How does nail psoriasis affect daily life. What are the common symptoms of nail psoriasis. Which treatments are most effective for managing nail psoriasis. How is palmoplantar psoriasis different from nail psoriasis. What self-care techniques can help improve nail psoriasis.

Understanding Nail Psoriasis: Prevalence and Impact

Nail psoriasis is a common manifestation of psoriatic disease that affects a significant portion of individuals with psoriasis. An estimated 90% of people with psoriasis will experience nail involvement at some point in their lives. This condition can have a profound impact on a person’s quality of life, affecting both fingernails and toenails, with fingernails being more commonly affected.

The prevalence of nail psoriasis increases in individuals with psoriatic arthritis (PsA), with up to 80% of PsA patients experiencing nail changes. Understanding the prevalence and impact of nail psoriasis is crucial for proper diagnosis and management of the condition.

Is nail psoriasis an indicator of psoriatic arthritis?

Nail psoriasis can indeed be an indicator of psoriatic arthritis. Many individuals experience both nail psoriasis and PsA concurrently. If you notice changes in your nails and suspect nail psoriasis, it’s essential to consult a dermatologist for diagnosis and a rheumatologist to screen for PsA. Early detection and treatment of both conditions can lead to better outcomes and improved quality of life.

Common Symptoms and Manifestations of Nail Psoriasis

Nail psoriasis typically affects multiple digits, including both fingers and toes. The most common nail problems associated with this condition include:

• Pitting: shallow or deep holes in the nail
• Deformation: alterations in the normal shape of the nail
• Thickening of the nail
• Onycholysis: separation of the nail from the nail bed
• Discoloration: unusual nail coloration, often yellow-brown

These changes can occur on the nail plate, in the nail bed, or in the nail matrix. The location of the affected area can influence the most effective treatment options.

How does nail psoriasis differ from fungal nail infections?

While nail psoriasis and fungal nail infections may share some similar symptoms, there are key differences. Nail psoriasis is an autoimmune condition that often affects multiple nails simultaneously and is frequently accompanied by skin psoriasis or joint pain. Fungal infections typically start on one nail and spread gradually. A dermatologist can perform tests to differentiate between the two conditions and provide appropriate treatment.

Palmoplantar Psoriasis: A Closer Look at Hands and Feet

Palmoplantar psoriasis is a specific form of psoriasis that affects the palms of the hands and soles of the feet. This condition can significantly impact a person’s quality of life due to its location and symptoms. Common manifestations of palmoplantar psoriasis include:

• Red or discolored skin
• Dry and thickened skin
• Deep fissures (cracks) on the soles of the feet

The pain and discomfort associated with palmoplantar psoriasis can limit mobility and interfere with daily tasks and work activities. This form of psoriasis requires specialized treatment approaches to manage symptoms effectively.

Can palmoplantar psoriasis coexist with nail psoriasis?

Yes, palmoplantar psoriasis and nail psoriasis can coexist in some individuals. Both conditions are manifestations of psoriatic disease and can occur simultaneously or independently. The presence of both conditions may require a comprehensive treatment approach that addresses symptoms on the hands, feet, and nails concurrently.

Treatment Options for Nail Psoriasis and Palmoplantar Psoriasis

Managing nail psoriasis and palmoplantar psoriasis often requires a multifaceted approach. Treatment options may include:

1. Topical treatments: These are commonly used for both nail and palmoplantar psoriasis. Application techniques may vary depending on the affected area.
2. Phototherapy: Specialized light therapy units designed for hands and feet can be effective for palmoplantar psoriasis.
3. Intralesional steroids: Injections into affected nails may be used for nail psoriasis.
4. Oral treatments: Systemic medications may be prescribed for severe cases or when other treatments are ineffective.
5. Biologic treatments: These targeted therapies can be beneficial for both nail and palmoplantar psoriasis, especially in severe cases.

The choice of treatment depends on the severity of the condition, the affected areas, and the individual’s response to previous treatments. A dermatologist or rheumatologist can help develop a personalized treatment plan.

Are there any natural remedies for nail psoriasis?

While medical treatments are essential for managing nail psoriasis, some natural remedies may provide additional relief. These include keeping nails moisturized, using tea tree oil for its antifungal properties, and taking omega-3 fatty acid supplements. However, it’s crucial to consult with a healthcare provider before incorporating any natural remedies into your treatment regimen, as they should not replace prescribed medications.

The Importance of Proper Nail Care in Psoriasis Management

Proper nail care is crucial for individuals with nail psoriasis. Here are some essential tips for maintaining healthy nails:

• Keep nails as short as possible to prevent injury and further damage
• Protect nails from trauma by wearing gloves during manual tasks
• Avoid aggressive cleaning under lifting nails, which can worsen the condition
• Be gentle when treating affected nails and avoid clipping or pushing back cuticles
• Moisturize nails and surrounding skin regularly to reduce dryness and cracking

By incorporating these nail care practices into daily routines, individuals with nail psoriasis can help minimize symptoms and prevent exacerbations of the condition.

How often should nails be trimmed in cases of nail psoriasis?

The frequency of nail trimming for individuals with nail psoriasis depends on the severity of the condition and the rate of nail growth. Generally, it’s recommended to trim nails every 1-2 weeks or as needed to keep them short and prevent snagging or further damage. Always use clean, sharp nail clippers and file rough edges gently to avoid causing additional trauma to the nails.

The Connection Between Nail Psoriasis and Psoriatic Arthritis

Nail psoriasis and psoriatic arthritis (PsA) are closely linked, with nail involvement often serving as an early indicator of PsA. Understanding this connection is crucial for early diagnosis and treatment of both conditions. Key points to consider include:

• Up to 80% of individuals with PsA experience nail changes
• Nail psoriasis can precede joint symptoms in some cases
• The presence of nail psoriasis may increase the risk of developing PsA
• Both conditions can significantly impact quality of life and require comprehensive management

Regular monitoring of nail changes and joint symptoms is essential for individuals with psoriasis to ensure timely diagnosis and treatment of PsA if it develops.

What are the early signs of psoriatic arthritis in individuals with nail psoriasis?

Early signs of psoriatic arthritis in individuals with nail psoriasis may include joint pain, stiffness, and swelling, particularly in the fingers and toes. Morning stiffness lasting more than 30 minutes, fatigue, and changes in nail appearance (such as separation from the nail bed) can also be indicators. If you experience these symptoms, consult a rheumatologist for a thorough evaluation and appropriate management.

Psychological Impact of Nail and Palmoplantar Psoriasis

The visible nature of nail and palmoplantar psoriasis can have significant psychological effects on individuals living with these conditions. Common psychological impacts include:

• Decreased self-esteem and confidence
• Social anxiety and avoidance of social situations
• Depression and feelings of isolation
• Frustration with the chronic nature of the condition
• Stress related to managing symptoms and treatment regimens

Addressing the psychological aspects of nail and palmoplantar psoriasis is crucial for comprehensive care. Mental health support, such as counseling or support groups, can be beneficial in managing the emotional impact of these conditions.

How can individuals cope with the emotional challenges of visible psoriasis?

Coping with the emotional challenges of visible psoriasis involves several strategies. These include educating oneself about the condition, joining support groups to connect with others facing similar challenges, practicing stress-reduction techniques like meditation or yoga, and seeking professional mental health support when needed. Additionally, focusing on self-care and maintaining a positive attitude can help individuals build resilience and improve their overall well-being while managing their condition.

Nail and palmoplantar psoriasis are complex conditions that require comprehensive management and care. By understanding the symptoms, treatment options, and associated impacts, individuals can work with healthcare providers to develop effective strategies for managing these conditions and improving their quality of life. Regular monitoring, proper nail care, and attention to both physical and emotional well-being are key components of successful psoriasis management.

Nail Psoriasis, Hands and Feet : National Psoriasis Foundation

This is called palmoplantar psoriasis.

(Merola et al., 2016)

Hands and Feet (Palmoplantar)

Symptoms include red/discolored, dry, and thickened skin, as well as deep fissures (cracks) on the soles of the feet. Psoriasis on the hands and feet can significantly impact your quality of life because of the way the disease may impair the use of the hands and feet. The pain from palmoplantar psoriasis may limit mobility and keep you from working or doing daily tasks.

Treatments

Topicals are a common treatment for psoriasis on the hands and feet. Follow your health care provider’s instructions for applying topical treatments. Since the skin on the hands and feet can be delicate, you should carefully apply treatment to your hands and feet.

Phototherapy is another treatment option. There are special light therapy units specifically designed for the hands and feet.

Oral treatments and biologic treatments are also options, especially if your psoriasis is severe or you are not responding well to other treatments.

An estimated 90 percent of people with psoriasis will experience nail psoriasis at some point.

(Betteridge et al., 2016, and Jiaravuthisan et al., 2007)

Nails

Nail psoriasis normally affects several digits (fingers and toes) and is more common on the fingernails than the toenails. Pain and tenderness from nail psoriasis can impact daily activities.

Nail psoriasis may be an indicator of psoriatic arthritis (PsA), as many people have both. If you notice changes in your nails and suspect it might be nail psoriasis, visit a dermatologist to diagnose nail psoriasis and see a rheumatologist to screen for PsA.

The most common nail problems are:

• Pitting — shallow or deep holes in the nail
• Deformation — alterations in the normal shape of the nail
• Thickening of the nail
• Onycholysis — separation of the nail from the nail bed
• Discoloration — unusual nail coloration, such as yellow-brown

Nail changes may occur on the nail plate or in the nail bed or nail matrix. Where the nail is affected can determine which treatment may be most effective. Your health care provider will discuss your treatment options which may include topicals, intralesional steroids (an injection into each affected nail), phototherapy, oral treatments, or biologics.

When Psoriatic Disease Strikes the Hands and Feet

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Nail Psoriasis: Symptoms, Treatments, and More

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Nail Care

Keep nails as short as possible. Loose nails can continue to be injured if they rub against surfaces. It is important to protect your nails from damage because trauma will often trigger or worsen nail psoriasis. One easy way to do this is to wear gloves while working with your hands. Care should be taken to treat the affected nails gently and cuticles should not be clipped or pushed back. If a nail is lifting, avoid overly aggressive cleaning under the nail tip, which can make lifting worse.

Nail Psoriasis Fact Sheet

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Betteridge, N., Boehncke, W. H., Bundy, C., Gossec, L., Gratacos, J., & Augustin, M. (2016). Promoting patient-centred care in psoriatic arthritis: a multidisciplinary European perspective on improving the patient experience. J Eur Acad Dermatol Venereol, 30(4), 576-585. doi:10.1111/jdv.13306

Jiaravuthisan, M. M., Sasseville, D., Vender, R. B., Murphy, F., & Muhn, C. Y. (2007). Psoriasis of the nail: anatomy, pathology, clinical presentation, and a review of the literature on therapy. J Am Acad Dermatol, 57(1), 1-27. doi:10.1016/j.jaad.2005.07.073

Merola, J. F., Li, T., Li, W. Q., Cho, E., & Qureshi, A. A. (2016). Prevalence of psoriasis phenotypes among men and women in the USA. Clin Exp Dermatol, 41(5), 486-489. doi:10.1111/ced.12805

Last updated on 12/22/2022 by the National Psoriasis Foundation.

Psoriasis in the fingernails and toenails

Psoriasis can affect both fingernails and toenails, with half of those with psoriasis alone having some form of nail involvement. The risk increases in those with psoriatic arthritis, and it is reported that this could be as high as 4 out of 5 people seeing changes to their nails. For some unknown reason fingernails are more often involved than toenails. For many people, nail psoriasis is often mild and causes few problems.

The nails are part of the skin, so it is perhaps not surprising that a skin disease such as psoriasis can  affect the nails. No one knows why some people get nail involvement and others don’t. Nails grow from the nail root (matrix), which is just under the cuticle. In people who develop nail psoriasis it is involvement of the nail root that causes pitting and ridging of the nails.

Onycholysis , (on-ik -ol-is-is) subungual hyperkeratosis (sub-ung-gwal hi-per-ker-at-o-sis) and splinter haemorrhages (hem-or-ij-iz) are all caused by disease of the nail bed. These conditions are explained in the next section.

The nail is made of modified skin and, once it has grown, it can only be altered by filing or clipping. Treatments are usually directed at the nail bed that supports the nail or the nail folds that tuck around the edges. Soothing these tissues can result in better nail growth with fewer features of psoriasis.

The severity of nail involvement does not follow the severity of psoriasis elsewhere in the body, although locally it can correspond to problems in the nearby joint of a finger or toe. On rare occasions, the nails can be the only site of the body affected. More usually, if the nails are involved there will be areas of psoriasis elsewhere on the body. You can, however, develop severe nail changes with only minimal psoriasis.

What changes can occur with nail psoriasis?

These are the most common changes in nail psoriasis:

• Pitting of the nails – the surface of the nail develops small pits, looking rather like the surface of a thimble. The number of pits can vary from one to dozens.
• Onycholysis – the nail becomes detached from the underlying nail bed and a gap develops under the nail. When it starts there is a white or yellowish patch at the tip of the nail, and this then extends down to the cuticle. The gap between the nail and the nail bed can become colonised by particular bacteria, such as pseudomonas, which can then produce a dark green pigment. The nail can become infected and discoloured and can easily be mistaken for melanoma under the nail.
• Subungual hyperkeratosis – a chalky substance accumulates under the nail. The nail becomes raised and can become tender, especially when the surface of the nail is pressed. Subungual hyperkeratosis of the toenails can be particularly uncomfortable because when wearing shoes the nail may be put under constant pressure.
• Discolouration – this may be seen as unusual nail colouration, such as yellow/brown.
• Onychomycosis (on-ik-o-mi-ko-sis) – a fungal infection that can cause thickening of the nails. This could be present alongside nail psoriasis and can be confused in diagnosis. If diagnosed correctly it can be treated with systemic antifungal medication. It is estimated that approximately 35% of people who have nail psoriasis may also have a fungal infection that could make the nails worse. Treating the fungal infection may not have any effect on the clearance of nail psoriasis.

Some nail changes are caused by using systemic retinoid medication, which can help the skin but may result in format ion of very thin nails which do not appear normal. These nail changes can take several months to grow out only after retinoids are stopped.

In addition to these changes you may get longitudinal ridging of the nails and reddish marks under the nails, called splinter haemorrhages, due to tiny burst blood vessels under the nails.

What can be done about it?

Nail psoriasis is perhaps the most difficult part of psoriasis to treat. In the past a large number of treatments have been tried, none of which has given particularly good results. The first things to consider are the non-medical aspects of caring for your nails.

Tips on general nail care

• The basic strategy for both hands and feet should be to keep the nails short. Try to trim them back to the point of firm attachment and gently file them down with an emery board.
• Try to protect your nails from damage because this can worsen the problem. Consider wearing gloves to protect your nails whenever you are doing something that could cause damage.
• Do not clean debris from beneath the nail with a sharp object or a nail brush. This tends to increase any onycholysis and make the situation worse; soaking the affected nails in soapy warm water may be sufficient to remove the debris.
• Rubbing moisturisers into the nail and cuticle or soaking them in emollient oils may help.
• Toenails can benefit by being soaked for at least 10 minutes in a bowl or bath of warm water, which softens the nails, before gently filing the thickened part of the toenails with an emery board and using good, sharp scissors to trim off small pieces of the nails. You should cut straight across the toenail, which helps prevent it from becoming ingrown. It helps to always wear comfortable shoes which make enough room for your toes; friction can cause toenail thickening to occur. It may be worth considering buying shoes a size up from your normal size.

Medical treatments for nail psoriasis include:

The use of topical steroids rubbed into the cuticle – the nail plate is under the cuticle and by massaging steroid creams into the nail plate you can induce some improvement in nail psoriasis. Results are not consistent however and there is the risk that the cuticle can become thinned with fine blood vessels over the surface.

Anecdotally, a number of dermatologists noticed that psoriasis of the nails improved when patients were using vitamin D analogue preparations for psoriasis of their skin. This led to a more focused study of vitamin D analogue creams and ointments rubbed into the cuticle in the treatment of nail psoriasis. Experience from around the world has shown that this is an effective method of treatment and should be regarded as the first-line treatment of choice. The vitamin D analogue cream or ointment should be massaged into the cuticle for about five minutes twice a day. When onycholysis is present, calcipotriol scalp solution can be dripped under the nail and massaged in, which is effective.

Remember that nails grow extremely slowly and what you are influencing is not the existing nail but new nail that is developing from the nail plate. It may, therefore, take up to a year for fingernails, and two years for toenails, to grow out normally; you will need to be patient with any treatment. It’s worth noting that toenails can fail to respond where fingernails improve substantially.

Injections of steroids under the nail – these usually require additional injection of local anaesthetic and are not a good routine treatment.

Removal of the nail – nails can be removed quite painlessly using a high concentration of urea applied under polythene occlusion to the nail. The nail becomes rather jelly-like and can be peeled off. Nails can be removed by surgery, however, nails may still often grow back with an abnormal appearance. X-ray treatment may cause nail shredding, but is not an advisable treatment in most instances.

Systemic treatments – where nail psoriasis is severe and you are not able to walk or use your hand properly, it may be possible to take tablet-based or other injected systemic treatment to improve psoriasis on the nails and skin together.

Is there anything else I can do?

If your fingernails are affected, that hand can be painful and you may find the dexterity of your fingers is restricted. If the toenails are affected it’s sometimes helpful to seek attention from a chiropodist, who may be able to remove the excess thickening of the nails to reduce the pressure when wearing shoes. This can reduce pain and improve mobility. Specialist shoes may also prove helpful; you can easily find various suppliers by searching on the internet or asking a chiropodist or podiatrist for recommendations.

Nail psoriasis can also be a cosmetic problem. The nails may be distorted, which some people find embarrassing. Nail varnish can be used to conceal some of the damage. Application of a good nail hardener or wearing artificial nails if the nails are mostly intact can improve their appearance and also help to protect them. Some people are sensitive to the chemicals in the glue used to apply artificial nails, so it’s advisable to tell your manicurist about your psoriasis so that he/she can be extra careful. Also, where there is onycholysis, all nails should be kept short and this includes gel nails. If nails are extended by gel application or other form of artificial nail then it is likely to make the nail bed psoriasis worse and increase the onycholysis.

This article is adapted from the Nail psoriasis leaflet.

Download our nail psoriasis leaflet as a pdf

Always consult your doctor or healthcare provider.

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