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Intralesional injections of triamcinolone acetonide are widely used to treat nail psoriasis and other inflammatory nail conditions. But information on optimal dosing has been largely elusive -- until now.

Shari Lipner, MD, PhD, associate professor of clinical dermatology with Weill Cornell Medical College and Weill Cornell Medicine in New York served as an investigator in a study on intralesional injections, which appears in the . Lipner's exchange with the Reading Room has been edited for length and clarity.

What was the question or knowledge gap this study was designed to address?

Lipner: Intralesional matrix injections are the workhorse for patients who have isolated nail psoriasis with three or fewer affected nails, and as an adjunct in patients with three or more affected nails.

Even though these injections are commonly used in practice, safety and efficacy data have been lacking and optimal dosing levels were unknown. Optimal concentration has been heavily debated among dermatologists, which was part of the impetus for doing the study.

What were the key findings?

Lipner: We found that lower concentrations of kenalog (2.5 mg/mL) were non-inferior to higher concentrations of kenalog (5-10 mg/mL). Both were more effective than placebo (lidocaine).

Lower concentrations were also associated with fewer adverse events compared to higher concentrations.

Did anything surprise you about the study or its findings?

Lipner: I was not surprised by the primary findings, because my experience with my own patients was that low doses of intramatricial kenalog were highly effective.

What was surprising to me, however, was that a single injection into the matrix also improved nail-bed disease. We did not expect this result, but we hypothesized that there is some diffusion of kenalog from the matrix to the nail bed. This is an important finding because injections into the nail bed are very, very painful and not tolerated by most patients.

The idea of treating nail-bed disease or nail matrix and nail-bed disease with a single, less painful injection into the nail matrix could offer new treatment options.

What are the take-home messages?

Lipner: Intralesional kenalog at a concentration of 2.5 mg/mL is the preferred treatment for patients with nail psoriasis with matrix disease involving three nails or fewer. This dosage level maximizes efficacy while limiting adverse events.

Is there anything you would like to add?

Lipner: Data on treatment of isolated nail psoriasis patients are lacking. This study gives us evidence-based treatment with which to manage our patients.