Nail Psoriasis: Small Signs, Big Impact

Describe nail psoriasis.

Psoriasis of the fingernails and toes causes pitting, discoloration, thickness, and detachment from the nail bed. It is autoimmune and is often associated with cutaneous psoriasis or psoriatic arthritis. Nail psoriasis is a skin condition that affects the nail matrix or the nail bed. Prevalence: 10–55% of psoriasis patients; up to 90% of persistent plaque patients may develop it. Association: Often associated with psoriatic arthritis and early joint involvement.

Clinical Features

• Nail pitting: Small nail depressions.
• Discoloration: Yellow-brown “oil spots.”
• Onycholysis removes nails from the nail bed.
• Under-nail thickening.
• Nails crumble in severe situations.
• Functional effects include pain, trouble with fine motor activities, and nail fragility.
• Mental: Nail alterations can induce humiliation, social disengagement, and lower quality of life.
• Medical: May suggest severe systemic psoriasis or psoriatic arthritis.

Management and Treatment

• Treatment options for nails may include topical corticosteroids, vitamin D analogues, or tazarotene.
• Systemic treatments: Methotrexate, cyclosporine, acitretin, or biologics (e.g., TNF-α or IL inhibitors) for severe or extensive disease.
• Intralesional steroid injections, phototherapy, and laser treatments are all possible treatments.

Supportive care: 

• Trim and clean nails.
• Manual-work gloves prevent trauma.
• Keep cuticles and nail folds moisturized.
• Avoid nail-biting and aggressive manicures.

Prognosis

• Chronic illness: Manageable symptoms, no cure.
• A variable course: Some people experience occasional nail alterations, while others suffer from severe nail degeneration.
• Early detection helps prevent complications and allows for monitoring of psoriatic arthritis.

In summary, nail psoriasis is an autoimmune condition that often coexists with skin psoriasis or psoriatic arthritis. It pits, thickens, and discolors nails, affecting function and self-esteem. Medical therapy and proper nail care can enhance outcomes for conditions that cannot be cured.

How does nail psoriasis look?

Nail psoriasis 

Psoriasis nails have pits, discoloration, thickness, and detachment from the nail bed. The appearance of nail psoriasis varies based on whether the nail matrix or the nail bed is affected.

• Its Difference from Fungal Infection
• Psoriasis: Pitting and oil stains on several nails.
• Fungal infection: One or two nails with yellowing, thickness, debris, and no pitting.
• Nail scrapings may be needed when both symptoms coexist.

Could it be anything else?

Several illnesses can induce nail changes that resemble psoriasis. While onychomycosis is the most prevalent cause, dermatological, systemic, and traumatic reasons can mimic nail psoriasis.

Differential nail psoriasis diagnoses

• Fungal nail infection: Onychomycosis. A yellow, swollen, crumbly nail with detritus under it. Fungal culture or microscopy confirms fewer nails.
• Trauma-related nail dystrophy: Uneven ridges, discolouration, onycholysis. Habitual trauma (tight shoes, nail biting, manicures)
• Nail eczema/dermatitis: Scratchy, brittle nails. Often nail-area itching and inflammation.
• Lichen planus Ripping, thinning, pterygium (scarring nail fold forward) Purple, itchy skin elsewhere; oral mucosal involvement
• Nail involvement—alopecia areata. Rough, sandpaper-like nails, fine pitting

Linked to patchy hair loss

• Yellow nail syndrome: Yellow, thick, slow-growing nails. Many have lymphedema and respiratory illness.
• Disorders of the thyroid and connective tissue: Nails with brittleness, ridges, or spoon form. Other systemic and lab abnormalities

Why the Difference Matters: 

• Common overlap: Nail psoriasis and fungal infection might coexist, complicating diagnosis.
• Different therapies: Antifungals and psoriasis treatments won't cure fungus.
• Dermatologists employ nail clippings, scrapings, or biopsies to diagnose.

How common is nail psoriasis?

• About 40–50% of psoriasis patients have nail psoriasis, and 80–90% of those with long-term illness or psoriatic arthritis. Only 1–10% of cases are isolated without skin involvement.

A Brief Prevalence

• In general, 40–50% of psoriasis individuals suffer nail abnormalities.
• Psoriatic arthritis patients: Nail involvement is significantly more common, 70–90%.
• Nail psoriasis without skin lesions: Rare, 1–10% of cases.
• Men may have slightly higher nail involvement rates than women, according to several research studies.

Why is it important

• Nail psoriasis can indicate psoriatic arthritis, making it a helpful clinical indication.
• Quality of life: Nail alterations can cause discomfort, functional difficulties, and social shame but are not life-threatening.
• Underdiagnosed: Nail psoriasis is sometimes misdiagnosed as fungal diseases, delaying treatment.

Step-by-Step Diagnostic Method: 

1. Clinical Exam

• Checking nails for hallmarks:
• Little depressions
• Yellow-brown oil-drop/salmon spots
• Onycholysis (bed nail lifting)
• Nail thickening from subungual hyperkeratosis
• Ripping or crumbling
• Pattern recognition: Multiple nails with skin or joint psoriasis.

2. Patient History

• Known psoriasis or arthritis in the family.
• Timeline of symptoms: Nail alterations can precede, coincide with, or follow skin/joint disorders.
• Triggers: Systemic sickness, trauma, or stress.

3. Other Conditions Excluded

• Fungal onychomycosis is the most prevalent mimic.
• Detect fungus with nail clippings, scrapings, or culture.
• Other imitators: Eczema, alopecia areata, trauma-related dystrophy.

4. Diagnostics

• Dermoscopy (onychoscopy): Non-invasive nail structure magnification helps identify psoriasis from fungus.
• Imaging: Research/complex cases may use ultrasound or MRI to examine nail bed inflammation and enthesitis (linked to psoriatic arthritis).
• Nail biopsy: Rare but can establish diagnosis if clinical symptoms are ambiguous.

5. Severity and monitoring scoring systems

• Based on matrix and bed involvement, NAPSI is widely used to classify nail psoriasis severity.
• mNAPSI has been simplified for clinical use.
• Psoriasis Nail Severity Score: Another proven tool.

Key Patient Points

• Nail psoriasis is a clinical diagnosis supported by exclusion of alternative causes, not lab tests.
• Since psoriasis and fungus can coexist, fungal testing is often necessary.
• Nail problems can indicate psoriatic arthritis; thus, early detection is crucial.

Helping nail psoriasis

Nail psoriasis can be treated with medication, nail care, and lifestyle changes. No treatment exists, but reducing inflammation, improving nail appearance, and preventing additional damage are the goals.

The video explains relief from nail psoriasis without drugs

Medical Treatments

• Apply corticosteroid creams, vitamin D analogs (calcipotriol), or tazarotene on nails or cuticles.
• Injections of corticosteroids into the nail matrix for severe localized illness.
• For severe or resistant cases, systemic drugs like methotrexate, cyclosporine, acitretin, or biologics (e.g., TNF-α, IL-17, IL-23 inhibitors) may be used.
• Phototherapy: PUVA (psoralen + UVA) or excimer laser may benefit some people.

Self-Care, Nail Protection

• Keep nails short and smooth to avoid damage and lifting.
• Keep cuticles and nail folds moist to prevent cracking and inflammation.
• Wear gloves for manual tasks and don't bite or pick nails.
• Gently grooming: Avoid forceful manicures, synthetic nails, and filing.
• Avoid irritants: Reduce detergent, solvent, and harsh chemical use.

Lifestyle & Prevention

• Manage triggers: Smoking, drinking, and stress aggravate psoriasis.
• Fungal infections can aggravate nail damage, so treat them quickly.
• Healthy habits: Balanced diet, exercise, and sleep boost immunity.
• Early signs of psoriatic arthritis include nail psoriasis, stiffness, edema, and discomfort.

Practical Patient Checklist

• File edges and trim nails frequently.
• Use heavy moisturizer or cuticle oil daily.
• Use cotton-lined gardening or cleaning gloves.
• Avoid fake nails and strong nail polish removers.
• If nails are painful, thick, or have joint symptoms, see a dermatologist.

Medical Treatment Options

Topicals for mild disease:

• Nail folds receive corticosteroid creams/ointments.
• Calcipotriol/tazarotene.
• Reduce thickening using salicylic acid or urea.
• Intralesional corticosteroids help alleviate nail matrix pitting and thickening, however they may hurt.
• Some cases may benefit from PUVA (psoralen + UVA) or pulsed dye laser phototherapy.
• Methotrexate, cyclosporine, and acitretin are among the systemic treatments available for severe or widespread illness or psoriatic arthritis.
• Biologics (TNF-α, IL-17, and IL-23 inhibitors) effectively treat nail psoriasis, particularly when skin or joint illness is present.

Self-Manage Nail Care

• Maintain short, smooth nails: Anti-lifting and trauma reduction.
• Daily moisturize cuticles and nail folds.
• Prevent nail trauma: Use gloves for cleaning, gardening, and manual labor.
• Avoid severe manicures, acrylics, and nail biting.
• Acetone-free nail polish removers are mild.
• Fungal infections can destroy nails, so treat them quickly.

Lifestyle & Prevention

• Manage triggers: Smoking, drinking, and stress aggravate psoriasis.
• Balanced diet, exercise, and sleep boost immunity.
• Psoriatic arthritis monitoring: Report joint stiffness, edema, or pain with nail psoriasis.

Severity-Based Treatment

• Few nails, cosmetic only/mild Nail care + topicals
• Multiple nails, functional impact: moderate Phototherapy or intralesional injections
• Serious (painful, debilitating, skin/joint illness) Methotrexate, biologics

General Prognosis

• Chronic course: Nail psoriasis can last for years, with flare-ups and improvements.
• Different severity: Some have mild pitting or discolouration, while others have swollen, uncomfortable, or disintegrating nails.
• Treatment response: Many patients see nail health improve with newer medicines, especially biologics.

Forecasting Factors

• Nail involvement: More nails impacted = harder to treat.
• Disease location: Matrix involvement (pitting, ridging) is tougher to treat than nail bed involvement (onycholysis, oil spots).

Related conditions:

• Psoriatic arthritis: Nail psoriasis is strongly connected; joint involvement may complicate development.
• Skin psoriasis severity: Nail illness typically coexists with severe skin disease.
• Fungus can aggravate nail changes and postpone improvement.

Impact on Life Quality

• Functional: Pain, fine motor skill issues, nail fragility.
• Mental: Nail alterations can cause humiliation, social disengagement, and low self-esteem.
• Medical: Nail psoriasis is a risk factor for psoriatic arthritis; therefore, monitor it.

Long-term outlook

• Non-life-threatening: Nail psoriasis isn't fatal.
• Manageable: Consistent topical, injectable, or systemic treatment can improve nails, although full normalisation is rare.
• Slow progress: Nail growth (fingernails ~6 months, toenails ~12-18 months) delays apparent effects.
• Stopping treatment typically causes relapse.

Also, read https://taylorandfrancis.com/knowledge/Medicine_and_healthcare/Dermatology/Nail_psoriasis/.

Conclusion

Nail psoriasis is persistent yet manageable. Modern medicines and protective nail care can improve symptoms, nail appearance, and quality of life, but a cure is improbable. Monitoring nail psoriasis is crucial, as it may indicate the presence of psoriatic arthritis.

Identifying nail abnormalities, ruling out fungal infections and other mimics, and occasionally using dermoscopy or biopsy helps to identify psoriatic nail disease. Scoring systems like NAPSI measure