a sign of temporary arrest of growth of nails be likely?

In conclusion, even though we highly appreciate the effort taken by authors, it would be worthwhile if we could postulate the rationale of mechanism of action of these antipsoriatic agents on nail psoriasis to help us understand better.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References
1.
Mittal J, Mahajan BB. Intramatricial injections for nail psoriasis: An open-label comparative study of triamcinolone, methotrexate, and cyclosporine. Indian J Dermatol Venereol Leprol 2018;84:419-23.
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Wolverton SE. Comprehensive Dermatologic Drug Therapy. Philadelphia: Saunders; 2001.
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Bannwarth B, Péhourcq F, Schaeverbeke T, Dehais J. Clinical pharmacokinetics of low-dose pulse methotrexate in rheumatoid arthritis. Clin Pharmacokinet 1996;30:194-210.
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Grekin DA, Van Scott EJ. Dermal role and controls in psoriasis. Arch Dermatol 1973;108:425.
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Malakar S, Dhar S. Spontaneous repigmentation of vitiligo patches distant from the autologous skin graft sites: A remote reverse Koebner's phenomenon? Dermatology 1998;197:274.
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Martín JM, Conde A, Pinazo I, García L, Sánchez AL, Pinazo J, et al. Reverse koebnerization after radiotherapy in a woman with a mastectomy for a breast carcinoma. J Am Acad Dermatol 2006;55:S90-1.
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De Berker D. What do Beau's lines mean? Int J Dermatol 1994;33:545-6.
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