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Nail Psoriasis

Updated : January 31, 2024





Background

Nail psoriasis is a type of psoriasis that affects the nails of the fingers and toes. It is a chronic skin condition characterized by thick, scaly patches on the skin, known as plaques. In people with nail psoriasis, the nails may become thickened, discolored, or distorted. They may also develop pits or grooves on the surface of the nail, brittle or crumbly nails, nail separation from the nail bed, and bleeding around the nails.

Nail psoriasis is often associated with other forms of psoriasis, such as plaque or scalp psoriasis. Nail psoriasis is caused by psoriatic involvement of the nail matrix or nail bed. Involvement of the nails is a visible sign of upcoming joint inflammatory injury and disease activity. Depending on the area of the nail units affected, nail psoriasis can present clinically as a range of nail alterations, including nail discoloration, pitting, subungual hyperkeratosis, and onycholysis.

 

Epidemiology

It is challenging to determine the exact global prevalence of nail psoriasis, as studies on the prevalence of the condition have often been small and conducted in specific populations or regions. However, it is estimated that nail psoriasis affects about 10-50% of individuals with psoriasis. Both children and adults are affected by nail psoriasis.

It affects both sexes equally and becomes more prevalent as individuals age. With incidence rates of 10% to 55% respectively, cutaneous psoriasis is the most common condition in which nail psoriasis develops. Psoriasis of the nails might emerge as a sole symptom. When a patient has cutaneous psoriasis, their nails may get involved at the same time as or later than the development of cutaneous symptoms.

 

Anatomy

Pathophysiology

Nail psoriasis is a condition in which the nails are affected by psoriasis, which causes the skin to produce new skin cells at an accelerated rate. In nail psoriasis, the nails are also affected, becoming thickened and distorted, and may develop pits or grooves on the surface. Nail psoriasis is thought to occur when inflammation and excess skin cell production affect the nails.

In severe cases, the nails may become detached from the nail bed, and the nail plate may become brittle and prone to breaking. The nail matrix is the area of the nail responsible for producing new nail cells, which becomes inflamed and produces abnormal nail cells. The nail bed, which is located just under the nail plate, is essential for the nail plate’s attachment to the nail bed.

These abnormal cells may change the appearance and structure of the nails, such as thickening, discoloration, and pitting. The inflammation associated with nail psoriasis may also cause damage to the nail bed, leading to the separation of the nail from the nail bed (onycholysis). The presence of inflammation also leads to the accumulation of debris under the nails and changes in the shape of the nails.

 

Etiology

The exact cause of nail psoriasis is not fully understood, but it is thought to be related to an immune system malfunction. A combination of genetic, environmental, and hormonal factors may contribute to the development of the condition. People with a family history of psoriasis or other autoimmune conditions are more likely to develop nail psoriasis.

Several factors may contribute to the development of nail psoriasis:

  • Genetics: Nail psoriasis tends to run in families, suggesting that there may be a genetic component to the condition.
  • Environmental factors: Exposure to specific environmental triggers, such as infections, trauma, or stress, may trigger the onset of nail psoriasis or worsen existing symptoms.
  • Co-morbidities: People with certain medical conditions, such as psoriatic arthritis or Crohn’s disease, are more likely to develop nail psoriasis.
  • Medications: Some medications, such as lithium and beta blockers, may increase the risk of developing nail psoriasis.

 

Genetics

Prognostic Factors

The outcome of nail psoriasis can vary depending on the severity of the condition and the effectiveness of treatment. In mild cases, treatment can help improve the nails’ appearance and reduce the risk of further damage. In more severe cases, the nails may not fully return to their normal appearance, and there may be ongoing issues with nail growth and function.

It is essential to seek treatment for nail psoriasis as soon as possible, as untreated or poorly controlled nail psoriasis can lead to more significant problems, including difficulty with writing or typing. In severe cases, it can also lead to a decreased quality of life due to the appearance of the nails.

 

Clinical History

Nail psoriasis is a condition that is often associated with other forms of psoriasis, such as cutaneous psoriasis and psoriatic arthritis. It can present with various symptoms, including pitting, it is a common and characteristic finding in nail psoriasis and is characterized by small, shallow, evenly sized, and shaped indentations on the nail’s surface. These pits may be scattered randomly or arranged in a pattern on the nail. They are caused by small areas of psoriasis in the matrix that result in the production of excess keratin, which then breaks off and leaves these indentations when the nail grows out.

Nail psoriasis can cause a various change to the nails, including red spots in the lunula (the crescent-shaped area at the base of the nail), red or mottled lunulae, destruction of the nail, leukonychia (white lines or spots on the nails), splinter hemorrhages, salmon or oil spots, and swelling and rounding of the nail fold. These changes may be caused by various factors, such as dilated blood vessels in the matrix, the incorporation of excess keratin into the nail, bleeding under the nail, and inflammation of the skin surrounding the nail. These symptoms can occur individually or in combination and may affect one or multiple fingers or toes.

Nail psoriasis is often associated with other psoriasis, such as cutaneous psoriasis and psoriatic arthritis. A complete medical history, including any history of skin lesions and joint-related symptoms, is required to evaluate nail psoriasis. In particular, the presence of swelling and pain in the joints, especially the distal interphalangeal joints, may suggest the presence of psoriatic arthritis. However, the presentation of nail psoriasis alone, without any other signs or symptoms of the skin or joint involvement, can be challenging to diagnose.

Physical Examination

Physical Examination

Thorough examination of the skin, including the scalp and genital area, in order to determine the extent and severity of nail psoriasis. This examination should evaluate signs of psoriatic arthritis, such as joint swelling and tenderness, particularly in the distal interphalangeal joints of the hands and feet and swelling of the digits.

In patients with nail psoriasis, it is also common to find evidence of psoriatic arthritis. It is often necessary to rule out a fungal nail infection as a possible cause of nail changes that could be mistaken for nail psoriasis. Dermatoscopy and videodermatoscopy can be helpful in examining the nails and making a diagnosis of nail psoriasis.

Age group

Associated comorbidity

Associated activity

Acuity of presentation

Differential Diagnoses

Differential Diagnosis

Onychomycosis

Pityriasis Rubra pilaris

Lichen planus

Alopecia areata

Laboratory Studies

Imaging Studies

Procedures

Histologic Findings

Staging

Treatment Paradigm

Management

Topical treatment: Topical treatments, such as creams or ointments, can be applied directly to the nails to help reduce inflammation and improve the appearance of the nails. Topical corticosteroids and topical vitamin D analogs are first-line while topical tacrolimus, tazarotene and calcipotriol are the second-line therapy.

Biologic therapy: A biologic agent is an effective first-line treatment to treat moderate to severe psoriasis of the nail. The common biological agents use to treat nail psoriasis are Eternacept, Adalimumab, infliximab, ustekinumab (inhibitor of p40 subunit of IL-12/23), and secukinumab, ixekizumab (a monoclonal antibody inhibiting the IL-17A ligand).

Oral therapy: Oral medications are used to treat nail psoriasis when topical treatments are ineffective or when the condition is severe. Medications such as methotrexate, cyclosporine and apremilast are immunosuppressive medications that can help reduce inflammation and improve the appearance of nails affected by psoriasis. It is often used for severe cases of nail psoriasis that do not respond to other treatments and may be prescribed to help control the underlying cause of nail psoriasis. These medications can be effective but can also have significant side effects.

Light therapy: Phototherapy, also known as light therapy, can help improve the appearance of nails affected by psoriasis. This treatment involves exposing the nails to specific wavelengths of light, which can help reduce inflammation and promote healing.

 

by Stage

by Modality

Chemotherapy

Radiation Therapy

Surgical Interventions

Hormone Therapy

Immunotherapy

Hyperthermia

Photodynamic Therapy

Stem Cell Transplant

Targeted Therapy

Palliative Care

Medication

Media Gallary

References

https://www.ncbi.nlm.nih.gov/books/NBK559260/

Nail Psoriasis

Updated : January 31, 2024




Nail psoriasis is a type of psoriasis that affects the nails of the fingers and toes. It is a chronic skin condition characterized by thick, scaly patches on the skin, known as plaques. In people with nail psoriasis, the nails may become thickened, discolored, or distorted. They may also develop pits or grooves on the surface of the nail, brittle or crumbly nails, nail separation from the nail bed, and bleeding around the nails.

Nail psoriasis is often associated with other forms of psoriasis, such as plaque or scalp psoriasis. Nail psoriasis is caused by psoriatic involvement of the nail matrix or nail bed. Involvement of the nails is a visible sign of upcoming joint inflammatory injury and disease activity. Depending on the area of the nail units affected, nail psoriasis can present clinically as a range of nail alterations, including nail discoloration, pitting, subungual hyperkeratosis, and onycholysis.

 

It is challenging to determine the exact global prevalence of nail psoriasis, as studies on the prevalence of the condition have often been small and conducted in specific populations or regions. However, it is estimated that nail psoriasis affects about 10-50% of individuals with psoriasis. Both children and adults are affected by nail psoriasis.

It affects both sexes equally and becomes more prevalent as individuals age. With incidence rates of 10% to 55% respectively, cutaneous psoriasis is the most common condition in which nail psoriasis develops. Psoriasis of the nails might emerge as a sole symptom. When a patient has cutaneous psoriasis, their nails may get involved at the same time as or later than the development of cutaneous symptoms.

 

Nail psoriasis is a condition in which the nails are affected by psoriasis, which causes the skin to produce new skin cells at an accelerated rate. In nail psoriasis, the nails are also affected, becoming thickened and distorted, and may develop pits or grooves on the surface. Nail psoriasis is thought to occur when inflammation and excess skin cell production affect the nails.

In severe cases, the nails may become detached from the nail bed, and the nail plate may become brittle and prone to breaking. The nail matrix is the area of the nail responsible for producing new nail cells, which becomes inflamed and produces abnormal nail cells. The nail bed, which is located just under the nail plate, is essential for the nail plate’s attachment to the nail bed.

These abnormal cells may change the appearance and structure of the nails, such as thickening, discoloration, and pitting. The inflammation associated with nail psoriasis may also cause damage to the nail bed, leading to the separation of the nail from the nail bed (onycholysis). The presence of inflammation also leads to the accumulation of debris under the nails and changes in the shape of the nails.

 

The exact cause of nail psoriasis is not fully understood, but it is thought to be related to an immune system malfunction. A combination of genetic, environmental, and hormonal factors may contribute to the development of the condition. People with a family history of psoriasis or other autoimmune conditions are more likely to develop nail psoriasis.

Several factors may contribute to the development of nail psoriasis:

  • Genetics: Nail psoriasis tends to run in families, suggesting that there may be a genetic component to the condition.
  • Environmental factors: Exposure to specific environmental triggers, such as infections, trauma, or stress, may trigger the onset of nail psoriasis or worsen existing symptoms.
  • Co-morbidities: People with certain medical conditions, such as psoriatic arthritis or Crohn’s disease, are more likely to develop nail psoriasis.
  • Medications: Some medications, such as lithium and beta blockers, may increase the risk of developing nail psoriasis.

 

The outcome of nail psoriasis can vary depending on the severity of the condition and the effectiveness of treatment. In mild cases, treatment can help improve the nails’ appearance and reduce the risk of further damage. In more severe cases, the nails may not fully return to their normal appearance, and there may be ongoing issues with nail growth and function.

It is essential to seek treatment for nail psoriasis as soon as possible, as untreated or poorly controlled nail psoriasis can lead to more significant problems, including difficulty with writing or typing. In severe cases, it can also lead to a decreased quality of life due to the appearance of the nails.

 

Nail psoriasis is a condition that is often associated with other forms of psoriasis, such as cutaneous psoriasis and psoriatic arthritis. It can present with various symptoms, including pitting, it is a common and characteristic finding in nail psoriasis and is characterized by small, shallow, evenly sized, and shaped indentations on the nail’s surface. These pits may be scattered randomly or arranged in a pattern on the nail. They are caused by small areas of psoriasis in the matrix that result in the production of excess keratin, which then breaks off and leaves these indentations when the nail grows out.

Nail psoriasis can cause a various change to the nails, including red spots in the lunula (the crescent-shaped area at the base of the nail), red or mottled lunulae, destruction of the nail, leukonychia (white lines or spots on the nails), splinter hemorrhages, salmon or oil spots, and swelling and rounding of the nail fold. These changes may be caused by various factors, such as dilated blood vessels in the matrix, the incorporation of excess keratin into the nail, bleeding under the nail, and inflammation of the skin surrounding the nail. These symptoms can occur individually or in combination and may affect one or multiple fingers or toes.

Nail psoriasis is often associated with other psoriasis, such as cutaneous psoriasis and psoriatic arthritis. A complete medical history, including any history of skin lesions and joint-related symptoms, is required to evaluate nail psoriasis. In particular, the presence of swelling and pain in the joints, especially the distal interphalangeal joints, may suggest the presence of psoriatic arthritis. However, the presentation of nail psoriasis alone, without any other signs or symptoms of the skin or joint involvement, can be challenging to diagnose.

Physical Examination

Thorough examination of the skin, including the scalp and genital area, in order to determine the extent and severity of nail psoriasis. This examination should evaluate signs of psoriatic arthritis, such as joint swelling and tenderness, particularly in the distal interphalangeal joints of the hands and feet and swelling of the digits.

In patients with nail psoriasis, it is also common to find evidence of psoriatic arthritis. It is often necessary to rule out a fungal nail infection as a possible cause of nail changes that could be mistaken for nail psoriasis. Dermatoscopy and videodermatoscopy can be helpful in examining the nails and making a diagnosis of nail psoriasis.

Differential Diagnosis

Onychomycosis

Pityriasis Rubra pilaris

Lichen planus

Alopecia areata

Management

Topical treatment: Topical treatments, such as creams or ointments, can be applied directly to the nails to help reduce inflammation and improve the appearance of the nails. Topical corticosteroids and topical vitamin D analogs are first-line while topical tacrolimus, tazarotene and calcipotriol are the second-line therapy.

Biologic therapy: A biologic agent is an effective first-line treatment to treat moderate to severe psoriasis of the nail. The common biological agents use to treat nail psoriasis are Eternacept, Adalimumab, infliximab, ustekinumab (inhibitor of p40 subunit of IL-12/23), and secukinumab, ixekizumab (a monoclonal antibody inhibiting the IL-17A ligand).

Oral therapy: Oral medications are used to treat nail psoriasis when topical treatments are ineffective or when the condition is severe. Medications such as methotrexate, cyclosporine and apremilast are immunosuppressive medications that can help reduce inflammation and improve the appearance of nails affected by psoriasis. It is often used for severe cases of nail psoriasis that do not respond to other treatments and may be prescribed to help control the underlying cause of nail psoriasis. These medications can be effective but can also have significant side effects.

Light therapy: Phototherapy, also known as light therapy, can help improve the appearance of nails affected by psoriasis. This treatment involves exposing the nails to specific wavelengths of light, which can help reduce inflammation and promote healing.

 

https://www.ncbi.nlm.nih.gov/books/NBK559260/