Symptoms — Nail Changes

Approximately 87% of patients with psoriatic arthritis experience symptoms of nail psoriasis, also called nail dystrophy. Nail psoriasis is common in patients with psoriasis and even more frequent in patients with psoriatic arthritis. Rarely, about 5-10% of the time, patients only have psoriasis in the nails. It is more common for patients who first experience nail psoriasis to later develop psoriasis of the skin and/or psoriatic arthritis. In addition, patients with psoriasis that also have nail psoriasis have a greater likelihood of developing psoriatic arthritis.
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Characteristics of nail psoriasis

Nail psoriasis affects the physical appearance of the nails, as well as the underlying structure and function of the nails. Psoriasis can affect any of the structures within the nail matrix and the nail bed.

When psoriasis affects the nail-forming unit, known as the nail matrix, it can cause the following symptoms:

  • Pitting, small depressions on the nail
  • Psoriatic leukonychia, appearing as white spots in the nail
  • Red spots in the lunula, the crescent shape at the base of the nail
  • Beau’s lines, transverse or horizontal grooves
  • Crumbling, which represents a merging of pitting due to a longer duration of nail psoriasis4

Psoriasis of the nail bed presents as:

  • Oil drop or salmon patch discoloration, so named because it resembles a drop of oil or is reddish like a salmon
  • Splinter hemorrhages, small areas of bleeding that run in the direction of nail growth
  • Nail bed hyperkeratosis, a thickened layer
  • Onycholysis, detachment of the nail from the nail bed4

In addition, nail psoriasis can cause:

  • Pain
  • Inability to grasp small objects, tie shoe laces or button clothes
  • Altered sense of fine touch

Nail psoriasis is highly visible and can have a substantial impact on the person’s quality of life and psychological health.1,3

How is nail psoriasis diagnosed?

Nail psoriasis is visually apparent and can be diagnosed during a physical examination. Occasionally, a small sample of the nail tissue is collected for microscopic examination.4

How is nail psoriasis treated?

Nail psoriasis can be effectively treated with the anti-tumor necrosis factor-alpha treatments, such as Cimzia (certolizumab pegol), Enbrel (etanercept), Humira (adalimumab), Remicade (infliximab) and Simponi (golimumab). The FDA has also recently approved Inflectra (infliximab-dyyb), a biosimilar to infliximab, for the treatment of psoriatic arthritis.5 The anti-interleukin (IL)-17 and anti-IL 12/23 antibodies, including Stelara (ustekinumab) and Cosentyx (secukinumab), have also proven to be effective in treating nail psoriasis. Other conventional systemic treatments that are effective in treating nail psoriasis are methotrexate, cyclosporine, acitretin, and apremilast.1,4

For mild cases of nail psoriasis, topical treatments may be effective. Topical treatments include corticosteroids, calcipotriol, tacrolimus, and tazarotene. Light therapy may also be helpful when only a few nails are affected.1,4

Patient education is also critical for nail psoriasis, as patients are advised to avoid activities that can cause minor repetitive trauma to the fingertips or nails, which is known to exacerbate the nail psoriasis. Keeping affected nails short, especially when typing or playing piano, can also help, and wearing gloves while gardening or doing household chores is recommended. Excessive nail grooming should be avoided.1

Written by: Emily Downward | Last reviewed: October 2016.
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