Nail psoriasis

Nail psoriasis is nail disease associated with psoriasis. It is also known as psoriatic nail dystrophy. Nail psoriasis usually begins years after psoriasis first appears on the skin. Psoriasis is a common skin disease affecting 1 in 50 people. It occurs equally in men and women. It can appear at any age. Psoriasis is a long-term condition which may come and go throughout your lifetime. It is not infectious; therefore you cannot catch psoriasis from someone else. It does not scar the skin although sometimes it can cause a temporary increase or reduction in skin colour. Although psoriasis is a long-term condition there are many effective treatments available to keep it under good control.

Psoriasis can affect the nails and the joints as well as the skin. Psoriatic arthritis produces swelling and stiffness in the joints or stiffness in the lower back and should be managed by a rheumatologist who works closely with your dermatologist and/or your doctor.

Psoriasis, particularly moderate to severe psoriasis, is associated with an increased risk of anxiety, depression and harmful use of alcohol. Moderate to severe psoriasis increases the risk of heart disease and stroke and treatment of psoriasis may reduce this risk. Psoriasis can also be associated with diabetes, obesity, venous thromboembolism, high cholesterol and high blood pressure. Psoriasis is also associated with inflammatory bowel disease and there is a small increased risk of skin cancer.

If you have psoriasis, it’s important to check your fingernails and toenails for signs of nail psoriasis. Common signs include:

• Tiny dents in your nails (called “nail pits”)
• White, yellow, or brown discoloration
• Crumbling nails
• Nail(s) separating from your finger or toe
• Buildup beneath your nail
• Blood under your nail

Nail psoriasis, which affects 80–90 % of people with skin psoriasis at some time during their life, can be a frustration and a challenge for patient and physician alike ¹. Psoriasis affects the nails in 10–50 % of psoriatics and occasionally nail psoriasis can be the
sole feature or the presenting clinical finding of cutaneous psoriasis. Only 5% of patients present with typical nail psoriasis as an isolated disorder; most patients have chronic plaque psoriasis. About 50–80% have psoriatic arthritis, particularly arthritis mutilans. A recent large study of pediatric patients found a 39 % prevalence of nail psoriasis ². Nail psoriasis severity is positively correlated with duration, extent and severity of plaque psoriasis, and with psoriatic arthritis ³. In fact, studies show a 70 % prevalence of nail psoriasis in patients with psoriatic arthritis, and in some cases the nail involvement occurs early in the disease process and may be predictive of subsequent psoriatic arthritis development ⁴.

Patients with nail psoriasis may be of any age or race. Nail dystrophy is often precipitated or aggravated by trauma. Psoriatic nail dystrophy can negatively affect occupational activities and hobbies. Moreover, unsightly fingernail psoriasis can cause psychological distress and may cause patients to avoid certain activities and social situations ⁵. Thus, nail psoriasis impairs nail function and appearance and is a burden for patients by seriously impacting quality of life as it interferes with occupational, social, and recreational activities ⁶.

Determining treatment for nail psoriasis is as much an art as science. All patients with nail psoriasis benefit from education about psoriatic nail disease, the timeline for nail improvement, strategies to protect nails from exacerbating factors, and the overall treatment landscape for psoriatic nail disease.

Treating nail psoriasis can be a challenge. It often takes time to treat. To get results, you need to treat your nails as directed and for as long as directed. Some patients need to try a few treatments to find one that works.

The right nail care can help you get the best results from treatment.

Choice of nail psoriasis treatment depends on many factors which are either patient related or psoriasis disease related. In general, topical medications, intralesional, and device- based therapy are early steps on the therapeutic ladder, and systemic medications including biologics are used in moderate to severe psoriatic disease and when the nail psoriasis does not respond to local therapy.

Figure 1. Nail bed psoriasis

Footnote: Nail bed psoriasis, features of onycholysis, and oil drop discoloration.

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Figure 2. Nail matrix psoriasis

Footnote: Nail matrix psoriasis, features of pitting (depressions in the nail plate), and psoriatic leukonychia (smooth white spots in the nail plate)

[Source ⁷ ]

Nail psoriasis causes

Nail psoriasis arises within the nail matrix. The specific pathogenesis of nail psoriasis is unknown.

How can nail psoriasis be prevented?

At this time, scientists do not know how to prevent nail psoriasis. Avoidance of trauma is essential.

Nail psoriasis can be stubborn. When you combine a treatment plan for nail psoriasis with the recommended nail care, you’re much more likely to see improvement.

Here are 7 nail-care tips that can reduce nail psoriasis

If you have nail psoriasis, it’s important to protect your nails. Anything that dries or injures a nail can worsen nail psoriasis — or trigger a flare-up.

To help patients get the best results from treatment for nail psoriasis and reduce flare-ups, dermatologists recommend the following:

1. Keep your nails short. This helps prevent nails from lifting off of fingers and toes. It can also help prevent buildup under the nails — a common problem with nail psoriasis.
2. Wear gloves when doing any type of manual work. This includes housework, yard work, and repairs around your home. Any time you irritate your skin or nails, psoriasis can flare. When doing wet work like washing dishes, it’s best to wear a cotton glove and then place a vinyl or nitrile glove over the cotton glove. Latex gloves cannot give your nails enough protection.​
3. Moisturize your hands. Psoriasis dries your skin and nails. Applying a moisturizer after each hand washing and within 3 minutes of bathing can help lock in much-needed moisture. A thick cream or ointment works best.
4. Leave your cuticles alone. Cutting or pushing up your cuticles can injure your skin or lead to an infection. When people who have psoriasis injure their skin or get a skin infection, psoriasis can flare. This reaction is called the Koebner phenomenon.
5. Avoid biting (or picking at) your nails and the skin around them. This, too, can injure your skin and increase your risk of getting an infection. Injuring your skin or getting a nail infection can worsen psoriasis. Need help to stop biting your nails? Tune in and find out what dermatologists recommend at: How to stop biting your nails.
6. Resist the temptation to scrape the buildup from under your nails. Removing the buildup can loosen nails and increase your risk of getting an infection. With treatment, the buildup will gradually clear.
7. Skip the artificial nails. Nail polish and gentle nail buffing are okay and a great way to hide dents (nail pitting) that can develop when you have nail psoriasis. Artificial nails, however, can increase the risk of your nails separating from your fingers — a common problem in nail psoriasis.

Nail psoriasis symptoms

Nail psoriasis can affect any part of your fingernails, toenails, or both. There are often scaly plaques on the dorsum of the hands and fingers due to associated plaque psoriasis. Signs depend on the part of the nail affected. Its severity may or may not reflect the severity of the skin or joint psoriasis.

As with other nail disorders, the clinical appearance of your nail depends on which part of the nail unit is involved with psoriatic inflammation. Psoriatic inflammation can involve the nail bed, nail matrix, and nail fold, resulting in different clinical findings accordingly. Nail bed psoriasis is characterized by onycholysis (separation of the nail plate from the underlying nail bed and hyponychium) and associated features of oil drop/salmon patch dyschromia, splinter hemorrhages, and nail bed hyperkeratosis (see Figures 1 and 2). The hallmark of nail matrix psoriasis is pitting and associated features of crumbling and psoriatic leukonychia which are the same process involving different portions of the matrix and for different durations. Both nail bed and nail matrix psoriasis present the challenge of local delivery of drug to the part of the nail unit responsible for the nail changes. For that reason, the nail bed and nail matrix may respond differently to some nail psoriasis treatments. Psoriasis of the proximal and lateral nail folds can result in cuticle loss and lead to psoriatic paronychia. When nail fold attachment to nail plate is altered by psoriasis involving the nail folds, irregularities of the surface of the nail plate is seen as similar to other types of chronic paronychia.

• Psoriasis can enhance the speed of nail growth and thickness of the nail plate.
• Nail pitting is a sign of partial loss of cells from the surface of the nail plate. It is due to psoriasis in the proximal nail matrix.
• Leukonychia (areas of white nail plate) is due to parakeratosis within the body of the nail plate and is due to psoriasis in the mid-matrix.
• Onycholysis describes the separation of the nail plate from the underlying nail bed and hyponychium. The affected distal nail plate appears white or yellow.
• Oil drop or salmon patch is a translucent yellow-red discoloration in the nail bed proximal to onycholysis. It reflects inflammation and can be tender.
• Subungual hyperkeratosis is scaling under the nail due to excessive proliferation of keratinocytes in the nail bed and hyponychium.
• Transverse lines and ridges are due to intermittent inflammation causing growth arrest followed by hyperproliferation in the proximal nail matrix. The lines and ridges move out distally as the nail grows.
• Psoriatic inflammation can also lead to nail plate crumbling, splinter hemorrhage, and a spotted lunula.
• Acrodermatitis continua of Hallopeau is a rare pustular eruption that affects nail bed, nail matrix and tips of digits.

Nail psoriasis causes changes to your fingernail toenails, or both, may shows these signs of nail psoriasis:

1. Crumbling,
2. Roughness or ridges,
3. Blood under the nail,
4. Tiny dents in the nail (pits),
5. White discoloration,
6. Lifting (the nail is separating from the finger),
7. Most people who have plaque psoriasis develop nail psoriasis at some point: Discoloration, nail lifting from the finger, and a thin line of blood are common signs of nail psoriasis.

Nail psoriasis complications

Nail psoriasis is unsightly. It can also lead to:

• Pain and tenderness
• Functional disability
• Psychological distress
• Secondary bacterial infection (acute paronychia) or fungal infection (chronic paronychia, onychomycosis).

Nail psoriasis diagnosis

Psoriatic nail disease is readily recognized in a patient with current or prior chronic plaque psoriasis. It is frequently confused with fungal nail infection (onychomycosis). Fungal infection can complicate nail psoriasis. To further complicate the matter, roughly one third of patients with nail psoriasis have concomitant nail fungus ⁸.

If in doubt, or antifungal treatment is planned, nail clippings and scrapings of subungual debris should be sent for potassium hydroxide microscopy and fungal culture.

A biopsy of the proximal nail matrix is occasionally needed to confirm the diagnosis of nail psoriasis, particularly if dystrophy affects a single nail and a tumour is a possible explanation. The biopsy can lead to permanent nail deformity.

Nail psoriasis treatment

It is difficult to treat nail psoriasis effectively. Improvement from treatment happens slowly. Nails grow slowly, so it will take 6 months or longer to clear debris.

While the extent and severity of nail psoriasis and the impact on quality of life are important in choosing a therapy for nail psoriasis, other factors should also be considered. Obviously the effi cacy and safety of a particular therapy for nail psoriasis is important, as are patient acceptance, ease of administration, convenience, and cost, which are also considerations when selecting a treatment for nail psoriasis.

Important factors that guide and determine the choice of nail psoriasis treatments:

• Age of patient
• Previously used treatments
• Sex, pregnancy, or nursing
• Medical history/medications/comorbidity, tuberculosis risk,
• infection risk, contraindications
• Severity of nail disease based on symptoms such as pain
• Impact on quality of life caused by the nail disease
• Psychological factors impact on quality of life
• Extent of skin disease
• Presence of psoriatic arthritis
• Cost of therapy
• Convenience of treatment
• Motivation of patient
• Availability of treatment
• Resources available to pay for therapy
• Risk vs. benefi t for each patient

There are many treatments for nail psoriasis. Your treatment plan may include one or more of the following:

Topical treatment

Patients who are minimally bothered by their nail psoriasis and who have had no previous therapy for their nails should be given a trial of topical therapy as first line. Many different topical treatments have been used to treat nail psoriasis in the form of solutions, creams, ointments, lacquers, gels, and foams, both with and without occlusion. The most well-studied drugs for topical treatment of nail psoriasis are clobetasol solution and lacquer ⁹, tazarotene ¹⁰ and calcipotriol (Vitamin D3) ¹¹. Additional small studies have been published on tacrolimus, dithranol ¹², topical fl uorouracil ¹³, and cyclosporine ¹⁴. A recent report showed efficacy of indigo naturalis in improving nail psoriasis in children ¹⁵.

Topical treatment must be applied to the nail matrix and hyponychium for months or years, and its effects are often disappointing. Treatment you apply to your nails can be helpful for mild or early nail psoriasis. Nails grow slowly, so you’ll need to apply these treatments for several months, often once or twice a day. Because nail psoriasis can be stubborn, you may need to use more than one treatment. Sometimes, two medicines are combined to give you a faster response.

Topical treatment options include:

• Topical potent or very potent corticosteroid solution or ointment as weekend pulses under cellophane occlusion at night. This can be helpful for most signs and symptoms of nail psoriasis. It’s safe to use this medicine once or twice a day for up to 9 months.
• Calcipotriol (Vitamin D3) solution twice daily. In one study, researchers found this to be as effective as a potent corticosteroid at treating the buildup beneath the nail.
• Clobetasol propionate 8% in a lacquer vehicle twice daily for 3 weeks then twice weekly
• 5-fluorouracil cream twice daily.
• Tazarotene: This treatment can be especially helpful for treating pitting, a separating nail, and discoloration.

Other treatment options

Other options include treatment given in a dermatologist office or clinic:

• Intralesional triamcinolone acetonide (corticosteroids or another psoriasis medicine) injections into proximal nail folds; this is painful. This involves getting injections directly into or near your nails with psoriasis. If the first treatment shows poor results, you may get another one in a few months. Corticosteroid injections can be effective for treating buildup under the nail, nail ridges, nail thickening, and nails separating from fingers or toes.
• Localized phototherapy with UVA, UVB, and photochemotherapy (PUVA). Photochemotherapy (PUVA) involves first soaking in (or taking) a medicine called psoralen. Afterwards, you are carefully exposed to UVA rays. PUVA can be effective to clear plaque psoriasis, discolored nails and nails that are separating from fingers or toes. It does little to treat nail pitting.
• Laser treatment: Some lasers can be effective. More recently, 595 pulse dye laser (PDL) has shown efficacy in some small studies ¹⁶. Photodynamic therapy (PDT) using methyl-aminolevulinic acid with PDL 595 did not add any benefi t over pulse dye laser (PDL) alone ¹⁷.
• Treatment that works throughout the body – systemic treatment with methotrexate, acitretin, apremilast, ciclosporine, retinoid and biologics. If you have severe psoriasis and nail psoriasis, your dermatologist may prescribe medicine that can treat both your skin and nails. Patients with severe nail psoriasis who have not responded to local therapy or who have widespread plaque psoriasis and/or psoriatic arthritis will usually benefit from systemic therapy with either traditional agents such as methotrexate or with biologics. The past decade has ushered in the era of biologics, which are highly effective and safe in the treatment of psoriasis and psoriatic arthritis. There is data that infl iximab ¹⁸, adalimumab ¹⁹, etanercept ²⁰, golumumab ²¹, alefacept ²² and ustekinumab ²³ all show signifi cant effi cacy in improving nail psoriasis.  Acitretin, an oral retinoid, has been shown to benefi t nail psoriasis at very low dose 0.2–0.3 mg/kg/day ²⁴ and also at 0.5 mg/kg when used with urea nail lacquer ²⁵. Although methotrexate and cyclosporine have been shown to be effective in psoriasis vulgaris, there are very few trials that look at nail psoriasis ²⁶. As with other treatment for nail psoriasis, it can take months to see results.

Note: Acitretin thins the nail plate and reduces its speed of growth, which can be helpful or not, depending on the type of nail psoriasis.

Nail infection needs treatment, too

A nail infection can develop if you have nail psoriasis. Because a nail infection can look a lot like nail psoriasis, it’s important to find out if you have an infection. Testing, which usually consists of scraping the nail, can find an infection.

Topical and oral antifungal treatment may be prescribed if fungal infection is present.

Chemical or surgical avulsion therapy, i.e. complete removal of the nail, is occasionally recommended. A risk is that the regrowing nail may be as bad, or more severely affected than prior to the procedure.

Nail psoriasis prognosis

Nail psoriasis varies in severity over time. In some patients, it resolves completely spontaneously or as a response to systemic treatment. In others, it persists long term.

References

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