According to reports, 7.4 million people have psoriasis in the United States. Psoriasis leads to the excess production of skin cells, which end up forming scaly red or white patches, blisters, and sores. In general, psoriasis affects the arms, legs, chest, trunk, and nails. However, keep in mind that this condition can appear on any part of the body.
One particular aspect of this disease is nail psoriasis.
Researchers found that 35% of patients with psoriasis have their nails involved. The number goes even higher for people with psoriatic arthritis, reaching up to 80%.
In this article, we will cover the causes, signs and symptoms, and treatments of nail psoriasis.
What causes nail psoriasis?
Nail psoriasis results from the same autoimmune mechanisms that trigger skin psoriasis. During psoriasis flareup, the immune system will consider the normal tissues of your nail to be harmful and launch an immune response. As a result of the active inflammation, the nails accelerate the process of keratinocyte reproduction, leading to the classic signs and symptoms of psoriasis.
One of the signs will be the development of characteristic plaques in the fingernails and toenails, making the nails look thick, deformed, and discolored.
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What are the signs and symptoms of nail psoriasis?
Nail psoriasis has a diverse clinical presentation that includes the following signs and symptoms:
Pitting The nail plate has a hard surface made of keratin cells.As a result of nail psoriasis, the plate develops small pits that range in number and depth from one individual to another.
Nail bed separation The nail sits on what is known as the nail bed. The separation of the nail (i.e., onycholysis) leaves an empty space under it. Patients with nail psoriasis usually notice a yellow patch at the tip of the nail that gradually moves all the way to the cuticle. Unfortunately, bacteria can easily grow between the space left by the nail, which leads to a dark coloration of the nail.
Changes in nail shape Besides pitting, many people notice some changes in the texture of their nails. For instance, Beau’s lines are common in nail psoriasis spreading across your nails. Additionally, the negative impact on the structural integrity of your nails can lead to their crumbling. When a fungal infection develops under the nail (i.e., onychomycosis), the whole structure becomes thick.
Changes in nail color Nail psoriasis also leads to color change, manifesting as a yellow-red patch in the nail bed.
Due to the similarity between this condition and the appearance of a drop of oil under the nail, researchers call it the oil-drop spot.
The treatment options for nail psoriasis
The treatment of nail psoriasis is generally challenging due to the development of patches during the growth of the nails.
The therapeutic options may consist of:
Topical medications The most commonly prescribed class of medications is the corticosteroid family, which you can find in the following forms:
• Nail polishes
Your doctor will instruct the application of these products once or twice a day.
In case you experience thickening, ridges, or the separation of nails, your doctor may recommend corticosteroids injections. Besides corticosteroids, drugs such as calcipotriol and calcipotriene may be used. These medications are a synthetic form of vitamin D that helps reduce the inflammation and the rate of epidermal regeneration. Experts also noted the effectiveness of using topical retinoids (e.g., Tazorac) in improving nail discoloration, pitting, and separation. Finally, anthralin is another anti-inflammatory ointment used to slow down the growth of skin cells. This drug improves symptoms of nail thickening and onycholysis.
Note that moisturizers may help relieve the itching and redness associated with nail psoriasis; however, they do not treat this condition.
Oral medication When topical treatments fail, your doctor may opt for systemic drugs, such as cyclosporine, methotrexate, and retinoids to manage nail psoriasis. These drugs will regulate the immune response throughout the body, which will clear skin and nail psoriasis. Note that the prescription of these drugs is mainly indicated for moderate to severe psoriasis. Mild cases do not require systemic treatments.
New drugs Over the past few years, researchers developed a new class of medication known as biological drugs, which target specific functions of the immune system and inflammatory response. For instance, drugs such as adalimumab (Humira), etanercept (Enbrel), and infliximab (Remicade) will dampen the activity of the immune system, which relieves symptoms of psoriasis. The administration of these drugs is usually by infusion or injection. Your doctor will not opt for biological drugs unless you don’t respond to other treatments of psoriasis. The primary reason for this is the high cost of these drugs and their unavailability.
Phototherapy During phototherapy sessions, your doctor will expose the affected skin to ultraviolet (UV) light, which slows down the growth of skin cells. For psoriasis, experts refer to this treatment as PUVA or photochemotherapy. The chemo part refers to soaking your hands or taking a drug known as psoralen; after that, your skin/nails get exposed to UVA light, which helps with nail separation and discoloration.
Laser treatment Laser therapy may yield some positive results for patients with nail psoriasis. The purpose of this treatment is to target the blood vessels under the skin with a beam of light that reduces the severity of skin growth and inflammation.
The prevention of nail psoriasis flareups
As you may already know, psoriasis is an autoimmune disease with poorly understood mechanisms. Therefore, we still don’t know how to prevent this disease altogether.
With that said, there are a few steps that you can take to reduce the risk of flareups, including:
• Keeping your nails short and avoiding injuries to your nail beds. Trimming your nails will prevent the buildup to occur underneath them.
• Make sure to wear protective gloves when your hands and nails are exposed to harsh environments. This includes activities such as gardening, playing sports, and washing the dishes.
• Avoid biting your nails, as these injuries can trigger psoriasis flareups – the Koebner phenomenon.
• Use a moisturizing cream on your nails to prevent the appearance of cracked or brittle nails.
• Clean your nails regularly to avoid bacterial or fungal infections.
• Avoid using a nail brush or any other sharp object to clean your nails, as this could precipitate their separation.
Nail psoriasis is a very common condition that affects millions of people. The psychological toll of nail deformation can be quite substantial, particularly in susceptible individuals. For this reason, we need to focus more on nail psoriasis treatment. Hopefully, this article highlighted one of the classic subtypes of psoriasis and how to treat it effectively.
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Written by Zac Hyde M.D.