Psoriatic nails

Psoriatic nails are a common manifestation of psoriasis, a chronic autoimmune condition that affects the skin and nails. About 50% to 80% of individuals with psoriasis also experience nail involvement, which can range from mild changes to severe deformities. The following are the main definition and types of psoriatic nails.

Definition: Psoriatic nails are nail changes that occur as a result of psoriasis. They can be accompanied by skin changes, such as red, scaly patches called plaques, or they may occur on their own. The nails become thick, brittle, discolored, and distorted, and may separate from the nail bed. The nails can also become pitted, ridged, or have ridges that run vertically down the nail.

Types:

Nail Pitting: This is the most common type of nail change seen in psoriatic nails. It is characterized by small, shallow pits or indentations in the nails. The pits are usually round or oval in shape and may appear in a single row or multiple rows.
Nail Hyperkeratosis: This type of nail change is characterized by thickening of the nails, which can become brittle and difficult to cut. The nails may also appear opaque and discolored, and may have ridges or deformities.
Onycholysis: This type of nail change occurs when the nails separate from the nail bed. The nails become loose and may even detach completely from the nail bed. This can result in pain and discomfort, and can also increase the risk of infection.
Nail Dystrophy: This type of nail change is characterized by deformities of the nails, such as ridges, grooves, or irregular shapes. The nails may also become discolored, brittle, and may have a ridged or pitted surface.
Oil Spotting: This type of nail change is characterized by small, dark spots or dots on the nails. The spots are caused by bleeding under the nail, and can be a sign of more severe nail involvement.
Nail Clubbing: This type of nail change is characterized by a softening and rounding of the fingertips and nails, which can result in the nails appearing spoon-like in shape. Nail clubbing can be a sign of a more severe underlying medical condition and should be evaluated by a healthcare provider.

In addition to these specific types of nail changes, individuals with psoriatic nails may also experience pain, tenderness, and difficulty with activities of daily living, such as typing or gripping objects.

Causes

The exact causes of psoriatic nails are not well understood, but several factors have been identified as contributing to their development.

Genetics:

Psoriasis is known to have a strong genetic component, and a family history of the condition increases the risk of developing psoriatic nails. Studies have identified several genes that are associated with an increased risk of developing psoriasis and psoriatic nails, including HLA-Cw6, IL-23R, and IL-12B.

Immune system dysfunction:

Psoriasis is an autoimmune condition, which means that the body’s immune system attacks healthy skin cells. In people with psoriasis, the immune system triggers an overproduction of skin cells, leading to the development of thick, scaly patches on the skin. This same immune dysfunction is thought to also affect the nails, leading to changes in the appearance and structure of the nails.

Inflammation:

Inflammation is a key component of psoriasis and is thought to play a role in the development of psoriatic nails. Inflammation can cause the nails to become thick, pitted, and discolored. In severe cases, the nails can separate from the nail bed and become deformed.

Trauma:

Injury to the nails, such as repeated manicure procedures or frequent exposure to harsh chemicals, can trigger the development of psoriatic nails in people with psoriasis. This is because the trauma can cause inflammation in the nails, which can then trigger an immune response.

Medications:

Certain medications, such as lithium, antimalarials, and high-dose corticosteroids, have been linked to the development of psoriatic nails. This is because these medications can cause changes in the skin and nails that mimic the symptoms of psoriasis.

Infections:

Infections, such as fungal infections of the nails, can trigger the development of psoriatic nails in people with psoriasis. This is because the infection can cause inflammation in the nails, which can then trigger an immune response.

Stress:

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Stress has been linked to the development and worsening of psoriasis, including psoriatic nails. This is because stress can trigger inflammation in the body, which can then trigger an immune response.

Hormonal changes:

Hormonal changes, such as pregnancy or menopause, have been linked to the development of psoriatic nails in some women. This is because the hormonal changes can cause changes in the skin and nails that mimic the symptoms of psoriasis.

The exact causes of psoriatic nails are not well understood, but the combination of genetics, immune system dysfunction, inflammation, trauma, medications, infections, stress, and hormonal changes likely all play a role in their development. In order to effectively treat psoriatic nails, it is important to address all of these contributing factors.

Symptoms

Here is a list of the main symptoms of psoriatic nails:

Nail pitting: This is one of the most common symptoms of psoriatic nails and is characterized by small, shallow dents or pits in the nail plate.
Onycholysis: This refers to the separation of the nail from the nail bed, causing the nail to become loose and potentially fall off.
Nail thickening: Psoriatic nails can become thick and abnormally shaped, which can make it difficult to perform daily activities that require the use of your hands.
Discoloration: People with psoriatic nails may notice a yellow-brown or white discoloration of their nails.
Nail plate deformities: This refers to abnormal growth patterns in the nail plate, such as spoon-shaped nails or nails with ridges or furrows.
Subungual hyperkeratosis: This is a thickening of the skin under the nail, which can cause pain and discomfort.
Splinter hemorrhages: These are small, red or brown lines that run vertically along the nail, resembling splinters.

The symptoms of psoriatic nails can vary from person to person, and not all people with psoriasis will develop nail changes. However, for those who do, the symptoms can be painful, unsightly, and interfere with daily activities.

Diagnosis

Diagnosing psoriatic nails can be challenging, as the symptoms can be similar to those of other nail conditions, such as fungal infections. However, there are several diagnostic lab tests that can help confirm a diagnosis of psoriatic nails.

Nail Clippings Test: One of the simplest tests for psoriatic nails is a nail clippings test. A small sample of the affected nail is collected and sent to a laboratory for analysis. The laboratory can examine the sample under a microscope to look for signs of psoriasis, such as thickening and discoloration of the nail plate, as well as the presence of any fungal infections.
KOH Preparation Test: A KOH (potassium hydroxide) preparation test is often used to identify fungal infections of the nails. In this test, a small sample of the affected nail is placed in a solution of KOH, which dissolves the keratin in the nail and makes it easier to examine under a microscope. The laboratory can then examine the sample for the presence of fungal hyphae, which are characteristic of fungal infections.
Nail Matrix Biopsy: A nail matrix biopsy is a more invasive test that involves removing a small piece of the nail matrix, the part of the nail that produces the nail plate. This test can provide a more accurate diagnosis of psoriatic nails, as it allows the laboratory to examine the underlying tissue for signs of inflammation and other characteristic features of psoriasis.
Blood Tests: Blood tests can be used to help diagnose psoriatic nails and rule out other conditions that may be causing similar symptoms. Common blood tests for psoriasis include the erythrocyte sedimentation rate (ESR) test and the C-reactive protein (CRP) test, which can help determine the level of inflammation in the body. Blood tests can also be used to measure the level of certain antibodies, such as anti-dsDNA and anti-Ro/SSA, which are often present in individuals with psoriasis.
Imaging Tests: Imaging tests, such as X-rays or MRI scans, can be used to help diagnose psoriatic nails and rule out other conditions that may be causing similar symptoms. For example, X-rays can be used to determine if there is any damage to the bones underneath the nails, while MRI scans can help identify any changes in the surrounding tissues, such as inflammation or fluid accumulation.
Skin Biopsy: In some cases, a skin biopsy may be necessary to confirm a diagnosis of psoriatic nails. A small sample of skin is taken from the affected area and sent to a laboratory for analysis. The laboratory can examine the sample for signs of psoriasis, such as thickened skin, inflammation, and the presence of psoriasis-specific antibodies.
Nail Scrapings: A scalpel or curette is used to gently scrape the affected nail and the debris is collected for analysis. This can help to identify any fungal, bacterial or yeast infections that may be causing the nail changes.
Wood’s Lamp Examination: A Wood’s lamp emits ultraviolet light and can help to distinguish between different types of nail diseases. In psoriatic nails, the affected nails may fluoresce yellow-green under the Wood’s lamp.
Culture: A culture is a laboratory test that can identify the specific type of fungus or bacteria that is causing an infection. A sample of the affected nail is placed in a culture medium, which provides the conditions necessary for the growth of microorganisms.
Blood Tests: Blood tests can be used to help diagnose psoriatic nails and other forms of psoriasis. These tests may include a complete blood count (CBC), erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) test, which can help to detect inflammation in the body. Additionally, a rheumatoid factor (RF) test may be performed to help differentiate between psoriasis and other inflammatory conditions.
HLA-B27 Test: The HLA-B27 test is a blood test that can help to identify individuals who have a genetic predisposition to develop psoriasis. People with psoriasis often have a positive HLA-B27 result.

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It is important to note that the diagnosis of psoriatic nails should be made by a healthcare provider based on a combination of clinical examination, laboratory tests, and the patient’s medical history. No single test can definitively diagnose psoriatic nails, and a combination of tests may be necessary to confirm the diagnosis.

Treatment

The treatment of psoriatic nails can be challenging, as the nails grow slowly and it can take a long time for the effects of treatment to become evident. However, with proper management, it is possible to improve the appearance and function of affected nails.

Here is a list of the main treatments for psoriatic nails:

Topical medications: Topical medications are applied directly to the nails and surrounding skin. They can be used to treat mild to moderate cases of psoriatic nails. The most commonly used topical medications include coal tar, salicylic acid, and corticosteroids.
Coal tar: Coal tar is a byproduct of the distillation of coal. It is a potent anti-inflammatory and keratolytic agent that can help to soften and remove thickened, scaly skin. It is applied to the nails and surrounding skin in the form of a cream, lotion, or ointment.
Salicylic acid: Salicylic acid is a type of beta-hydroxy acid that is commonly used to treat skin conditions such as psoriasis. It works by breaking down the intercellular cement that holds skin cells together, making it easier to remove thickened, scaly patches of skin. It is available in various forms, including creams, gels, and medicated shampoos.
Corticosteroids: Corticosteroids are potent anti-inflammatory drugs that can be used to reduce redness, swelling, and itching associated with psoriasis. They can be applied directly to the nails and surrounding skin in the form of creams, gels, or ointments. However, long-term use of high-potency corticosteroids can cause skin thinning and other side effects.
Systemic medications: Systemic medications are drugs that are taken orally or by injection and work throughout the body. They are used to treat moderate to severe cases of psoriatic nails, or in cases where topical treatments are not effective. The most commonly used systemic medications for psoriatic nails include methotrexate, cyclosporine, and biologic agents.
Methotrexate: Methotrexate is a disease-modifying antirheumatic drug (DMARD) that is commonly used to treat psoriasis. It works by suppressing the immune system, which can help to reduce inflammation and slow the progression of the disease. Methotrexate is taken orally and is typically given once a week.
Cyclosporine: Cyclosporine is an immunosuppressive drug that is used to treat a variety of autoimmune and inflammatory conditions, including psoriasis. It works by suppressing the immune system, which can help to reduce inflammation and slow the progression of the disease. Cyclosporine is taken orally and is typically given twice a day.
Biologic agents: Biologic agents are a newer class of drugs that are designed to target specific parts of the immune system. They are used to treat moderate to severe cases of psoriasis, and some are specifically approved for the treatment of psoriatic nails. Biologic agents include tumor necrosis factor (TNF) inhibitors, such as adalimumab, etanercept, and infliximab, and interleukin (IL) inhibitors, such as ustekinumab and secukinumab.

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More treatment options for psoriatic nails include:

Topical medications: Topical medications, such as corticosteroids, calcipotriene, and tazarotene, are applied directly to the affected nails. These medications can reduce inflammation, relieve itching, and improve nail appearance. Topical medications are generally well-tolerated, but they may not be effective in severe cases of psoriatic nails.
Systemic medications: Systemic medications, such as methotrexate, cyclosporine, and biologic agents, are taken orally or by injection. These medications can help to control the underlying inflammation associated with psoriasis and improve nail involvement. Systemic medications are typically used for severe cases of psoriatic nails and can have serious side effects, so they should be used under the supervision of a doctor.
Light therapy: Light therapy, also known as phototherapy, uses ultraviolet light to treat psoriasis. Light therapy can be effective in improving nail involvement, but it may take several months to see results.
Nail debridement: Nail debridement involves removing the damaged part of the nail to allow for new, healthy nail growth. This can be done with a scalpel, file, or chemical debrider. Nail debridement should be performed by a professional and can be uncomfortable, so a local anesthetic may be used.
Surgery: In severe cases of psoriatic nails, surgery may be necessary to remove the affected nail. This procedure is called a matrix ectomy and involves removing the matrix, the part of the nail that produces the nail plate. After the matrix is removed, the nail will not grow back.
Home care: In addition to medical treatments, there are several steps that can be taken at home to improve the appearance and function of affected nails. These include:

Keeping the nails clean and dry: Keeping the nails clean and dry can help to reduce the risk of infection and improve nail appearance.
Wearing gloves: Wearing gloves can help to protect the nails from trauma and reduce the risk of infection.
Moisturizing the nails: Moisturizing the nails can help to improve their appearance and prevent dryness and cracking.
Avoiding harsh chemicals: Avoiding harsh chemicals, such as nail polish remover, can help to prevent damage to the nails.

In conclusion, the treatment of psoriatic nails requires a multi-disciplinary approach that includes medical and home care treatments. The right combination of treatments will depend on the severity of the nail involvement and the overall health of the individual. With the right combination of treatments, it is possible to improve the appearance and function of affected nails and reduce the impact of psoriasis on daily life.

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