Psoriatic Nail Disease | Patient

What is psoriatic nail disease?

Psoriatic nail disease is a type of psoriasis. It is not caused by infection and you cannot pass it on to anyone else.

Psoriasis is a common skin condition that usually causes patches (plaques) of red, scaly skin but sometimes only affects the nails. There is also a form of arthritis that is linked to psoriasis, called psoriatic arthritis. Psoriatic nail disease is particularly common if you have psoriatic arthritis. You can read more about these conditions in the separate leaflets called Psoriasis and Psoriatic Arthritis.

Psoriatic nail

Psoriasis can affect fingernails and toenails. There are different types of nail changes that can occur. These changes include:

• Pitting of the nails – small pits appear on the surface of the nail. There may be one pit or many pits on the surface of a single nail.
• Onycholysis – the nail separates from the skin underneath the nail. At first this looks like a white or yellow patch at the tip of the nail. This patch gradually gets bigger and reaches the base of the nail. The gap between the nail and the skin underneath the nail can become infected and change colour.
• Subungual hyperkeratosis – chalk-like material builds up under the nail. The nail becomes raised and often tender.
• Oil drop or salmon patch – a see-through yellow-red patch appears in the nail bed that looks like there is a drop of oil under the nail.
• The colour of the nail may change, such as turning to yellow-brown.

What else could it be?

infections of the nail can occur at the same time as psoriatic nail disease and can sometimes look like psoriatic nail disease. Fungal nail infections also cause thickening of the nails. It is important to get the correct treatment as some treatments for fungal nail diseases (eg, terbinafine) can aggravate psoriasis.

Onycholysis is the loosening or separation of the nail from the skin underneath it. Treatment depends on the cause. Apart from psoriasis it has many other causes – for example:

• Trauma to the nail bed – for example, by repeated tapping of the fingernails on a keyboard or by pressure from shoes in long-distance runners and walkers.
• Allergy to nail glue (acrylate).
• Infections, such as fungal infections, bacterial infections, or the cold sore virus (herpes simplex).
• Many medicines – for example, some forms of chemotherapy for cancer, and tetracycline and fluoroquinolone antibiotics.
• Other diseases, such as diabetes or thyroid disease.

In most of these situations the onycholysis is not permanent and the nail will grow out normally once the cause has been removed or treated.

How common is psoriatic nail disease?

About 1 in 50 people have psoriasis at some time in their lives. It can first develop at any age but it most often starts between the ages of 15 and 30 years. Nail changes occur in about half of all people with psoriasis, so about 1 in a 100 people.

About 4 in every 5 people with psoriatic arthritis have psoriatic nail disease. See the separate leaflet called Psoriatic Arthritis for more details.

Only a few people have psoriatic nail disease without having psoriasis affecting either their skin or their joints.

How is psoriatic nail disease diagnosed?

The diagnosis of psoriatic nail disease is usually made by the appearance of the affected nails. Sometimes scrapings from under the nail, and nail clippings, are sent to the laboratory to be tested for fungal infection of the nail, which can sometimes look like psoriatic nail disease.

Occasionally, a sample of nail (a biopsy) is needed to confirm the diagnosis.

What can you do to help improve psoriatic nail disease?

• Keep your fingernails and toenails as short as possible – long or loose nails are more likely to catch and can cause more damage to the skin underneath the nail.
• Keep your nails dry.
• Protect your nails by wearing gloves when doing any manual work.
• Avoid a manicure of the base of the nail. This may cause an infection.
• Avoid false nails as they may damage the cuticle and make it difficult to apply treatments to the nail.
• Nail varnish can be used to cover up pitting. Nail varnish remover containing acetone should not be used, as it can cause damage to the nail.
• If you have painful toenail psoriasis then you should see a person who is qualified to diagnose and treat foot disorders (a podiatrist).

Note: if you have psoriatic nail disease and develop pain or swelling in one or more of your joints (including your fingers and toes) or if you develop pain in your heel (Achilles tendinopathy) then you should see your doctor as soon as possible. You may be developing psoriatic arthritis. It is important that you are seen by a doctor specialising in joint diseases (a rheumatologist) early. It has been shown that the sooner this condition is treated, the less likely you are to suffer permanent damage to your joints.

What treatments are available?

Mild nail disease which isn’t causing discomfort does not need any treatment. If the nail disease is severe and causing problems then your doctor may refer you to see a skin specialist for advice and treatment. Unfortunately treatment of psoriatic nail disease is difficult and not always successful.

Treatments for nail psoriasis include:

• Treatments applied to the nail, which include steroids, salicylic acid, calcipotriol or tazarotene. Local treatments applied to the nail are often not very effective but are worth trying. If the nail is lifting off (onycholysis) then strong steroid scalp application can be trickled under the nail.
• Antifungal treatment – this may be required for fungal nail infection if this is also present.
• A steroid injected into the nail – this may be effective for some types of nail psoriasis but it is painful.
• Light therapy (phototherapy) – psoralen plus ultraviolet light A (PUVA) treatment is effective for some types of nail psoriasis but not for pitting of the nail.
• Removing an affected nail – this can be done by applying a special type of ointment and then covering the nail for seven days. Otherwise the nail can be surgically removed using local anaesthetic.

Patience is important. Once the nail has formed, nothing can be done to change it other than trimming it. The treatments are all aimed at treating the nail bed and the skin around the edge of the nail. Nails grow extremely slowly and it may take as long as a year for a damaged fingernail to grow out completely, or even two years for a damaged big toenail.

If nail psoriasis is severe and not helped by the treatments listed above then a powerful medicine which can suppress inflammation is sometimes used. For example, methotrexate, ciclosporin, acitretin, infliximab, etanercept, efalizumab, ustekinumab or adalimumab. There is some risk of serious side-effects with these medicines, so they are only used on the advice of a specialist and usually when there is psoriasis also affecting the skin.

What is the outlook (prognosis) for psoriatic nail disease?

Psoriatic nail disease can be difficult to treat and there is no cure. It doesn’t usually grow out without treatment, so can continue to cause problems. The appearance of the affected nails can also sometimes cause distress.

The treatment of severe psoriatic nail disease is now improving with modern medicines.

Psoriatic nail disease can also be mild, not needing any treatment, and able to be hidden with nail varnish.

Psoriasis of the Nails – StatPearls

Continuing Education Activity

Psoriasis is a common and chronic inflammatory disease involving skin, nails, and joints. Nails are the visible parts of the body and it affects the quality of life with social and psychological impacts. Due to the slow growth pace of nails, its treatment is prolonged and often with incomplete recovery, which further enhances the stress and anxiety of the patients. This activity reviews the clinical presentation, evaluation, and treatment of nail psoriasis and highlights the role of the interprofessional team in evaluating and treating patients with this condition.

Objectives:

• Describe the pathophysiology of psoriasis of nails.

• Outline the importance of history and physical examination of nail psoriasis.

• Explain the management options of psoriasis nails according to the severity of the disease.

• Explain the importance of improving care coordination amongst the interprofessional team to improve outcomes for patients with psoriasis of the nails.

Access free multiple choice questions on this topic.

Introduction

Psoriasis is a common chronic inflammatory condition of the skin, which also has nails and systemic involvement. Psoriatic involvement of the nail bed or nail matrix results in nail psoriasis.[1] Nail involvement is a visible indicator to predict future joint inflammatory damages and disease activity. Nail psoriasis can manifest clinically as a wide variety of nail changes, like nail discoloration, subungual hyperkeratosis, pitting and onycholysis, depending upon the part of the nail units affected. Patients with psoriatic nails have impaired quality of life due to the appearance of nails, and significant morbidity and functional impairments may arise in large cases. Its management is challenging because it is long term, and often not satisfying the patients leads to depression, which further deteriorates the condition. Patient education with explaining the prognosis and outcomes of the treatment is the most important aspect.[2]

Etiology

The exact etiology of nail psoriasis is unclear, but multiple factors may contribute to being the etiology of nail psoriasis, which include genetic, immunological, and environmental factors. However, dysregulation of innate immunity is thought to be the stronger associated factor, while genetic factors are not well understood. Family history is common, and human leukocyte antigens (Cw6, B13, B17) are associated with it.[3]

Epidemiology

Nail psoriasis affects both children and adults. It equally affects males and females and has increase prevalence with increasing age. Nail Psoriasis mostly develops in association with cutaneous psoriasis and psoriatic arthritis with a prevalence of 10% to 55% and 80% to 90%, respectively. Nail psoriasis may develop as a sole manifestation. The involvement of nail in a patient with cutaneous psoriasis is concurrent or develops after the onset of cutaneous symptoms.[2]

Pathophysiology

Nail psoriasis usually results from psoriatic inflammation involving the nail bed or nail matrix. The matrix of the nail is mainly responsible for nail plate formation and is located beneath the proximal nail fold. The superficial part of the nail plate is formed from the proximal nail matrix while the deep part is formed from the distal nail matrix. The nail bed lies directly beneath the nail plate and plays a significant role in the adherence of the nail plate to the nail bed.[4] Clinical features related to nail matrix involvement are nail Pitting, red spots in the lunula, leukonychia, and crumbling of the complete nail plate. The involvement of the nail bed manifests clinically as Onycholysis, splinter hemorrhages, subungual hyperkeratosis, and oil drop discoloration.[1]

Genetic contributions to the formation of nail psoriasis are still uncertain. Psoriatic nail disease may, however, align more closely with innate immunity dysregulation. Thus, psoriatic nail disease can contribute differently to innate and adaptive immunity than the disease limited to the skin.

Histopathology

Histopathological findings of nail psoriasis are similar to cutaneous psoriasis, and it includes mild to moderate hyperkeratosis, spongiosis, and focal hyperkeratosis. Other prominent features are neutrophilic inflammatory infiltrate, hypergranulosis, and papillomatous epidermal hyperplasia. Papillary dermis shows dilated tortuous inflamed capillaries. The hyponychium shows the loss of the granular layer while there is hypergranulosis in the nail bed and matrix of the nail.[4]

History and Physical

As nail psoriasis is strongly associated with cutaneous psoriasis and psoriatic arthritis, one should take the proper history of the skin lesions and joint-related symptoms like swelling and pain. Most of the patients with psoriatic arthritis present with involvement of distal interphalangeal joints. Presentation of nail psoriasis alone without any cutaneous and joint involvement is always a diagnostic challenge in many cases.[5]

A patient of nail psoriasis may have either one or multiple affected finger and toenails. The psoriatic nail may have more than one clinical manifestation in a single nail depending upon the part of the nail apparatus affected. The common clinical manifestations of nail psoriasis are nail Pitting, subungual hyperkeratosis, onycholysis, and oil drop discoloration. However, nail plate crumbling, red spots in lunula, leuconychia, and splinter hemorrhages are other features. Patients may have manifestations like onychorrhexis and beau lines, which are longitudinal ridges with distal nail plate splitting and transverse grooves, respectively.

A complete thorough examination of the skin, including the scalp and anogenital area, is important to assess the extent and severity of the condition. [6][4] Nail psoriasis is a common feature of patients presenting with psoriatic arthritis, and it is prudent to assess signs of psoriatic arthritis. Examine for the swelling and tenderness of the joints, especially distal interphalangeal joints of both feet and hands and swelling of digits.

Evaluation

Nail psoriasis is usually diagnosed on a clinical basis by a proper history and complete physical examination. Fungal infection testing is also necessary in few cases to rule out onychomycosis. The biopsy is not necessary except for selective cases where the diagnosis is uncertain, and biopsy of the nail bed or nail matrix is taken and sent for histological examination.[7]

Treatment / Management

Patient with nail psoriasis is treated with either topical or systemic therapy. Other options include biologic agents, photodynamic therapy, phototherapy, intense pulsed light, and lasers treatment. The treatment options mainly depend upon the severity and extent of disease. The various other factors which need to be considered for treatment options are the age of the patient, comorbidities, profession, concomitant skin and joint involvement, impact on the quality of life, patient preference, and cost of treatment.[8]

Mild nail psoriasis:

• In mild cases, where the disease is limited to one or two nails with no significant symptoms, topical therapy is the best option. Topical corticosteroids and topical vitamin D analogs are first-line while topical tacrolimus and topical tazarotene are the second-line therapy. Systemic therapy is limited to patients who did not respond to topical therapy.

Moderate to severe nail psoriasis:

It is considered when nail psoriasis is associated with severe nail dystrophy that usually involves more than two nails with significant functional impairment.[9][10]

• First-line 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) (TNF alpha inhibitors), Ustekinumab (inhibitor of p40 subunit of IL-12/23), and Secukinumab, Ixekizumab (a monoclonal antibody inhibiting the IL-17A ligand).

This therapy is very effective, but few patients don’t prefer this option due to cost and affordability issues. These biological agents increase the risk of fungal skin infections.[11]

• Second-line therapy: The second-line therapy for moderate to severe psoriasis includes topical therapies, (topical tacrolimus, topical tazarotene, topical calcipotriol, and potent topical corticosteroid )intralesional corticosteroids, pulsed dye LASER. Systemic therapies are  Methotrexate and apremilast.[12]

Additional therapies need further recommendations to include oral tofacitinib, topical cyclosporine, topical indigo naturalist, oral acitretin, oral cyclosporine, and phototherapy.

Differential Diagnosis

• Onychomycosis: The changes of onychomycosis resemble nail psoriasis, and sometimes it is difficult to distinguish between the two. Nail pitting, onycholysis, and oil drop sign are the main features of nail psoriasis. Onychomycosis can be diagnosed by fungal culture, nail clipping with periodic acid Schiff( PAS)and potassium hydroxide (KOH) preparations.[1]

• Alopecia areata: It usually appears as linear ridging, nail pitting, longitudinal nail fissuring, and some other nail abnormalities along with non-scarring patchy alopecia of the scalp or other body areas.

• Lichen planus: Nail involvement presents as thinning of nails with ridges and grooves of the nail plate sometimes scarring of cuticle occur leading to pterygium formation. Lichen planus also involves the mucosa or skin. The skin manifestations of lichen planus are itchy, purple, polygonal papules or plaques.[13]

• Pityriasis Rubra pilaris: It is an uncommon skin disorder that usually presents as hyperkeratotic follicular papules, orange-red plaques with fine scales, and hyperkeratosis of palms and soles. The nails usually become thickened, and distal edges often show splinter hemorrhages.

Prognosis

Patients with nail psoriasis have a chronic and protracted course with periods of improvement and worsening with a greatly profound effect on the quality of life.patient may have periods of normal nails without alteration.patients of psoriasis with nail involvement have a poor prognosis. nail trauma may be the trigger and exacerbating factor for nail psoriasis.treatment with topical agents in case of mild disease and systemic therapy in moderate to severe disease may alter the disease process in the long run but on the cost of side effects and complications.[11]

Complications

The patient suffering from nail psoriasis may develop complications either due to the disease process itself or as a result of drugs used in treatment. The major complications can be grouped into functional disability, psychological distress, and infections, including bacterial and fungal infections. acute and chronic paronychia and onychomycosis.

Deterrence and Patient Education

Nail psoriasis is a chronic disease process, treatment may be prolonged, and education of patients is an essential part of management.[14] The treatment is prolonged due to a slow nail growth pace, which leads to a prolonged course of treatment. Proper communication with the patient may encourage reasonable perceptions of treatment outcomes, and it may facilitate therapy adherence. Patients need to follow gentle hand and foot care measures that may help to decrease the symptoms. These general measures include the regular application of emollients, regularly trimming of the nails, keep them dry and protection from trauma to prevent Koebner phenomena. In addition, they need to take photographs of nails periodically as these pictures would help to assess the treatment response.[5]

Enhancing Healthcare Team Outcomes

Nail psoriasis is a difficult condition to manage, and its management is best by an interprofessional team. [1]

• Consider the impact of nail psoriasis on psychosocial distress and quality-of-life and remember that it may lead to anxiety or psychiatric disease.

• The dermatologist and pharmacist can help to promote the appropriate use of topical and systemic agents.

• Patient education and skincare measures would help to manage the disease effectively.

• Nail psoriasis and psoriatic arthritis frequently coexist, a team-based approach with the involvement of rheumatologist and orthopedics is mandatory to treat such patients.

Even though sometimes primary clinicians manage these patients, it is best to refer these patients to the dermatologist. Dermatology specialty-trained nurses can also help by counseling the patient, providing direction on medical management, and monitoring and charting treatment progress. A pharmacist should also be on the case, with assistance in selecting the most appropriate agents, verifying dosing, offering patient education, and performing medication reconciliation, informing the prescriber of any issues encountered. Close communication between interprofessional team members is vital to achieving desired outcomes.[4]

Figure

Nail Psoriasis. Contributed by DermNetNZ

Figure

Nail pitting as seen in a Psoriasis patient. Contributed by Lawrence Brent, MD

References

1.

Jendoubi F, Ben Lagha I, Rabhi F, Doss N, Mrabet A, Jaber K, Dhaoui MR. Nail Involvement in Psoriatic Patients and Association with Onychomycosis: Results from a Cross-Sectional Study Performed in a Military Hospital in Tunisia. Skin Appendage Disord. 2019 Aug;5(5):299-303. [PMC free article: PMC6751431] [PubMed: 31559254]

2.

Egeberg A, See K, Garrelts A, Burge R. Epidemiology of psoriasis in hard-to-treat body locations: data from the Danish skin cohort. BMC Dermatol. 2020 May 20;20(1):3. [PMC free article: PMC7238562] [PubMed: 32434510]

3.

Pouw JN, Leijten EFA, Tekstra J, Balak DMW, Radstake TRDJ. [Spectrum of psoriatic conditions]. Ned Tijdschr Geneeskd. 2019 Jul 29;163 [PubMed: 31361418]

4.

Wanniang N, Navya A, Pai V, Ghodge R. Comparative Study of Clinical and Dermoscopic Features in Nail Psoriasis. Indian Dermatol Online J. 2020 Jan-Feb;11(1):35-40. [PMC free article: PMC7001394] [PubMed: 32055506]

5.

Dopytalska K, Sobolewski P, Błaszczak A, Szymańska E, Walecka I. Psoriasis in special localizations. Reumatologia. 2018;56(6):392-398. [PMC free article: PMC6330687] [PubMed: 30647487]

6.

Rusk AM, Fleischer AB. In psoriasis treatment, greater improvement in skin severity predicts greater improvement in nail severity. J Dermatolog Treat. 2020 Feb 05;:1-4. [PubMed: 31971034]

7.

Kaya İslamoğlu ZG, Uysal E, Demirbaş A, İslamoğlu N. Evaluating nail thickness and stiffness with shear-wave elastography in nail psoriasis: A preliminary study. Skin Res Technol. 2020 Jan;26(1):45-49. [PubMed: 31338888]

8.

Lanna C, Galluzzi C, Zangrilli A, Bavetta M, Bianchi L, Campione E. Psoriasis in difficult to treat areas: treatment role in improving health-related quality of life and perception of the disease stigma. J Dermatolog Treat. 2020 May 28;:1-4. [PubMed: 32419527]

9.

Tada Y, Ishii K, Kimura J, Hanada K, Kawaguchi I. Patient preference for biologic treatments of psoriasis in Japan. J Dermatol. 2019 Jun;46(6):466-477. [PMC free article: PMC6594072] [PubMed: 30985030]

10.

Lanna C, Zangrilli A, Bavetta M, Campione E, Bianchi L. Efficacy and safety of adalimumab in difficult-to-treat psoriasis. Dermatol Ther. 2020 May;33(3):e13374. [PubMed: 32246516]

11.

Rigopoulos D, Baran R, Chiheb S, Daniel CR, Di Chiacchio N, Gregoriou S, Grover C, Haneke E, Iorizzo M, Pasch M, Piraccini BM, Rich P, Richert B, Rompoti N, Rubin AI, Singal A, Starace M, Tosti A, Triantafyllopoulou I, Zaiac M. Recommendations for the definition, evaluation, and treatment of nail psoriasis in adult patients with no or mild skin psoriasis: A dermatologist and nail expert group consensus. J Am Acad Dermatol. 2019 Jul;81(1):228-240. [PubMed: 30731172]

12.

Krajewska-Włodarczyk M, Owczarczyk-Saczonek A, Placek W, Wojtkiewicz M, Wojtkiewicz J. Effect of Methotrexate in the Treatment of Distal Interphalangeal Joint Extensor Tendon Enthesopathy in Patients with Nail Psoriasis. J Clin Med. 2018 Dec 14;7(12) [PMC free article: PMC6306839] [PubMed: 30558114]

13.

Baran R. [How to diagnose and treat psoriasis of the nails]. Presse Med. 2014 Nov;43(11):1251-9. [PubMed: 25443636]

14.

Moreno-Romero JA, Grimalt R. Nail Pitting in Psoriasis. N Engl J Med. 2018 Nov 29;379(22):e39. [PubMed: 30485773]

Nail Psoriasis: The Journey So Far

Indian J Dermatol. 2014 Jul-Aug; 59(4): 319–333.

Alka Dogra

From the Department of Dermatology and Venereology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India

Amanjot Kaur Arora

From the Department of Dermatology and Venereology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India

From the Department of Dermatology and Venereology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India

Address for correspondence: Dr. Alka Dogra, Department of Skin and Venereal Diseases, Dayanand Medical College and Hospital, Ludhiana – 141 001, Punjab, India. E-mail: ni.oc.oohay@argod_la

Received 2013 Feb; Accepted 2013 May.

This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

This article has been cited by other articles in PMC.

Abstract

Nail involvement is an extremely common feature of psoriasis and affects approximately 10-78% of psoriasis patients with 5-10% of patients having isolated nail psoriasis. However, it is often an overlooked feature in the management of nail psoriasis, despite the significant burden it places on the patients as a result of functional impairment of manual dexterity, pain, and psychological stress. Affected nail plates often thicken and crumble, and because they are very visible, patients tend to avoid normal day-to-day activities and social interactions. Importantly, 70-80% of patients with psoriatic arthritis have nail psoriasis. In this overview, we review the clinical manifestations of psoriasis affecting the nails, the common differential diagnosis of nail psoriasis, Nail Psoriasis Severity Index and the various diagnostic aids for diagnosing nail psoriasis especially, the cases with isolated nail involvement. We have also discussed the available treatment options, including the topical, physical, systemic, and biological modalities, in great detail in order to equip the present day dermatologist in dealing with a big clinical challenge, that is, management of nail psoriasis.

Keywords: Biologicals, infliximab, intralesional injections, nail biopsy, nail psoriasis, nail psoriasis severity index, nail psoriasis treatment

Introduction

What was known?

1. Nail psoriasis is a common condition seen in about 10-78% of patients with psoriasis vulgaris and 70-80% of patients with psoriatic arthritis.

2. 5-10% cases have isolated nail involvement.

3. The clinical features of nail psoriasis are extremely variable and depend upon the site affected.

4. Treatment is often difficult, prolonged, and unsatisfactory.

Psoriasis is a chronic inflammatory skin disease characterized by T-cell-mediated hyperproliferation of keratinocytes in the skin.[1,2] It affects about 2-3% of the world’s population with equal sex incidence.[2] Approximately, 10-78% of patients with psoriasis have concurrent nail psoriasis,[3,4,5] while isolated nail involvement is seen in 5-10% of patients.[1,6] Ghosal et al.,[7] in their study found that the frequency of nail changes in patients with Koebner’s phenomenon is 56%, whereas as in those without Koebner’s phenomenon it is 29.33%. Nail psoriasis is approximately 10% more common in males than in females and is positively associated with higher bodyweight.[8] Recently, a questionnaire-based survey done by Klaassen et al.,[9] revealed that patients with nail psoriasis are more frequently associated with psoriasis capitis, genital psoriasis, and psoriatic arthritis. Different studies have shown that up to 30% of patients with psoriasis have psoriatic arthritis of which 70-80% have nail involvement.[10,11] Therefore, being a dermatologist, one should look for early signs and symptoms of psoriatic arthritis in a patient with nail psoriasis in order to avoid progressive joint damage.[11,12,13,14]

Human leukocyte antigen (HLA) studies have shown that type 1 psoriasis which usually affects the skin is strongly associated with HLA-Cw6[13] and these patients have an earlier onset of disease which is also more extensive and severe, whereas, type 2 psoriasis that predominantly damages the nails and the joints is not associated with HLA Cw6 suggesting a different immunopathology.[2,15,16]

Burden of Nail Psoriasis: The Impact of Nail Psoriasis on Quality of Life

Nail psoriasis engenders both physical and psychological handicap, leading to significant negative repercussions in the quality of life.[4] Cosmetic handicap in nail psoriasis is sometimes so extensive that the patients tend to hide their hands and/or feet or shy away from social and business interactions.[4,11,17] The burden of nail psoriasis on its sufferers can be imagined from the results of a study done by de Jong et al.,[4] in 1728 patients, which showed that nail psoriasis caused significant cosmetic handicap in 93% of patients, restriction of daily housekeeping and professional activities in 60% patients, and 52% patients described pain as a symptom. In 2009, Ortonne et al.,[18] devised the Nail Psoriasis Quality of Life Scale-NPQ10-to evaluate the impact of nail psoriasis on quality of life. The scale correlated well with the Dermatology Life Quality Index. A valid and reliable questionnaire consisting of 10 questions was prepared with all the questions specifically targeting the impact of nail psoriasis on quality of life. The questionnaire was answered by 1309 patients and showed that 86% patients considered nail psoriasis as bothersome, 87% as unsightly, and 59% as painful. Such an impact of nail psoriasis definitely warrants an insight into its clinical manifestations and treatment options by a present day dermatologist.

Clinical Manifestations

Nail psoriasis affects the fingernails more commonly than the toenails.[1]

The features of nail psoriasis start predominantly after the onset of cutaneous lesions.[9] A mean delay of 9 and 11.5 years in the onset of nail psoriasis has been reported by van der Velden et al.,[19] and Klaassen et al.,[9] respectively. This time lag, perhaps, is responsible for a lower prevalence of nail psoriasis in children.[9] The clinical manifestations of nail psoriasis depend upon the part of the nail unit affected by nail psoriasis [].[1]

Table 1

Clinical signs of nail psoriasis

Common clinical manifestations of nail matrix psoriasis include

Pitting

Pitting is the commonest manifestation of nail psoriasis.[9,20] Pits affect the fingernails more commonly than the toenails.[20] They are superficial depressions in the nail plate that indicate abnormalities in the proximal nail matrix []. Psoriasis affecting the proximal nail matrix disrupts the keratinization of its stratum corneum by parakeratotic cells.[1] These cells are exposed as the nail grows and are sloughed off to form diffuse and coarse pits.[1,21,22] The length of a pit is suggestive of the length of time, the matrix was affected by the psoriatic lesion and a deeper pit is suggestive of involvement of intermediate and ventral matrix along with the dorsal matrix.[21] Pitting may be arranged in transverse or longitudinal rows or it may be disorganized.[21] They may be shallow or large to the point of leaving a punched out hole in the nail plate known as elkonyxis.[22] More than 20 fingernail pits per person are suggestive of a psoriatic etiology and more than 60 pits per person are unlikely to be found in the absence of psoriasis.[23]

Pitting affecting the fingernails

Transverse grooves are formed in the same way as pits when the psoriatic lesion affects a wider area of the nail matrix [].[2]

Transverse grooves on the nail plate in a patient with psoriasis

Nail plate thickening and crumbling

It suggests an extensive involvement of the entire nail matrix by the psoriatic process [].[24]

Nail plate thickening and crumbling resulting in complete nail dystrophy

Leukonychia

It occurs when psoriasis induced parakeratosis affects only the intermediate and ventral matrices that form the undersurface of a nail plate, as opposed to the dorsal nail matrix. In these situations, the affected area appears leukonychic (whitish) because of the internal desquamation of parakeratotic cells, as opposed to the materialization of pits externally [].[1,25]

Leukonychia in a patient with psoriasis

Clinical manifestations of nail bed psoriasis include

Oil spot or salmon patch

They result from focal nail bed parakeratosis which leads to focal onycholysis, where serum and cellular debris accumulate and become entrapped.[1,26] There is usually a yellowish brown margin visible between the white oily spot or salmon patch lesion and the normal pink nail. Extension of an oil spot to the distal free edge leads to onycholysis [].

Onycholysis along with salmon patches on thumbnails in a patient with psoriasis

Onycholysis (separation of nail plate from nail bed)

Results from psoriasis affecting the distal nail bed or hyponychium or extension of oil spots distally. Onycholysis allows air to enter the distal end of the nail plate leading to white color[27] [Figures and ]. Serum exudates may accumulate and appear yellowish.[28]

Onycholysis along with pitting and salmon patches in fingernails

Subungual hyperkeratosis

It affects the toenails more frequently than the fingernails.[5] It results from raising of the nail plate off the nail bed as a result of deposition of cells that have not undergone desquamation[1] [Figures and ]. This accumulated tissue is friable and is liable to be infected by Candida and Pseudomonas leading to either yellow/green discoloration.

(a) Nail plate thickening with discoloration and subungual hyperkeratosis (arrow) of the toenail (b) Subungual hyperkeratosis affecting toenails

Splinter hemorrhages

They are a non specific finding of nail psoriasis and appear as small linear structures, about 2-3 mm long, arranged at the distal end of a nail plate. They reflect the rupture of wide calibre vessels and tracking of extravasated blood down the longitudinal furrows beneath the nail plate.[21]

Other manifestations

Acropustulosis

It is characterized by destructive pustulation of the nail unit which may occur as a part of pustular psoriasis, palmoplantar pustulosis,[29] and acrodermatitis continua of Hallopeau.[30] The nail plate may be lifted off by sterile pustules in the nail bed and matrix resulting in complete destruction of the nail plate. Usually, there is erythema and discomfort at the end of the digit. Resorptive osteolysis of finger or toes may also occur in acrodermatitis continua of Hallopeau.[31]

Subacute or chronic paronychia

Psoriatic paronychia usually develops when the periungual skin is affected by psoriasis, but it is also commonly seen in psoriatic arthritis with nail involvement. The chronic inflammation causes thickening of the free edge of the proximal nail fold with consecutive loss of cuticle and the attachment of the nail fold’s ventral surface to the underlying nail plate. This allows foreign material such as dirt, microorganisms, or allergenic substances to enter the space beneath the nail fold where they may aggravate inflammation.[32]

Psoriatic onychopachydermoperiostitis

It is a very recently described uncommon variant of psoriatic arthritis.[33] It is characterized by psoriatic onychodystrophy or onycholysis, soft tissue thickening over distal phalanx, and periosteal reaction with absence of distal interphalangeal joint (DIP) involvement. Psoriatic onychopachydermoperiostitis may involve nails of any finger or toe. However, nails of great toes are involved in most reported cases in literature.[34]

Assessment of Nail Psoriasis: Nail Psoriasis Severity Index

Nail Psoriasis Severity Index (NAPSI), initially described Rich and Scher,[35] is an objective and a reproducible tool for estimating the severity of psoriatic nail involvement and is mainly used to measure the efficacy of various therapeutic interventions. Eight features of nail psoriasis have been identified for the NAPSI score: Four involve the nail matrix (pitting, leukonychia, red spots in the lunula, nail plate crumbling) and four of the nail bed (onycholysis, splinter hemorrhages, subungual hyperkeratosis, oil spot/salmon patch). However, van der Velden et al.,[19] in a case-controlled study on nail psoriasis found that leukonychia was present in 65% of the control population and therefore questioned the position of leukonychia in NAPSI score.

For estimation of NAPSI, each nail is divided into four quadrants Each quadrant is evaluated for the presence of any manifestation of psoriasis in the nail matrix (M) or nail bed (B) []. The lesion(s) of nail matrix and nail bed are given a score of 1 in each quadrant, so that there is nail matrix score of 0-4 and nail bed score of 0-4 per nail with a total maximum score of 8 and a minimum score of 0 per nail. For example, in , the presence of onycholysis and salmon patches in three of the four quadrants of the thumbnail gives a nail bed score of 1 to three of the quadrants. Pitting gives all the four quadrants a nail matrix score of 1; therefore, the total NAPSI score of the thumbnail is 7. This method has been used differently by different research workers, some using NAPSI score of all fingers and/or toes (80 and 160, respectively) or often, specific nails are targeted to assess the effects of therapy.[8]

Estimation of NAPSI-the affected nail is divided into four quadrants and the presence of lesions of the nail matrix (M) and nail bed (B) are given a score of 1 in each quadrant

Diagnosis of Nail Psoriasis

Diagnosis of nail psoriasis can be made easily in a patient with concomitant skin psoriasis. Close examination with a hand lens can help in appreciating the above mentioned changes in a greater detail. However, in cases of isolated nail psoriasis (5-10% of cases) and in patients presenting with a diagnostic dilemma to a dermatologist the following techniques can be used.

Nail biopsy

The trick behind getting a diagnostic biopsy lies in choosing the area to be biopsied, that is, the area that will show diagnostic histopathological changes. summarizes the sites to be biopsied as per the clinical manifestations.[36]

Table 2

Technique of nail biopsy

The selected digit is anesthetized with a proximal ring block or a distal wing block and then exsanguinated. A tourniquet is then applied at the base of the digit to achieve complete hemostasis and a relatively avascular field, keeping in mind that the tourniquet should not be kept in place for more than 15 min at a stretch. Nail biopsy can then be taken as an excision biopsy or punch biopsy or longitudinal nail biopsy. A punch or an excision biopsy can be applied to any individual anatomical part of the nail unit, like the nail bed, nail plate, nail fold, or matrix, whereas with a longitudinal nail biopsy, a part of all the parts of the nail unit are biopsied. The defect is then sutured using 3-0 – 6-0 silk. After completion of biopsy, adequate hemostasis is secured and pressure dressing is done. The sutures are then removed after 10 days.[36,37]

Histopathology of nail psoriasis varies according to the clinical focus of the disease. contrasts the important histopathological differences between a normal nail and a nail affected by psoriasis.[38,39,40] Hanno et al.,[40] proposed diagnostic criteria of nail psoriasis in the form of presence of neutrophils in the nail bed epithelium (major criterion), hyperkeratosis with parakeratosis, serum exudates, focal hypergranulosis, and nail bed epithelium hyperplasia (minor criteria).

Table 3

Histopathology of nail psoriasis in comparison to normal nail

Dermoscopy

Dermoscopy is a noninvasive, quickly applied, and inexpensive test that may aid in diagnosis of nail psoriasis in inconclusive cases especially in a resource poor set up.[41] It is performed with manual devices which do not require computer assistance and generally employs ×10 magnifications.[42] Dermoscopic description of common signs of nail psoriasis is as follows:[41]

1. Pits-appear as irregular depressions surrounded by a whitish halo

2. Salmon patches-appear as marks that are irregular both in size and shape with coloring that varies from red to orange

3. Onycholysis-appears as an area that is either homogenously white or composed of multiple longitudinal striations, generally surrounded by a reddish orange stain

4. Splinter hemorrhages-appear as longitudinal brown, purple or black marks

5. Blood vessels-appear as dilated tortuous vessels seen in the distal nail bed.

Videodermoscopy

Videodermoscopy represents an evolution of dermoscopy and is performed with a video-camera equipped with lenses providing magnification ranging from ×10 to ×1000.[42,43] The images obtained are visualized on a monitor and can be stored on a personal computer.[42] Iorizzo et al.,[44] showed that using videodermoscopy the capillaries of the hyponychium of nails affected by psoriasis were visible, dilated, tortuous, elongated, and irregularly distributed. The capillary density was different in each patient and positively correlated with disease severity.

Capillaroscopy

Periungual capillaroscopy shows that capillary density in the periungual area is decreased in patients with psoriasis which is even lesser in patients with nail psoriasis.[45] Avascular areas in the periungual area are more common in patients with nail psoriasis.[45] Also, the presence of coiled capillary loops in the periunguium can be appreciated.

New diagnostic techniques

Ultrasound

Ultrasonography of the nails requires a high-resolution ultrasound (US) machine and a high-frequency US probe.[46] In nails affected by psoriatic onychopathy, the nail plates may show hyperechoic parts or loss of definition, which can involve only the ventral plate or both plates.[47] In later stages, a wavy thickened appearance of both plates may be visible. The nail bed is thickened and these changes are associated with an increase in blood flow that can be observed with power Doppler technique.[47]

Optical coherence tomography

It works on the principle that infrared light reflected from nail is measured and the intensity is imaged as a function of position.[48] The optical coherence tomography (OCT) probe is applied directly to the nail and scanning lasts for a few seconds. This technique provides images of tissue pathology in situ with a higher axial resolution as compared to US.[48] Aydin et al.,[49] recently reported high-resolution OCT changes in nail psoriasis which consisted of a grossly dyshomogeneous and eroded ventral nail plate which was irregularly fused with the underlying epidermis.

OCT can also measure the thickness of the nail plate with a greater accuracy in comparison to US. This suggests that OCT has the potential to provide quantitative data regarding psoriatic nails and may become a more accurate and objective surrogate outcome measure for interventional trails in future.

Confocal laser scanning microscopy

It is a new noninvasive diagnostic tool which is becoming increasingly popular. It can visualize cell structures of the skin up to a depth of 300 μm in vivo. It works on the principle of increasing the optical resolution and contrast of a micrograph by using a spatial pinhole to eliminate out of focus light.[46] Confocal laser scanning microscopy (CLSM) enables reconstruction of three-dimensional images of nails and is a promising tool in the diagnosis of nail psoriasis.[50] Compared with the OCT images, which best allow the measurement of thickness of the entire nail plate and of the different layers of the nail unit, CLSM gives better information on the microscopic structures of the nail plate.[51] Even the borders of the corneocytes can be evaluated and their integrity can also be investigated. For instance, in a patient presenting with leukonychia, Sattler et al.,[51] showed that by using CLSM disturbance of the integrity of the corneocytes of nail plate can be demonstrated.

Differential diagnosis

The most frequently encountered differential diagnosis of nail psoriasis is onychomycosis, which usually presents with a diagnostic dilemma.[19,32] Important points of difference between the two have been contrasted in .[21,36,52] However, onychomycosis can coexist with nail psoriasis as was established by Natrajan et al.,[53] who in a study on 48 patients with nail psoriasis showed that fungal infection coexisted in 47.91% of patients, consisting only of nondermatophytic moulds and yeasts. Lichen planus of nails can be differentiated by absence of pitting and presence of longitudinal grooves, longitudinal fissures, and the presence of dorsal pterygium. Nail pitting in cases of alopecia areata is usually fine and stippled and the diagnosis can be made from clinical observation of hair. Pityriasis rubra pilaris (PRP) also, sometimes presents with thickened and discolored nails but the presence of follicular papules on the dorsum of the fingers and palmoplantar keratoderma favors the diagnosis of PRP. In Darier’s disease, characteristic nail changes include red or white longitudinal bands of varying width, often ending in a pathognomonic notch at the free margin of the nail. The nails are often brittle and pits are present on palms and soles. Norwegian scabies is also characterized by the presence of large psoriasis like scales under the nail plate where the mites usually reside and later colonize the skin, first around the nail plate and then proximally. The patient in these cases is usually old, infirm, or mentally ill or has HIV infection.

Table 4

Differences between nail psoriasis and onychomycosis

Treatment of Nail Psoriasis

Nail disease is usually overlooked in the management of psoriasis, with skin involvement being the primary concern. Also, treatment of nail psoriasis is a big challenge for a dermatologist because of the following reasons:

1. Poor drug delivery: the matrix pathology is hidden by the proximal nail fold and the nail bed changes are protected against treatment by the overlying nail plate and nail bed hyperkeratosis, making delivery of drug to the affected site very difficult.

2. Slow rate of nail growth attributes to a longer duration of treatment required, leading to a questionable long-term compliance by the patient.

3. Keeping in mind the potential significant toxicities of the various systemic agents advocated for psoriasis, the use of systemic agents is not generally advisable for treating nail psoriasis alone and is recommended for cases with coexistent severe skin or joint disease or in patients with extensive or recalcitrant nail psoriasis.

4. Also, despite the recognized burden of nail psoriasis,[4] there is a dearth of good-quality evidence for the management of nail psoriasis. A recent systematic review on treatment options for nail psoriasis, published in January 2013, highlighted the fact that the quality of trials done so far is generally poor and the data available is insufficient to advocate a consistent treatment approach or algorithm for the management of psoriasis.[54]

Various treatment options, however, have been advocated for the treatment of nail psoriasis depending upon the site of nail involvement and the presence of nail psoriasis in few or many nails.[1,55,56] For example, nail matrix involvement manifesting as pitting, trachyonychia, dystrophy, and leukonychia should be treated with different modalities as compared to nail bed involvement manifested by onycholysis, subungual hyperkeratosis, oil spot/salmon patch and splinter hemorrhages. A therpeutic algorithm has been suggested by Jiaravuthisan et al.:[1]

Psoriatic lesions in a few nails

Topical therapy

1. Nail matrix involvement

   • Intralesional steroids

   • Tazarotene

   • Topical potent steroids

2. Nail bed involvement

Psoriatic lesions in many nails

Systemic therapy

gives an account of the work done on various treatment options for nail psoriasis, which will also be discussed below.

Table 5

Treatments for nail psoriasis including level-of-evidence assignments as used by group for research and assessment of psoriasis and psoriatic arthritis

General measures

Before starting treatment for nail psoriasis, it is imperative for any dermatologist to allay fear and concern in the patient regarding his/her disease.[56,57] It is also recommended to highlight the need for long-term treatment, and the importance of good treatment compliance by the patient. The importance of simple approaches, as follows, in nail psoriasis should not be underestimated:

1. Nails should be kept short to avoid exacerbating onycholysis and to avoid the accumulation of exogenous material under the nail.

2. Trauma of manual removal of exogenous material should be avoided as it may worsen onycholysis and allow entry of pathogens

3. Protection of nails from injury is important, by wearing gloves and application of emollient creams on the psoriatic skin of hands and nail folds.

4. Protection against irritants is prudent, and aggressive manicure of the cuticle, which may provoke paronychia, should be avoided.

5. Cosmetic camouflage: Prosthetic nails are generally inadvisable. Nail buffing and nail varnish may temporarily conceal pitting.

Topical therapies

If nail changes are mild and not bothersome to the patient or if nail psoriasis is the only manifestation of the disease, topical therapies are often an appropriate first choice.[58] The digits in bracket in the text ahead denote the level of evidence for each modality discussed.

Corticosteroids

The most popular preparations for the treatment of nail psoriasis are potent to very potent glucocorticoids like clobetasol propionate 0.05% (4)[59] and betamethasone dipropionate 0.05% (2b).[60] They have been used once or twice a day for up to 9 months.[56] Recently, 8% clobetasol-17-propionate in a colorless nail lacquer vehicle used once daily for 21 days and then twice weekly for 9 months has shown good results (4).[61] If psoriasis affects the nail matrix, the topical agent is often applied to the nail folds, but if psoriasis is derived from the nail bed, nail needs to be trimmed to the hyponychium before treatment is applied.[1] It is often recommended to apply high potency steroids under the covering of an occlusive dressing, such as a pair of plastic gloves to increase the drug penetration.[25,62] The potential side effects of long-term therapy with high potency topical steroids are skin atrophy when the proximal or lateral nail folds are involved, formation of striae and telangiectasia, tachyphylaxis and potential systemic absorption of steroid.[1] Furthermore, with persistent use of very potent topical steroids over years, a number of studies have documented a possible tapering of the treated digit, which can be caused by atrophy of the underlying phalanx and is commonly known as “disappearing digit”.[63,64,65]

Vitamin D analogues

Calcipotriol (50 μg/g) twice daily application for 3-6 months has been evaluated in the treatment of nail psoriasis. Tosti et al.,[60] found calcipotriol twice daily for 6 months to be as effective as topical steroids in treating subungual hyperkeratosis (2b). Rigopoulos et al.,[59] found that combining calcipotriol with clobetasol propionate, led to a 77% improvement in hyperkeratosis of the fingers and toes within 6 months. Side effects like erythema, periungual irritation, burning at the site of application, and diffuse urticaria have been associated with the use of vitamin D analogues.

5-fluorouracil

5-fluorouracil (5-FU) in a formulation of 1% solution has been used as a topical treatment in nail psoriasis. A small study showed improvement in pitting and hyperkeratosis after application of 5-FU twice daily for 6 months, although, it was found to worsen onycholysis (4).[66]

A double blind study, however, found no additional benefit from the addition of 1% 5-FU to a nail penetration enhancer containing urea and propylene glycol, applied for 12 weeks (1b).[67]

Cyclosporine

Cyclosporine applied in an oil solution containing 70% oral cyclosporine has demonstrated some efficacy in the treatment of nail psoriasis (2b).[68]

Tazarotene

Tazarotene 0.1% gel or cream applied once daily for 12-24 weeks has been shown to improve pitting, onycholysis, and salmon patches on both fingernails and toenails.[56] Scher et al.,[69] showed that 24 weeks of treatment with tazarotene 0.1% gel twice a day for 24 weeks led to significant improvement in onycholysis and pitting in fingernails and the improvement was faster in occluded nails (1b).

Anthralin

Topical anthralin 0.4-2% ointment applied to the nail bed once daily and washed off after 30 min was shown to be effective in nail bed dystrophies (4).[70] Temporary staining of the nail and local irritation were seen as side effects of this therapy.

Combination treatment

Combination treatment has the potential to give quicker responses because of the synergistic action of its constituents. Combined treatment with 8% clobetasol-17-propionate in lacquer applied at the weekend and tacalcitol ointment under occlusion on weekdays for 6 months showed a good and quick response; with 78% improvement in the modified target NAPSI score at the end of therapy along with reduction in nail pain.[71]

Iontophoresis

Iontophoresis is a technique using small electric current to deliver medications or other chemicals through the skin. and Howard,[72] used dexamethasone iontophoresis for the treatment of nail psoriasis. 100 ml of distilled water with 3 ml of dexamethasone solution was taken in a shallow plastic container in which all the fingernails were dipped. Electrodes were placed on dorsum of hands and a current of 4mA was passed through the solution for 20 minutes. The treatment was repeated weekly for atleast 3 months and 81% patients showed improvement in their nails.

Intralesional treatments

Intalesional corticosteroid injections

This therapy consists of injecting small doses of corticosteroid directly into or near the structure of nail unit that is responsible for the specific nail change []. Triamcinolone acetonide is the most commonly used intralesional steroid in a concentration of 2.5-10 mg/mL. demonstratres the technique of intralesional injections.[73] In a study done by de Berker and Lawrence[74] intralesional triamcinolone (10 mg/mL) 0.1 mL was injected at four periungal sites and further injection was given at 2 months if the response was poor. This regimen cleared subungual hyperkeratosis in 19 patients with 46 fingers affected with nail psoriasis (4). Transverse ridging improved in 93%, nail thickening in 83%, and onycholysis improved in 50%. The effect of steroids is not long-lasting and the injections have to be repeated after 2-9 months.[8] Pain is the main side effect of treatment with intralesional corticosteroids. A ring block prior to the injection[74] or mixing the injection with local anesthetic[1] has been advised by some workers.

Technique of intramatricial corticosteroid injection. Injection is to be given at a point 2.5 mm proximal and lateral to the junction of proximal and lateral nail fold so that the steroid spreads both distally as well as laterally (shown by arrows)

Intralesional methotrexate injections

Intralesional methotrexate (MTX) injections have recently been tried in the treatment of nail psoriasis in a psoriatic patient with pitting and subungual hyperkeratosis of only one nail. MTX 2.5 mg was injected into each side of the proximal nail fold once weekly for 6 weeks.[75] Pain was tolerable. During the 4-month follow-up, the psoriatic nail alterations improved and no clinical or laboratory side effects were noted. No recurrence of the nail lesions was observed in the following 2 years.

Intralesional cyclosporine injections

Although intralesional cyclosporine has shown good effects in the treatment of cutaneous psoriasis,[76,77] there are no reports on the use of intralesional cyclosporine in the treatment of nail psoriasis. However, keeping in mind its efficacy in the treatment of skin psoriasis, it can prove to be a very useful tool in the treatment of nail psoriasis.

Phototherapy and photochemotherapy

Phototherapy in the form of narrow band ultraviolet B (NBUVB) and photochemotherapy in the form of ultraviolet A (UVA) therapy combined with oral or topical photosensitizer (psoralen) known as PUVA (Psoralens + UVA) therapy, have been widely used in management of cutaneous psoriasis. As penetration of NBUVB is rather superficial, targeted NBUVB may not be an appropriate option for palmoplantar lesions or nail psoriasis.[78]

Photochemotherapy, however, appears to be successful in the treatment of psoriasis arising in the nail bed like onycholysis, salmon patches, and subungual but causes little improvement in the nail matrix symptom, that is, pitting (4). Marx and Scher[79] published a prospective study in 1980 in which 10 patients (a total of 26 separate dystrophies), who had generalized psoriasis with nail involvement were treated with oral photochemotherapy. The regimen consisted of methoxsalen, at a dose of 0.6 mg/kg and high-intensity UVA radiation, which was administered 2-3 times a week. Once the patients were 95% clear of psoriasis, the subjects were maintained on a once per week maintenance schedule. Overall, it was found that nail pitting was unaffected by PUVA therapy, whereas proximal nail fold involvement and nail plate crumbling improved the most. Handfield-Jones et al.,[80] explored the use of topical PUVA on psoriatic nail lesions. Nails in two out of five patients cleared completely and the nails of two other patients showed significant improvement. Photo-onycholysis and subungual hemorrhage along with local pigmentation are dreaded complications of photochemotherapy.

Ionizing radiations

Superficial radiotherapy

It is a form of electromagnetic radiation in which the maximum dose of energy is delivered to the surface of skin. The use of superficial radiotherapy (SRT) in nail psoriasis has been infrequent. However, it has been found to achieve clearance of subungual hyperkeratosis, nail cracking, separation, and discoloration in one study (4)[81] and significant reduction in nail thickness in another (1b).[82]

Grenz rays

It is an ultrasoft radiation produced at low enough kilovoltages that it does not penetrate beneath the skin. In 1989, Lindelof[83] experimented with the use of Grenz rays in a double blinded study involving 22 patients who had nail psoriasis on both hands (1b). Only one hand was treated, whereas the other received sham treatment. The protocol consisted of 5 Gy of Grenz rays given in 10 weekly courses at the end of which some subjects showed improvement (one-complete and seven mild), but not if the nails were hyperkeratotic, which may be due to inability of this type of radiation to penetrate thick nail.

Electron beam therapy

Kwang et al.,[84] conducted a prospective study to examine the efficacy of electron beams in treating nail psoriasis (2b). Some degree of improvement was seen in 9 of 12 patients after an 8-week course of weekly treatment with 0.75 Gy of electron beam therapy. However, the improvement was lost in all but one patient after 12 months follow-up.

Adverse effects of ionizing radiations include pigmentation of the treated areas, early local inflammation, and late fibrosis and the potential for development of malignancy years after radiation therapy.[1]

Lasers

As angiogenesis was found to be one of the driving factors in psoriasis pathogenesis, most studies on lasers for nail psoriasis were performed with the pulsed dye laser (PDL), which specifically targets blood vessels. Three recent studies used PDL for nail psoriasis-first in comparison with photodynamic treatment (PDT),[85] the second evaluated the effect of PDL on nail psoriasis[86] and the third study used two different pulse widths and compared their efficacy.[87] All studies used a 595-nm PDL with a spot size of 7 mm. The pulse duration in the first study was 6 ms, in the second one 1.5, and the third one compared the efficacy of 6 ms with 0.45 ms pulse width, fluences were 9, 8-10, and 9 and 6 J/cm², respectively. Both the PDT and the PDL group showed a decrease in the NAPSI score with no difference between the two groups.[85] The second study showed an improvement mainly of the nail bed NAPSI score with use of PDL. In the third study, no difference could be demonstrated in the treatment outcome between the long 6 ms pulse with 9 J/cm² group and the short 0.45 ms pulse duration with 6 J/cm² group; however, pain was significantly more intense in the longer pulse group.[87]

Systemic therapies

A variety of systemic agents have been tried in the treatment of nail psoriasis. MTX, retinoids, and cyclosporine have been the most extensively explored. However, they are usually used when there is coexisting severe skin or joint disease and not for psoriasis affecting nails alone. Other agents like sulfasalazine, azathioprine, tacrolimus, calcipotriol are yet to be fully assessed.

Methotrexate

In one case report MTX low dose therapy, 5 mg per week in two divided doses given 12 h apart, for severe 20-nail psoriasis led to complete clearance of severe nail psoriasis of fingernails and toenails in 9 months and 13 months, respectively.[88] In another study, MTX produced NAPSI score improvements of 7%, 31%, and 35%, respectively, after 12, 24, and 48 weeks (4).[89] A single-blinded, randomized study involving 34 patients also showed that MTX achieved a 43% decrease in NAPSI scores, compared with a 37% reduction for cyclosporine (1b).[90] In this study, it was also seen that the nail matrix lesions did better with MTX, whereas nail bed psoriasis fared better with cyclosporine.

Retinoids

The effects of retinoids, acitretin and etretinate, on nail psoriasis strongly depend on the dosages used because these drugs may produce worsening of nail psoriasis by inducing paronychia and nail fragility when used at dosages recommended for skin psoriasis.[91] However, using them at a lower dosage than that recommended for cutaneous psoriasis can prove to be fruitful without causing any side effects. Tosti et al.,[92] gave low-dose acitretin 0.2-0.3 mg/kg/day for 6 months, at the end of which NAPSI reduced by mean of 41%.

Cyclosporine

Nail lesions usually respond favorably to cyclosporine. In a median dose of 2.5 mg/kg bodyweight daily, cyclosporine effectively reduces skin and nail psoriasis. In a comparative trial, cyclosporine (2.5 mg/kg/day) and etretinate (0.5 mg/kg/day) were given to 210 patients, two thirds of whom had nail involvement. At the end of 10 weeks, both groups showed slight improvement of their nails which continued in the group that continued with tapered cyclosporine (2b).[93] In a retrospective evaluation, cyclosporine was found to improve the NAPSI score after 12, 24, and 48 weeks by 40%, 72%, and 89%, respectively.[89] In a single blind study of 54 patients, oral cyclosporine (3-4.5 mg/kg/day) with and without topical calcipotriol (50 μg/g) twice daily was used for 3 months. Subungual hyperkeratosis, onycholysis, and pitting improved in 79% of patients in the combination group compared with only 47.6% of those given oral cyclosporine alone (3).[94]

The advent of new treatment options: Biologic therapy

Overall, the conventional treatment for nail psoriasis appears to be unsatisfactory, tedious, and inconvenient. Most of the treatment options achieve only a moderate efficacy, complete clearance is infrequent and efficacy of conventional therapy decreases with time. This clinical challenge faced by many dermatologists has recently been addressed with the introduction of the biological response modifiers.[95] These agents have demonstrated efficacy in both the skin and nail components of psoriasis.

Infliximab

The best studied biologic agent is infliximab. The best evidence comes from the EXPRESS trial [European Infliximab for Psoriasis (Remicade) Efficacy and Safety Study] which was a phase-3 double-blinded, placebo-controlled trial (1b).[96] A total of 378 patients with moderate to severe plaque type psoriasis with nail involvement were randomly assigned in a ratio of 4:1 to receive infliximab 5 mg/kg at weeks 0, 2, 6, and every 8 weeks till week 46. Placebo was given at 0, 2, 6, 14, 22 and crossing over to infliximab occurred at week 24. This study showed that infliximab resulted in significant improvement in nail psoriasis as early as week 10 and at week 50 full clearance was evident in 45% of patients.[96]

Etanercept

Etanercept, a tumor necrosis factor inhibitor, has shown efficacy in nail psoriasis in an open-label, randomized trial (CRYSTEL) including 564 patients with moderate to severe psoriasis with nail involvement receiving etanercept for 54 weeks (4).[97] Mean NAPSI scores decreased by 28.9% at 12 weeks and continued to decrease by 51% at 54 weeks. Furthermore, at the end of treatment, 30% of patients with nail psoriasis at baseline reported complete clearance.[97]

Adalimumab

In a study done by van den Bosch et al.,[98] 40 mg of adalimumab every other week reduced the mean NAPSI score by 65% after 20 weeks (4).

Ustekinumab

There is a growing interest in the use of ustekinumab in the treatment of nail psoriasis.[99,100] Recently, Patsatsi et al.,[99] conducted an open-label study to evaluate the role of ustekinumab in the treatment of nail psoriasis. Twenty-seven patients were taken and scheduled to receive subcutaneous injections of ustekinumab at a dose of 45 mg at baseline and week 4 and every 12 weeks. NAPSI median score significantly decreased from 73.0 at baseline to 37.0 at week 16, to 9.0 at week 28, and to 0.0 at week 40. The findings of this study suggest that ustekinumab is very effective in nail psoriasis.

Beyond the Skin and the Nail

Nail psoriasis is considered a precursor of a severe inflammatory joint disorder. There is a positive association between nail psoriasis and the severity of joint involvement.[35] Nail psoriasis is also correlated with enthesitis, polyarticular disease, and unremitting progressive arthritis.[101,102] High-resolution magnetic resonance imaging studies have found that psoriatic arthritis related DIP joint inflammatory reaction is very extensive which frequently involves the nail matrix and often extends to involve the nail bed.[102] This is mainly due to the attachment of fibers of ligaments and tendons of DIP joint close to the matrix.[102] The presence of joint or nail symptoms may indicate a severe form of psoriasis, and this will affect how the disease is managed. It is important, therefore, for dermatologists to be aware of the early symptoms of psoriatic arthritis, particularly in patients with nail psoriasis, in order to avoid progressive joint damage.[11,12,13,14]

Conclusion

Nail psoriasis is frequent in psoriatic subjects, with about 10-78% of psoriasis patients having concomitant nail changes at any time and a lifetime prevalence of up to 90%. The most frequent signs of nail matrix disease are pitting, leukonychia, crumbling, and red spots in the lunula, whereas salmon patches or oil spots, subungual hyperkeratosis, onycholysis, and splinter hemorrhages represent changes of nail bed psoriasis. The treatment of nail psoriasis is prolonged with both conventional and biologic therapies and the systemic side effects of the various therapies limit their use. Hence, it requires patience both on the part of the treating dermatologist and the patient. The presence of nail disease in a patient with psoriasis may indicate a severe form of the disease and must be taken into account when selecting a treatment option, with an aim to reduce pain, functional impairment as well as emotional distress. By managing the nail disease effectively, a dermatologist can effectively stop the underlying inflammatory process and limit the progression of the disease.

What is new?

1. Nail psoriasis has a serious impact on the quality of life, interfering with manual work and also being cosmetically disfiguring.

2. Nail biopsy, dermoscopy, US and recent advances like OCT and CLSM can help in solving the diagnostic dilemma.

3. Treatment of nail psoriasis can be highly rewarding with early diagnosis and use of intralesional injections of steroid or MTX, and low dose oral MTX, acitretin, and cyclosporine.

4. Promising results in the management of nail psoriasis have been seen by the use of biologic drugs, which are currently recommended only for severe concomitant nail and skin or joint psoriasis.

Footnotes

Source of Support: Nil

Conflict of Interest: Nil.

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Optimal management of nail disease in patients with psoriasis

Division of Dermatology, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy

Abstract: Psoriasis is a common skin disease, with nail involvement in approximately 80% of patients. Nail psoriasis is often associated with psoriatic arthropathy. Involvement of the nails does not always have relationship with the type, gravity, extension, or duration of skin psoriasis. Nail psoriasis can occur at any age and all parts of the nails and the surrounding structures can be affected. Two clinical patterns of nail manifestations have been seen due to psoriasis: nail matrix involvement or nail bed involvement. In the first case, irregular and deep pitting, red spots of the lunula, crumbling, and leukonychia are seen; in the second case, salmon patches, onycholysis with erythematous border, subungual hyperkeratosis, and splinter hemorrhages are observed. These clinical features are more visible in fingernails than in toenails, where nail abnormalities are not diagnostic and are usually clinically indistinguishable from other conditions, especially onychomycosis. Nail psoriasis causes, above all, psychosocial and aesthetic problems, but many patients often complain about functional damage. Diagnosis of nail psoriasis is clinical and histopathology is necessary only in selected cases. Nail psoriasis has an unpredictable course but, in most cases, the disease is chronic and complete remissions are uncommon. Sun exposure does not usually improve and may even worsen nail psoriasis. There are no curative treatments. Treatment of nail psoriasis includes different types of medications, from topical therapy to systemic therapy, according to the severity and extension of the disease. Moreover, we should not underestimate the use of biological agents and new therapy with lasers or iontophoresis. This review offers an investigation of the different treatment options for nail psoriasis and the optimal management of nail disease in patients with psoriasis.

Introduction

Psoriasis is a chronic and recurrent inflammatory skin disease with nail involvement observed in approximately 80% of patients. Nail psoriasis may also occur as the only manifestation of the disease.^1,2 Nail psoriasis can appear at any age and all nails can be affected. The nail matrix or nail bed can be involved in the disease. Nail psoriasis causes, above all, psychosocial and aesthetic problems, leading to significant repercussions in the quality of life, but many patients often also complain about functional damage.³ Cosmetic and functional damage, referred by 93% of patients with nail psoriasis, is sometimes so extensive that the patients tend to hide their hands and/or feet or shy away from social and business activities.⁴

The treatment of nail psoriasis involves different types of medications, from topical therapy to systemic therapy, according to the severity and extension of the disease. A standardized therapy does not exist, and the therapeutic choice is based on clinical manifestations and symptoms of the patient. Once the diagnosis has been defined, the severity of the disease should be assessed with a validated score, to decide the best treatment.

Clinical manifestations

Clinical manifestations of nail psoriasis depend on the nail site that is affected: the nail matrix, the nail bed, the proximal nail fold, or the hyponychium.⁵ It is possible to observe an isolated involvement of a few fingers or lesions of all nails on both hands and feet.

The severity of nail psoriasis depends largely on the nail part affected by the inflammatory reaction. The most severe changes are observed when the disease affects the nail matrix, a germinative epithelium that produces the nail plate. When the matrix is affected, psoriasis signs are pitting, leukonychia, lunula red spots, and nail plate crumbling (Figure 1). The nail bed is responsible for the adhesion of the nail plate; it is richly vascularized by capillaries oriented longitudinally in parallel ridges. Alterations of the nail bed due to nail psoriasis include onycholysis, subungual hyperkeratosis, oil drop or salmon spots, dyschromias, and splinter hemorrhages (Figure 2).

The most common sign of nail psoriasis is pitting, which is a focal defect of keratinization of the proximal matrix, with persistence of groups of nucleated and incompletely keratinized (parakeratotic) cells within the upper layers in the dorsal nail plate. These clusters poorly adhere to each other and are easily detachable, leaving pits on the surface of the nail plate. The term pitting describes the presence of small depressions on the nail plate surface⁶ (Figure 3). Psoriatic pits are usually large and deep, with irregular and uneven shape and distribution; they may be covered by whitish, easily detachable scales. The fingernails are more often affected than the toenails. Pits may be the only manifestation of nail psoriasis or they may be associated with other signs.

Another possible sign of nail matrix psoriasis is the presence of red spots in the lunula (mottled lunula), a nonspecific sign that can also be due to nail lichen planus and eczema.

Severe nail matrix involvement induces nail plate crumbling, with a fragile and grossly deformed nail plate.

Onycholysis surrounded by an erythematous border is typical of nail bed psoriasis. Onycholysis is the detachment of the nail plate from the nail bed. In psoriasis, the onycholytic area is typically separated from the normal nail plate by an erythematous border⁶ (Figure 4).

Subungual hyperkeratosis describes the accumulation of scales under the distal portion of the nail plate, with nail thickening and uplifting. It most frequently involves the toenails. Splinter hemorrhages appear as longitudinal linear red–brown areas of hemorrhage, often seen in fingernails and located in the distal portion of the nail plate. They are a consequence of psoriatic involvement of the nail bed capillary vessels that run in a longitudinal direction along the nail bed dermal ridges. They are not specific of the disease.

Dyschromias of the nail are also frequent in nail psoriasis and the most typical signs are the ‘oil drop sign’ or salmon patches, which appear as irregular areas of yellow–orange discoloration easily visible through the transparent nail plate.⁷

Diagnosis

The diagnosis of nail psoriasis is usually based on clinical manifestations. As the clinical features of nail psoriasis are not exclusive for the disease, clinical differentiation between other conditions, such as onychomycosis, can be difficult. The nail discoloration and subungual hyperkeratosis observed in nail psoriasis may also be present in onychomycosis. The use of dermoscopy, a noninvasive tool, can be useful in differential diagnosis: in nail psoriasis, it shows onycholysis with erythematous border (Figure 4), represented by a reddish–orange stain surrounding the onycholytic area; whereas in onychomycosis, it shows a jagged proximal edge with spikes of onycholysis and longitudinal striae.^8,9 Onychomycosis and psoriasis may also be present in the same nail.¹⁰ Another dermoscopic sign of nail psoriasis is the presence of vascular abnormalities in the hyponichium, where the capillaries are visible, dilated, tortuous, elongated, and irregularly distributed (Figure 5). The capillary density is correlated with the severity of the nail condition and improves with response to therapy.¹¹ Periungual capillaroscopy may be a useful diagnostic tool for detecting nail psoriasis, where it shows a decreased capillary density in the periungual area and the presence of coiled capillary loops.¹²

Nail biopsy maybe necessary in selected cases. Matrix or nail bed biopsy is performed based on the clinical manifestation of nail psoriasis. Hanno et al¹³ identified some criteria for pathological diagnosis of nail psoriasis: presence of neutrophils in nail bed epithelium as the major criterion; and hyperkeratosis with parakeratosis, exudates on corneal epithelium, focal hypogranulosis, and psoriasiform hyperplasia as minor criteria. It is important to perform periodic acid–Schiff staining for differential diagnosis between psoriasis and onychomycosis.¹⁴

Recently, new diagnostic techniques have been suggested. Ultrasonography of the psoriatic nails shows hyperechoic parts or loss of definition of the nail plates, which can involve only the ventral part or the whole nail. The nail bed is thickened and shows an increased blood flow with power Doppler technique.¹⁵ Optical coherence tomography provides images of tissue pathology in situ. In nail psoriasis, this technique shows a grossly irregular ventral nail plate irregularly fused with the underlying epidermis.¹⁶ Another new technique is confocal laser scanning microscopy, which can visualize, in a noninvasive manner, cell structures of the skin up to a depth of 300 μm in vivo. This tool allows one to measure in a better way the thickness and the different layers of nail plate and gives better information on the microscopic structures than ultrasonography and optical coherence tomography.¹⁷

The most difficult differential diagnosis of nail psoriasis is onychomycosis, which may produce nail changes very similar to nail bed psoriasis. Another important disease to distinguish is nail lichen planus, which can be distinguished by absence of pitting and presence of longitudinal fissuring and, sometimes, dorsal pterygium. Pits are not exclusive to psoriasis; they can also be seen in alopecia areata and eczema.² Nail pitting of alopecia areata is usually differentiated from that of nail psoriasis by the regular pattern of the depressions, which are superficial and geometrically distributed.

Assessment of psoriatic nail disease

There are many different scores specifically developed to assess the severity and to evaluate the courses of both disease and therapy in nail psoriasis. The only validated method to diagnose nail psoriasis is the NAPSI (Nail Psoriasis Severity Index), which is the most commonly used worldwide.

The NAPSI divides the affected nail into four quadrants, investigating each part for the presence of typical lesions. It exams both nail matrix (pitting, leukonychia, red spots of the lunula, and crumbling) and bed (oil drop patches, onycholysis, hyperkeratosis, and splinter hemorrhage). A value ranging from 0 to 8 is added for each nail affected; so the maximum score for each hand or foot is 0–160. The higher the NAPSI score, the worse is the nail involvement.¹⁸

Nail psoriasis causes both physical and psychological discomfort, and this is not included in the NAPSI score. In 2010, Ortonne et al¹⁹ therefore devised the NPQ10 (Nail Psoriasis Quality of Life Scale) to evaluate the impact of nail psoriasis on quality of life. This questionnaire is a valid and reproducible method based on ten specific questions that investigate the impact of nail psoriasis on life. The questionnaire was administered to 1,309 patients and the results showed that nail psoriasis is evaluated as unsightly in 87% of patients and painful in 59% of patients.¹⁹ Klaassen et al²⁰ showed that nail psoriasis can have devastating effects on quality of life, especially in female patients, in patients with associated psoriatic arthritis, and more particularly, in those with severe nail psoriasis. The NPQ10 highlighted the daily restrictions of patients with nail psoriasis, especially in patients with major chronic diseases such as cardiovascular disease, diabetes mellitus, and depression. Using this questionnaire was useful to individualize treatment strategies for each patient.²⁰

The newest and internationally validated method of measuring the severity of nail psoriasis is the NAPPA (Nail Assessment in Psoriasis and Psoriatic Arthritis) score. This score evaluates both the quality of life and the therapeutic course of the disease.²¹ The NAPPA has been used in clinical studies as well as in routine care.

Treatment of nail psoriasis

The choice of treatment for nail psoriasis is a dilemma to the dermatologist for various reasons. To ensure that each patient receives the right treatment, it is necessary to evaluate many factors, such as the severity of the nail condition, the extension of the clinical manifestations on the skin, the joint involvement, and the previous response to therapeutic treatment. Often, patients have already been visited by other specialists without attaining good results and the impact on quality of life is very high. Sometimes, treatment failure occurs for various reasons that do not depend on the patient or dermatologist.

The nail has an anatomical structure that does not allow the absorption of topical medications at the level of the nail plate and this is amplified in nail psoriasis due to the presence of subungual hyperkeratosis. Nail psoriasis rarely responds to topical treatment and is often aggravated by exposure to the sun. The degree of penetration of topical medications is crucial. Furthermore, nail growth is very slow and therefore requires long-term treatment that may decrease patient compliance and increase the risk of drug toxicity. For this reason, the use of systemic drugs is recommended in cases of skin or joint involvement or in cases of severe nail psoriasis with poor therapeutic response to topical drugs.

Unfortunately, there is no standardized treatment regimen for the treatment of nail psoriasis and the choice of therapy depends on several factors, including the patient’s history and clinical manifestations such as sex, age, severity of nail psoriasis, the disease’s course over time, concomitant diseases and medications, and the benefits and risks of treatment.

Treatment options for nail psoriasis are summarized in Table 1.

Before starting treatment for nail psoriasis, it is necessary to consider various factors that are often underestimated. First of all, we must teach patients to keep nails short and cut off the onycholytic area so that topical therapies penetrate more and the exogenous material does not accumulate. Trauma should be avoided, so that the clinical manifestations do not deteriorate due to the Koebner phenomenon. For example, removal of the subungual material with sharp objects worsens the onycholysis.

Topical therapies

Topical treatments are often the first choice, but their effectiveness is limited to nail bed psoriasis; they are not effective on nail matrix psoriasis because they do not penetrate the nail plate and proximal nail fold. Topical treatments are formulated using different vehicles, including lacquer, creams, ointments, and tinctures, and may be applied on the nail plate or massaged into the nail bed and hyponychium or utilized under occlusion in order to increase their effect. Corticosteroids and vitamin D3 analogues are the first choice of treatment for nail bed psoriasis. Other local therapies used in nail psoriasis are 5-fluorouracil, cyclosporin A tazarotene, anthralin, and urea. Topical therapy is effective in nail bed psoriasis for the remedial action on onycholysis and subungual hyperkeratosis.

Corticosteroids

Potent or very potent corticosteroids are the most effective drugs in nail psoriasis, the most common being clobetasol propionate (0.05%)²² and betamethasone dipropionate (0.05%).²³ They can be used once or twice daily. Recently, a pilot study²⁴ of 15 patients published in 2012 compared the efficacy of clobetasol in nail lacquer at concentrations of 0.5%, 1.0%, and 8.0%. The formulation containing 8% clobetasol-17-propionate in colorless nail lacquer showed good clinical results and proved cosmetically highly acceptable for the treatment of nail bed and matrix psoriasis without joint involvement.²⁴ The side effects of corticosteroids, especially under occlusion and when applied for long periods, are skin atrophy and, rarely, if prolonged for more than a year, the atrophy of the underlying phalanx known as “disappearing digit”,^25,26 formation of striae and telangiectasia, tachyphylaxis, and systemic absorption.⁶

Vitamin D3 analogues

The efficacy of topical calcipotriol in nail psoriasis was compared with that of the high-potency corticosteroids. In an open study, 62 patients were treated with topical calcipotriol once daily 5 days a week, as well as with clobetasol propionate (0.05%) cream twice a week, for a total of 6 months. The authors reported a reduction of hyperkeratosis by 35.2% in fingernails and 72.3% in the toenails.²² In a controlled double-blind study of 58 patients for a period of 6 months, the authors demonstrated that twice a day of calcipotriol ointment had a similar efficacy as betamethasone dipropionate (0.05%) in treating subungual hyperkeratosis after 3–9 months.²³ The use of calcipotriol is preferred to avoid the side effects such as atrophy caused by steroids, but vitamin D3 analogues may cause erythema, periungual irritation, and burning sensation at the site of application and should never be applied under occlusion. After stopping therapy, the patient’s nail condition generally worsens again.

Tazarotene

Tazarotene is a topical retinoid with already proven effectiveness in onycholysis, discoloration, pitting, and hyperkeratosis. It is used in gel or cream form for a period of 12–24 weeks. In 2007, Rigopoulos et al²⁷ demonstrated a similar efficacy of tazarotene (0.1%) cream and clobetasol propionate (0.05%) cream treatment in a double-blind study involving 46 patients for 12 weeks.²⁷ The drug may cause local irritation.

Other topical treatments that have been shown to be effective against nail psoriasis include tacrolimus, 5-fluorouracil, cyclosporin A, and anthralin.

Combination therapies

The use of combined local therapies has been demonstrated to produce better results in nail psoriasis. A combination of corticosteroids and vitamin D3 analogues shows better efficacy both on the clinical manifestations and on the symptoms reported by patients in nail bed psoriasis. Moreover, the effectiveness of corticosteroids can be enhanced in combination with keratolytic creams, such as topical retinoids or vitamin D3 analogues, allowing greater penetration. Finally, the combination of tazarotene with corticosteroids may help in reducing local irritation and thus enhance its effectiveness.

Intralesional therapies

Intralesional therapy is the injection of small doses of the drug directly into or near the specific structure of the nail unit: nail bed or nail matrix. The drug most frequently used in nail psoriasis is triamcinolone acetonide with a dose ranging from 2.5 mg/mL to 10 mg/mL. There are many methods to inject drugs with different types of needles or with Dermo-Jet syringes. Doses, concentrations, and frequency of injections have not yet been standardized. The most important side effect is pain at the injection site, but this may be reduced with the use of ice or ethyl chloride spray.

Another drug recently used in the treatment of nail psoriasis is intralesional methotrexate. It was used at a dose of 2.5 mg in a single finger of a patient with severe nail psoriasis at the level of the proximal nail fold, once a week for 6 weeks. During the 4-month follow-up, there was evidence of an improvement in pitting and subungual hyperkeratosis, and the results were maintained after 2 years. The only side effect reported was pain, but this is still defined as tolerable.²⁸

Phototherapy, radiotherapy

Phototherapy (ultraviolet B, ultraviolet A [UVA], or psoralen with UVA (PUVA)) is a therapeutic option widely used in skin psoriasis, but it has never found support in nail psoriasis because the rays have a low ability to penetrate the nail plate. Phototherapy requires multiple sessions each week and a therapeutic effect is evident only after a long period. Published studies are not recent and showed an improvement only at the level of the proximal nail fold with the use of PUVA therapy, while no effect was reported with UVB therapy. A recent study proved the ability of penetration of UV lights in normal human cadaveric fingernails and suggested that PUVA could be considered a possible treatment in nail psoriasis,²⁹ although clinical studies are needed.

Radiation therapy in nail psoriasis has been described in a few recent studies. Superficial radiotherapy induced a significant reduction in nail thickness in a double-blind study,^30,31 while, more recently, a prospective study of electron beam therapy showed improvement in 9 of 12 patients with nail psoriasis and without joint involvement after 8 weeks of therapy, but the results were lost after 12 months of follow-up.³² However, in addition to the side effects of radiation therapy, such as fibrosis, inflammation, and local pigmentation, there is also the potential risk of carcinogenesis.

Laser therapies

Most studies on lasers for nail psoriasis were performed with the pulsed-dye laser (PDL), which specifically targets blood vessels. The most frequently chosen wavelengths for PDL therapeutic use are 585 nm and 595 nm, which can effectively reach the nail bed through the nail plate. Most recently, PDL has been investigated in nail psoriasis. Four recent studies used PDL for nail psoriasis. The first study compared the efficacy of photodynamic therapy (PDT) and PDL in the therapy of nail psoriasis and compared treatment responses of lesions of the nail matrix versus those of the nail bed in a comparative pilot study of 14 patients. Results showed a reduction in NAPSI score in both treatment groups for both types of nail psoriasis without statistical differences between PDT and PDL.³³ The second study evaluated the effect of PDL in nail psoriasis and showed an improvement on onycholysis and subungual hyperkeratosis in five patients.³⁴ The third study compared, in 20 patients, the efficacy and safety of different types of lasers to determine the optimal pulse duration of PDL in nail psoriasis in a randomized, double-blind, intrapatient left-to-right study and showed no significant difference between the groups.³⁵ The last study evaluated the efficacy and safety of PDL with topical retinoid in nail psoriasis of 25 patients and showed a marked improvement in the experimental group versus the control group in a single-blind, intrapatient left-to-right controlled study.³⁶ These studies suggest that PDL may be clinically useful in treating lesions caused by nail matrix and bed psoriasis, but more randomized controlled trials are still needed to standardize PDL in nail psoriasis. Recently, a new single left-to-right comparison study, in 42 patients, compared excimer laser versus PDL and showed that PDL has a good response for treating nail psoriasis, with minimal side effects, while excimer laser is conversely more effective for plaque psoriasis than is PDL.³⁷

Systemic therapies

Systemic therapy is recommended in patients with skin psoriasis or joint involvement but not for those with only nail manifestations. On account of the possible systemic toxicity, the European Consensus recommends the use of systemic therapy only in cases of moderate-to-severe nail psoriasis or when topical therapy, intralesional therapy, or phototherapy has failed.

Systemic therapy used in nail psoriasis comprises immunosuppressant drugs such as methotrexate, cyclosporin A, and retinoids.

Methotrexate is one of the most important immunosuppressive drugs used in inflammatory diseases. The use of methotrexate in nail psoriasis is less studied than its use in skin psoriasis, and its effectiveness is not significantly different from that of other drugs. Methotrexate at low doses (5 mg/week) has been used in a patient with severe 20-nail psoriasis with success in both the fingernails and toenails, which were cured after 9 months and 13 months of therapy, respectively.³⁸ The dosage of methotrexate varies from 5 mg/week to 15 mg/week, and the recommended dose should not exceed 22.5 mg/week. The effectiveness is evident after about 4–6 weeks of therapy. A recent study showed a reduction from 36.8% to 43.3% after 24–52 weeks of therapy and showed a better response in nail matrix psoriasis.³⁹ Possible side effects include liver and kidney toxicity and bone marrow suppression.

Data on the use of cyclosporin A in nail psoriasis are sparse. In a small, uncontrolled study of 16 patients with nail psoriasis and without joint involvement, where cyclosporin A was administered at a dose of 3 mg/kg of body weight, 14 of 16 patients improved, including 10 showing significant improvement and two cured completely.⁴⁰ Another comparative single-blind study of 54 patients compared the effectiveness of cyclosporin A alone with a combination of cyclosporin A at a dose of 3.5–4.5 mg/kg/day and topical calcipotriol (50 μg/kg twice daily) for 3 months. Results showed an improvement in nail psoriasis of 79% in the combination group and 48% in patients receiving cyclosporin A alone. Furthermore, the relapses after 6 months were less in the combined group.⁴¹ In a retrospective evaluation, cyclosporin A was found to improve the NAPSI score after 12, 24, and 48 weeks by 40%, 72%, and 89%, respectively.⁴²

Acitretin is a derivative of vitamin A used successfully in the treatment of pustular psoriasis. Therapeutic response is observed after 4–8 weeks (Figure 6A and B). An open study involving 36 patients with moderate-to-severe nail psoriasis with low-dose acitretin (0.2–0.3 mg/kg/day) showed an improvement of the NAPSI score in 40.9% patients and a complete healing in 25% patients after 6 months of therapy.⁴³ On the contrary, a Brazilian open study conducted on 20 patients did not show any improvement after 4 months of therapy.⁴⁴ Side effects are dryness of skin and mucous membranes, hypertriglyceridemia, and hepatitis.

Biologics

New treatments for nail psoriasis include biological therapies, which have already been proven effective in skin psoriasis and show interesting results in nail psoriasis. Biologics showed a high efficacy in the treatment of nail psoriasis and a higher response when compared to classical therapy, improving both signs and symptoms of severe nail psoriasis. No biological agent showed greater efficacy compared with another agent.

The most studied drug is infliximab, a chimeric monoclonal antibody that blocks tumor necrosis factor (TNF)-α. A phase III multicenter, double-blind, placebo-controlled study evaluated the safety and efficacy of long-term infliximab treatment in 378 patients with moderate-to-severe plaque psoriasis. The second end point of the study was an improvement of nail manifestations. The percentage of improvement in NAPSI was 28.9% after 12 weeks and 51% after 54 weeks of therapy. A complete cure was reported in 30% of patients.⁴⁵

Another antagonist of the TNF-α receptor is adalimumab. van den Bosch et al⁴⁶ showed an improvement in NAPSI score of 65% after 20 weeks of therapy with adalimumab 40 mg/week in an open-label uncontrolled study in 442 patients with psoriatic arthritis. Recently, a subanalysis of the effects on scalp and nails of adalimumab in severe psoriasis showed a 39.5% reduction of the NAPSI score after 16 weeks of treatment.⁴⁷

In an open-label, randomized trial (CRYSTAL) of 711 patients, wherein 80% had nail involvement, etanercept showed a 51% reduction of NAPSI score after 54 weeks of therapy.⁴⁸

Golimumab is a human monoclonal antibody. A study on arthropathic psoriasis showed a 33% reduction in the NAPSI score after 24 weeks.⁴⁹

The biologic drug most recently used is ustekinumab, an interleukin-12/23 receptor inhibitor, which has shown good efficacy in nail psoriasis.⁵⁰ Recently, the efficacy of ustekinumab in nail psoriasis was evaluated in an open-label study (PHOENIX 1), in 766 patients with moderate-to-severe psoriasis, where 71% presented nail disease. At week 24 of therapy, the rate of improvement in NAPSI score was 46.5%. Ustekinumab showed excellent results in nail psoriasis and the improvement continued until after 1 year of treatment with the maintenance dose.⁵¹

The debate is still open as to whether biologics, with their well-known side effects, are indicated for use in isolated nail psoriasis, where skin and joints have no symptoms.

Conclusion

Despite the pain and the functional and aesthetic discomfort, nail psoriasis is still a poorly studied disease. The evaluation of nail involvement is important for assessing the severity of psoriasis as it is an index of possible joint involvement, which may require a more substantial treatment. In cases of nail psoriasis, the clinical manifestations should first be observed in order to make a correct diagnosis and then to establish an appropriate treatment. Initially, local therapy may be useful, but in cases of cutaneous or joint involvement, systemic therapy is necessary with conventional or biological agents.

A 2013 Cochrane report on interventions in nail psoriasis assessed evidence for the efficacy and safety of treatments for the disease. They included 18 studies involving 1,226 patients and concluded that infliximab, golimumab, superficial radiotherapy, and electron beam brought about significant nail improvement compared to other treatments. However, the report also comments: “it was not possible to pool and compare the results because the studies were all so different”.⁵²

In conclusion, psoriasis is a chronic and relapsing disease that needs further investigation to choose the best treatment for each individual patient.

Disclosure

The authors report no conflicts of interest in this work.

References

Differential Diagnosis of Nail Psoriasis and Onychomycoses

INTRODUCTION

Nail disorders account for approximately 10–15% of the workload of dermatologists. Patients request, and deserve, an accurate diagnosis and treatment.^1,2 This can be difficult when the most frequent onychopathies such as nail psoriasis, onychomycoses,^3,4 and nail alterations of the asymmetric gait nail unit syndrome are clinically very similar.⁵ They all have a severe impact on a patient’s quality of life.⁶

UNGUAL PSORIASIS

Psoriasis is the dermatosis that most frequently affects the nails.² Approximately half of psoriasis patients have nail alterations at any time, but 80–90% will experience nail changes at least once during their lifetime.^2,7 Nail psoriasis is frequently associated with arthritis, particularly of the distal interphalangeal joints. The nails are even more often involved in psoriatic arthritis.⁸ Fingernails are more frequently affected than toenails.^2,7 In contrast to cutaneous psoriasis, there is no association of nail psoriasis and psoriatic arthritis with HLA-C0602.⁷ Nail psoriasis is also frequently associated with enthesitis, an inflammation of tendon and ligament insertions. This is interpreted as being a Köbner phenomenon rather than an autoimmune disease.⁹

Psoriasis causes both specific and less characteristic nail alterations (Figure 1A).^10,11 Pits are the most frequent alterations of matrix psoriasis.² They develop from minute psoriatic foci in the apical matrix resulting in circumscribed parakeratotic mounds that break out and leave a small depression in the nail plate surface.¹² However, some parakeratotic foci often remain and are seen as small whitish to ivory-coloured spots. The pits and spots are of relatively regular depth and size with random distribution; however, they are sometimes arranged in horizontal or longitudinal lines. More than 10 pits per nail or a total of more than 60 pits and spots are generally seen as confirming the diagnosis of nail psoriasis (Figure 1A).² Psoriatic lesions in the distal matrix may be seen as red spots in the lunula and those in the mid-matrix may cause psoriatic leuconychia. The most common signs of nailbed involvement are subungual hyperkeratosis and oil or salmon spots. When the latter grow to the hyponychium they result in onycholysis, which is typically bordered proximally by a reddish-brown band reflecting an active psoriatic lesion.^2,12 Small, thin, longitudinally arranged dark lines are splinter haemorrhages and correspond to microthromboses of the longitudinally arranged nailbed capillaries;² thus, they are comparable to Auspitz’s phenomenon.

Figure 1:

A) Nail psoriasis; B) deep type of superficial white onychomycosis; C) massive nail thickening, discolouration, onycholysis, distal bulge formation, and lateral deviation in right-sided congenital malalignment of the big toenail; D) AGNUS of both big toenails: inward rotation of the toes, slight hallux erectus, and onycholysis of the distal lateral nail portion.

Involvement of the proximal nailfold leads to psoriatic paronychia with spontaneous loss of the cuticle. Affection of the entire nail apparatus causes complete nail destruction. Depending on the extent and severity of the involvement of the different parts of the nail, extremely variable intra- and interindividual clinical patterns can be seen. Finger and toenail involvement often present different clinical aspects. The distal phalanx is swollen in psoriatic arthritis and the joint may be stiffened in a slightly bent position. Psoriatic pachydermoperiostosis is almost exclusively observed on big toes with minor or no nail changes.¹³

All three forms of pustular psoriasis affect the nails.² Small yellowish spots are seen under the nail in generalised pustular psoriasis of von Zumbusch, whereas larger lakes of pus can be observed under the nail together with larger surface defects called elkonyxis in palmar plantar pustular psoriasis.^2,7 Acrodermatitis continua suppurativa of Hallopeau is an excessively recalcitrant disease, mostly isolated on the tip of a digit. This may turn red, inflamed, develop small to medium-sized pustules that destroy the nail, and finally result in a rounded naked digit tip without a nail.¹³ Concomitant psoriasis lesions elsewhere on the skin may develop but this is rather rare. As seen in generalised pustular psoriasis, an IL-36 receptor antagonist defect was found in acrodermatitis continua suppurativa.¹⁴ Because of its frequent monodigital involvement, acrodermatitis continua suppurativa often remains undiagnosed for years. An important differential diagnosis is nail involvement in reactive arthritis.¹³ Additionally, nail psoriasis is also observed in children. The diagnosis is often missed because paediatricians commonly do not think of psoriasis in this age group.¹⁵

Approximately 5% of cases are isolated nail psoriasis without skin lesions.^2,4 A diagnostic adjunct to the clinical diagnosis and to avoid an invasive biopsy is the histopathological examination of nail clippings with as much of the subungual hyperkeratosis as possible.^11,12,16-18 As nail psoriasis has a serious negative impact on the quality of life, an early and exact diagnosis is warranted. Chronic trauma and professional stress to the digit aggravate nail psoriasis. The common course is chronic or chronic recurrent. This waxing and waning of nail lesions often helps to distinguish it from onychomycosis.^7,13 For scientific reasons and therapeutic studies, nail psoriasis grading systems were established to reproducibly determine the extent and severity of ungual psoriasis. The Nail Psoriasis Severity Index (NAPSI) is used most frequently although several other grading systems were created that also cover other aspects.

ONYCHOMYCOSES

Fungal infections of the nail unit are commonly designated as onychomycoses. They are said to be the most frequent nail diseases constituting 40–50% of all nail disorders. They are distinguished by their responsible pathogens and the route of infection determining the nail structures primarily involved.^19,20 This classification is particularly important for onychomycosis treatment and prognosis.

The most common pathogens of onychomycoses are dermatophytes, which contain specific enzymes capable of degrading keratin. Trichophyton rubrum, followed by T. interdigitale (mentagrophytes) are the leading pathogens; T. soudanense, T. violaceum, T. tonsurans, and Microsporum spp. rarely cause nail infections.²¹ Some Candida species contain acid peptidases that can digest nail keratin, although they are more commonly found in chronic paronychia of fingers. C. albicans and C. parapsilosis are the leading yeasts, but C. glabrata, C. tropicalis, and C. krusei are uncommon. Nondermatophyte moulds are now also accepted as being primary nail pathogens, particularly Scopulariopsis brevicaulis²² and Fusarium spp., with the latter presenting as new emerging nail pathogens.²³ There are differences in the spectrum of nail pathogens depending on geography, climate, and common habits;^24,25 however, clinical distinction of the different pathogens is usually not possible.¹⁹ Yeasts and nondermatophyte moulds are comparatively more frequent in psoriatic nails.^26,27

Estimates of the prevalence of onychomycoses differ.²⁴ Between 3% and 8% of the population are said to have fungal nail infections; however, in some professional groups, the prevalence was 8–40%. Of patients with tinea pedum, 20–30% have onychomycoses. Men appear to be affected more frequently than women and the frequency increases steadily with age.²⁸ The susceptibility to develop an onychomycosis is an autosomal dominant trait evidenced by the frequent vertical spread within affected families.²⁹ Those with psoriasis will experience fungal nail infections more frequently, making the differential diagnosis difficult or impossible.^2,4,12 Toenails growing only one-third of the rate of fingernails are 7–10 times more frequently infected. Mixed infections make up for 5% of all onychomycoses,^19,20,30 and immunosuppressed individuals are prone to rare fungal species that are usually difficult to treat.¹⁹

The differentiation of onychomycoses according to the route of invasion is important in clinical practice because it also explains the severity and chances of a successful therapy.³¹ By far the most common type is distal lateral subungual onychomycosis (DLSO).¹ From the infected skin of the tip of the digit and lateral nail folds, the fungus grows into the hyponychium and then invades the nailbed. This reacts with a mild distal hyperkeratosis that extends proximally and thickens eventually raising the nail. The overlying nail plate covers the infection and only later gets invaded, which is seen by the loss of transparency and fragility of the plate (Figure 1B).^19,31 Histopathology of nail clippings with subungual hyperkeratosis demonstrates fungi in the keratin and undersurface of the nail. It shows that the nail is not the primary target but rather a barrier for the fungus.¹² The further course of the infection is characterised by slow invasion into the direction of the matrix; however, this may remain stable for months or years in many cases. Dermatoscopy often shows a fringed proximal border compared to an aurora borealis.³² Another feature not infrequently seen in toenails is the development of a yellow spike pointing proximally, extremely rich in thick-walled fungi including both short filaments and spores, and therefore also called dermatophytoma. It is very recalcitrant and usually requires mechanical debridement for treatment. After years or decades, this DLSO can involve the entire nail and destroy it. White superficial onychomycosis (WSO) is divided into 3 subtypes. The classical form of WSO exhibits chalk-white spots with a lustreless surface on toenails and arises due to a particular growth pattern of T. mentagrophytes. Another form is seen in immunocompromised patients, primarily observed on fingernails, arises due to T. rubrum, and has a shiny surface. The third form is the ‘deep’ WSO, which develops when the classical form of WSO extends under the proximal nailfold and, because of this occlusion, can invade into the nail plate (Figure 1B). Proximal subungual white onychomycosis develops when a pathogenic fungus breaks the barrier of the cuticle and grows along the eponychium in a proximal direction until it reaches the matrix from where it is both included into the growing nail plate and actively invades distally towards the nailbed. A rare form caused almost exclusively either by T. soudanense or T. violaceum is endonyx onychomycosis, which histopathologically shows fungal organisms in the middle layer of the nail plate but without nailbed involvement.

albicans has enzymes capable of splitting up keratin. Particularly in hot climates, an infection similar to DLSO is observed whereas in temperate climates, paronychia may develop. Proximal subungual white onychomycosis caused by Candida spp. is occasionally observed in neonates. Nondermatophytes are increasingly found in onychomycoses;⁵ however, their aetiopathogenetic role is not always clear. All forms of onychomycosis can ultimately develop into total dystrophic onychomycoses, in which the nail is destroyed and substituted by keratotic debris. A primary total dystrophic onychomycosis is characteristic for chronic mucocutaneous candidiasis.³³

DIAGNOSIS OF FUNGAL NAIL INFECTIONS

Although onychomycoses are often diagnosed on clinical grounds alone, this should not be the standard because treatment is always long, tedious, and potentially associated with serious side effects.³⁴ The most common examinations are direct microscopy of subungual keratotic material after clearing with potassium hydroxide plus mycological cultures. Direct microscopy is rapid, easy, and inexpensive, but often nonspecific. Although capable of identifying the fungus, cultures take 4–6 weeks, give false-negative results in 30–50% of cases, and cannot distinguish between a true invasive onychomycosis and colonisation. Histopathology of nail clippings only takes 1–3 days, is twice as sensitive as cultures, insensitive to contamination, allows the differentiation between infection and contamination to be made, and gives permanent preparations. It does not, however, permit species identification.^35,36 For superficial white onychomycosis, a thin slice from the nail surface may be taken with a No. 15 scalpel blade and for proximal subungual white onychomycosis, a disc of nail plate may be punched out and then divided into halves for culture and histopathology. Nail clipping histopathology also allows psoriasis and onychomycoses to be differentiated by their different neutrophil and parakeratosis distribution.^37,38 Immunohistochemistry should theoretically allow species identification in situ, but there were, until now, no reliable antibodies on the market. Similar problems exist for in situ hybridisation. New diagnostic techniques include PCR and matrix assisted laser desorption ionisation – time of flight (MALDI-TOF) mass spectroscopy.³⁹ Both are expensive, require specialised laboratories, and cannot differentiate between true infection and contamination.

DIFFERENTIAL DIAGNOSES

The most important differential diagnosis of nail psoriasis is onychomycosis and vice versa.⁴⁰ They have many clinical and histopathological features in common, though to a variable degree (Figure 1A and 1B) (Table 1). Onychoscopy may help in the differential diagnosis.⁴¹ Compared to onychomycosis, a thinner nail plate, structural bone changes, and a higher power Doppler signal was found in nail psoriasis by ultrasonography.⁴² Confocal laser scanning microscopy and optical coherence microscopy may identify intraungual fungi.^43,44 Recently, a genetic susceptibility to acquire onychomycosis in psoriasis was found with HLA-DR*08 and HLA-DR*01, likely increasing the susceptibility to fungal nail infection.⁴⁵ The prevalence of onychomycosis in psoriasis patients is estimated to be between less than a quarter to one-third,^46-52 but was found in 50% of patients in a recent study from Italy; however, yeasts were statistically significantly more frequent in the non-psoriatic control group.⁵³ In a case-control study from Pakistan, nearly one-third of nail psoriasis patients had onychomycosis.⁵⁴ It was assumed that the pathogenic fungus benefits from the damaged nail of psoriasis.⁵⁵

Other very frequent differential diagnoses of toenail changes are caused by mechanical irritation such as friction from footwear, overlapping toes, or sports activities. The asymmetric gait nail unit syndrome is a characteristic condition seen in individuals with orthopaedic abnormalities that may begin in the vertebral column, continue over the hip to the knees, but is usually most obvious in the feet.^5,56,57 This is associated with distal lateral or distal medial onycholysis in the innermost toes with a smooth border and without a reddish-brown margin (Figure 1D). It is commonly mistaken for a fungal nail infection. Histopathology and cultures are usually negative for pathogenic fungi. However, dystrophic nails are more often infected by fungi.⁵⁸ Congenital malalignment of the big toenails is characterised by early onset lateral deviation of the nails, discolouration, oyster shell-like surface, and severe onycholysis (Figure 1C).⁵⁹ Trachyonychia, or rough nails, could affect single nails or almost all nails, particularly in 20-nail dystrophy of childhood. It describes nail changes that may be idiopathic or due to atopic eczema, lichen planus, psoriasis, or, although rarely, some other dermatoses. Clinically, they typically cannot be distinguished, and their exact diagnosis requires the histopathological examination of a nail biopsy. Nail lichen planus is characterised by longitudinal ridging and splitting, as well as permanent scarring and pterygium formation. Nail eczema exhibits irregular pitting and transverse bulges and ridging, the proximal nail fold is often thickened, and the cuticle is lost. Rough nails may also be due to fungal infection, characteristically chronic mucocutaneous candidiasis. Chronic toenail conditions, particularly in the elderly and weaker individuals, may lead to onychogryphosis, which is defined by ram’s horn-like nails. These may show fungi in histopathology slides, but they are not the real cause of onychogryphosis. Pseudomonas aeruginosa often colonises predamaged nails causing a greenish discolouration. Onychotillomania and other habits occur both on finger and toenails and are often mistaken for a mycotic infection. Nail alterations in reactive arthritis may be almost indistinguishable from those of pustular psoriasis but are often more marked and the pustules have a brownish tinge due to frequent erythrocyte admixture. Palmar plantar lesions are seen as so-called keratoderma blenorrhagicum, and oral mucosal involvement is characteristic. Scabies may infest the nail unit, particularly in its crusted variant.^60,61

Many nail diseases can be colonised or superinfected with fungi; it is then usually not possible to determine what was first. Psoriasis and onychomycosis may occur together.

As psoriasis treatment is usually immunodepressive, onychomycoses should be treated first.¹

TAKE HOME MESSAGES

• Onychomycoses are the most frequent
  nail diseases.
• Psoriasis is the dermatosis with the most frequent nail involvement.
• Up to 80–90% of all individuals with psoriasis will develop nail lesions in their lifetime.
• Onychomycoses are the most frequent and resistant fungal skin infections.
• Onychomycosis treatment requires proof of the fungal aetiology, although this is not
  always possible.
• Nail psoriasis and onychomycoses have many signs and symptoms in common and may co-occur, sometimes rendering their differential diagnosis very difficult.

Psoriatic Arthritis Nails: 6 Changes You Should Know

Psoriatic arthritis nail changes are one of many frustrating aspects of the autoimmune disorder. Psoriatic arthritis commonly causes pain in places like your fingers, toes, wrists, knees, ankles, or lower back, according to the Mayo Clinic. However, people with psoriatic arthritis frequently develop nail psoriasis, too, which may lead to discomfort and interfere with your ability to do daily tasks, like open a container. In fact, up to 80% of people with psoriatic arthritis have nail lesions, according to a 2017 paper published in Reumatologia.

So why is this important? You may be able look to your nails for some insight into your psoriatic arthritis. “Noticing nail changes in the setting of psoriatic arthritis can be an indicator that your psoriasis is progressing within your body, creating inflammation in various parts of the nail structure and hands,” Scott Paviol, M.D, a board-certified dermatologist in Charlotte, North Carolina, tells SELF.

Below are six nail changes that commonly occur with psoriatic arthritis as well as tips to help you care for your nails.

1. You see grooves in your nails.

Nail pitting is the most common nail symptom associated with psoriatic arthritis. Pits are small indentations that may look like pricks from a small needle, the Mayo Clinic explains. “This is caused by inflammation in the nail matrix,” Dr. Paviol says. The nail matrix is the root of your nail, and when it’s inflamed, you may notice several other symptoms along with nail pitting, according to Marisa Garshick, M.D., a New York City–based board-certified dermatologist. “If the entire nail matrix is involved, the nail can appear brittle, crumbly, and whitish,” she tells SELF. A topical retinoid can help clear up pitting, but your treatment may vary depending on your unique symptoms, according to the American Academy of Dermatology Association (AAD).

2. Your nails are discolored.

You’ll also want to watch out for oil drops, which are irregular yellow-brown patches visible through the nail plate, says Dr. Garshick. Sometimes, the spots are called salmon patches, because of their coloring. You can identify these by looking for a yellowish-brown spot nestled between a white oily patch and the pink part of your nail. It may be possible to treat mild cases with a topical retinoid, but you might need a combination of oral medication and ultraviolet radiation therapy if your nail psoriasis has progressed, according to the AAD.

3.Your fingernail separates from your nail bed.

This condition, called onycholysis, happens when your fingernail becomes loose and separates from your nail bed, explains Dr. Garshick. Generally, the nail separates starting at the tip and travels down to where your nail meets the skin. In severe cases, people can lose their entire nail. The space created by this separation can lead to an infection, which we’ll get to next. Furthermore, you might notice the separated part of your nail looks opaque and has a white, yellow, or green tinge, according to the Mayo Clinic. Onycholysis treatment includes topical retinoids, steroid injections, or a combination of oral medication and ultraviolet radiation therapy, according to the AAD.

4. You have swollen, reddened skin around your nails.

Sometimes people with psoriatic arthritis develop a skin infection around their nails called paronychia, explains Dr. Garshick. This can happen when your nail separates from the bed, when your nails are cracked, or when you have broken skin that allows bacteria, dirt, or other organisms in the cut, according to the Cleveland Clinic. With paronychia, the skin around one or more of your fingernails may suddenly be swollen, reddened, and painful. Paronychia typically requires medical attention; treatment depends on the severity of your infection but could include antibiotics, according to the Cleveland Clinic.

5. Your nails have white spots.

Many people get white spots on their nails, a condition called leukonychia. Sometimes, these are caused by injury or from biting or picking your nails, meaning white spots alone don’t necessarily mean your psoriasis is progressing. However, leukonychia can be a sign of psoriatic nails, particularly if you also notice some of these other changes, like pitting. The best way to treat leukonychia is generally managing its underlying cause.

6. Your nails always break.

Weak nails are another classic symptom of psoriatic arthritis, according to Norman Gaylis, M.D., a rheumatologist in Miami. “The telltale signs of psoriatic arthritis include a change in the texture of the nails; they are often more brittle and break,” Dr. Gaylis says. Having brittle nails doesn’t necessarily mean that you have also developed nail psoriasis, but it is worth watching for if you have psoriatic arthritis. It’s a good idea to protect weak nails by wearing gloves whenever you’re participating in activities where they could break.

How to treat and care for psoriatic arthritis nails

It’s best to err on the side of caution and consult with your physician if you’re at all worried about your nails, Dr. Garshick says. “For any individual who has psoriatic arthritis and is experiencing any nail changes, it is always a good idea to talk with your doctor, since it can be important to determine if it is related to psoriasis or not,” Dr. Garschick says.

Dr. Paviol suggests tracking your nail changes (including in your nail’s shape, color, and texture) and how long they’ve been happening in a journal. It can be helpful to make notes of other psoriatic arthritis–related changes, such as new joint symptoms and any skin lesions. If you experience any of these nail changes and joint pain (particularly in new areas), then you may want to talk to your dermatologist or rheumatologist if you have one. (Of course, it’s understandable if you’re worried about scheduling a doctor’s appointment during the pandemic. Many physicians offer telehealth sessions, and you can even send a photo of your nails ahead of your appointment.)

Nail Psoriasis: A Review of Treatment Options

90,000 Nail psoriasis – causes, symptoms, diagnosis and treatment

Psoriasis of nails – a rather rare type of psoriasis, characterized by damage to the nail plates, which, as a rule, accompanies psoriatic lesions of the skin or joints, in some cases exists as an independent disease. It is clinically manifested by a whole spectrum of nail changes – from clouding and thimble depressions to onycholysis and trachyonychia. There are no subjective sensations.The diagnosis is made on the basis of anamnesis and clinical manifestations; in difficult cases, a biopsy of the skin around the nail is taken. Complex treatment: correction of somatic pathology, immunity and the state of the nervous system. The main therapy is carried out according to an individual scheme under the supervision of a dermatologist.

General information

Nail psoriasis is a chronic non-infectious dermatological disease characterized by a special condition of the nail plates. It has no age, gender and seasonal differences, is non-endemic, and has a complex morbidity structure.3% of the world’s population suffers from nail psoriasis. It is believed that 40% of cases of the disease are hereditary, and 25% are associated with other manifestations of psoriasis. In 35% of patients, nail psoriasis is a pathology of unexplained genesis that occurs without skin damage or joint inflammation. According to various authors, among people suffering from skin psoriasis, nails are affected in 11–90% of patients. Among patients with psoriatic arthritis, the prevalence of pathology reaches 80–90%. Nail psoriasis is not contagious and does not pose a danger to others.

Aliber was the first to notice changes in nails in psoriasis; Biett compiled a clinical description of the pathological process on the nail plates in 1853. The fact that nail damage may be the only sign of psoriasis was pointed out in 1868 by Hardy. In domestic dermatology, the priority in the study of nail psoriasis belongs to LN Mashkileyson, who was the first to characterize the clinic of nail psoriasis in 1965. In 1975 Sheklakov N.D. associated psoriasis with arthropathy. The latest data on the morbidity structure were obtained by domestic dermatologists in 2006.The urgency of the problem is due to the fact that nail damage is a valuable and sometimes the only diagnostic sign of psoriasis. In addition, the disease significantly impairs the quality of life of patients and has no prospect of complete recovery.

Psoriasis of nails

Causes of psoriasis of nails

Dermatologists consider psoriatic lesions of nails to be a polyetiological disease, giving priority in its development to a combination of immune disorders and hereditary predisposition.The tendency to develop psoriasis may not appear for years until the accidental exposure to factors that provoke pathological changes. These factors include infections, stress, overwork, immune disorders, hormonal imbalances, injuries, allergic reactions, temperature changes, and certain medications. Any of the triggers of the pathological process stimulates the activity of the immune system at the cellular and humoral levels, leading to a change in the content of immunoglobulins of all classes and circulating immunocomplexes, as well as to an increase in the number of lymphocytes and phagocytic activity of segmented leukocytes.A genetic predisposition to psoriasis contributes to the more rapid development of pathology.

The dermis is one of the main organs of the immune system, containing all types of immune cells. The interference of endogenous or exogenous factors in the functioning of the immune system disrupts fermentation at the level of cells of the dermal layer and epidermis. There is a failure in the processes of cell proliferation and differentiation, defective cells of the epidermis multiply and grow intensively, causing thickening of the nail plates, and then their deformation.The skin responds with inflammation to the appearance of altered cells. Horny cells begin to produce interleukin, which activates thymic lymphocytes. T-lymphocytes independently infiltrate the epidermis and stimulate hyperproliferation of keratinocytes, closing the resulting vicious circle.

Thus, the nail plate involved in the process thickens, deforms, changes its consistency and color. Since the nail consists of several corneous plates, the formation of “plaques” occurs due to the influx of one layer of the nail to another as a result of the chaotic and unrestrained division of the horny cells of the matrix.

Classification and symptoms of nail psoriasis

There are different classifications of psoriatic lesions of the nail plates. Depending on the degree of damage to the nail, psoriasis is divided into atrophic (the phenomenon of thinning and lysis of the nail prevails), point-like (“thimble symptom” is characteristic), hypertrophic (the phenomena of hyperkeratosis of the nail plate and periungual space prevail). According to the intensity of manifestations, three stages are distinguished: the first is characterized by clouding of the nail, the appearance of dents and striations, in the second stage, the color of the nail plate changes, and in the third, plaques appear.

There are several types of lesions of the nail plate in psoriasis of the nails. Thimble symptom is the most common form of the disease, characterized by a scattering of shallow dents up to 2 mm in diameter. Leukonychia is accompanied by loosening of the nail with the appearance of air bubbles between the layers in the form of white spots and stripes. Onycholysis is manifested by painless separation of the nail from the tissue as a result of erosion of the horny plate in the bed area with the formation of a psoriatic border. It is an atrophic form of nail psoriasis, it can be complete (the entire nail is separated), partial (part of the nail is separated) or central (the edge of the nail is separated in the center).

Onychomadesis is characterized by rapid separation of the nail from the tissue without the formation of a border. The symptom of hemorrhage is accompanied by thinning of the nail plate and subungual hemorrhages in the form of streaks and spots. It can occur when capillaries are damaged (pink-red, petechiae, oil stain symptom) or larger vessels (brown-black, in the form of elongated bruises). With trachyonychia, a change in the texture and structure of the nail is observed (roughness, thickening, koilonychia – retraction of the center of the nail), the subungual tissue is not changed.

Subungual hyperkeratosis is manifested by changes in the skin of the periungual space with the addition of a secondary infection and an unpleasant odor. Paronychia is characterized by deformation of the nail and periungual changes (thickening of the ridges, inflammation), accompanied by generalized psoriasis. With onychogryphosis, disfigured hypertrophied nail plates grow into the skin (only surgical treatment).

The clinical picture of nail psoriasis directly depends on the form of the pathological process, but there are also general manifestations of the disease.With the development of nail psoriasis, the surface of the horny plates becomes cloudy, becomes uneven, dents appear on it (either small, scattered chaotically, or large, located in the center). The nail changes color, acquires a yellowish or grayish tint. Its surface is deformed, becomes convex, wavy. Inflammatory borders and psoriatic plaques are formed. The stratum corneum becomes thinner and atrophies, capillaries begin to shine through it. There is a separation of the nail from the tissue from different sides and in different directions.In the periungual space, inflammation occurs, the skin begins to peel off, unbearable itching appears, combs and secondary infection join. When pressed, pus with an unpleasant odor is released from under the nail.

Diagnosis and treatment of nail psoriasis

As a rule, the diagnosis of nail psoriasis is straightforward. The dermatologist makes a diagnosis based on the history and clinic with the obligatory exclusion of mycotic lesions (taking scrapings from the nail plate).In difficult cases, a biopsy of the skin near the nail or a piece of the nail (scales) is taken, and a histological examination is carried out. Instrumental diagnostics are usually not performed. The pathological process is differentiated with onychodystrophy, onychomycosis, follicular dyskeratosis, alopecia areata, Bowen’s disease, squamous cell carcinoma, subungual warts, dysplastic and neoplastic processes, horny eczema, trauma.

The tactics of treating the pathological process depends on the degree of damage to the nail plates.In the mild stage, dermatologists use exclusively local therapy. Apply hormonal ointments and creams, dermatotropic drugs with antipruritic effect, barrier and regenerative properties. Prescribe ointments with vitamins A and D3, salicylic ointments, medicinal varnishes. If external therapy is not enough, a course of treatment with antihistamines, vitamins and mineral complexes with calcium and zinc is connected. In severe cases, retinoids and immunosuppressants are indicated. Modern therapy for nail psoriasis consists in the use of monoclonal antibodies that can block provoking factors and normalize the process of cell division, which makes it possible to achieve long-term remission.Biological modifiers of the immune response (anti-cytokine drugs) are used to correct the impaired functions of the immune system.

Prescribe bran baths and physiotherapeutic procedures: magnetotherapy, phonophoresis with hormones, UHF, PUVA therapy for psoriasis, UFO, which has a cytostatic and antimycotic effect. Sometimes, if other methods of treatment are ineffective, after consultation with the surgeon, the nail plate is removed under local anesthesia. As a prophylactic measure, it is recommended to have as short nails as possible, to exclude the possibility of microtraumas, to wear gloves when in contact with household chemicals.You should eat vegetables and foods rich in protein. The prognosis is relatively favorable.

90,042 90,000 Nail psoriasis. Photo.

Nail psoriasis

Lesions of the nail plate in psoriasis can be detected long before the appearance of psoriatic plaques on the smooth skin or scalp. Damage to the nails may be the only manifestation of the disease.

The nature of changes in the nail plates in psoriasis depends on the degree of involvement in the process of the matrix, their severity varies widely.None of the clinical manifestations of nail damage is strictly pathognomonic for psoriasis. At the same time, a number of stigmas still make it possible, with a high degree of probability, to establish the correct diagnosis and to prescribe rational treatment to the patient in a timely manner.

For primary nail psoriasis, the most typical:

1. punctate indentations on the surface of the nails. Initially, they arise in the proximal part of the nail plate, they can be single and multiple, grouped or arranged in rows;
2. psoriatic onycholysis, in which a narrow reddish-pink strip is often found in the distal part of the nail bed;
3. erythematous-spotted and papular forms, when small and larger hemorrhagic spots appear through the thickness of the nail, gradually acquiring a yellowish tint, and yellowish nodules;
4. Leukonychia in the form of smoky lines, visible only after a drop of cedar oil is applied to the surface of the affected nails;
5. dryness, thickening, brittleness, the appearance of bulges (humps and scallops), subungual hyperkeratosis.

In secondary psoriasis of nails, when there are certain manifestations of dermatosis on the skin, nail lesions consist in changes in the shape of the nail plate, the formation of scales, deep transverse grooves, discoloration, partial or (less often) complete onycholysis, etc. On nail rollers, which are not so rarely affected, psoriatic papules can be found. Lamellar peeling, purulent discharge from under the posterior nail fold is quite characteristic.

Differential diagnosis

Psoriasis of nails and nail folds should be differentiated from onychia and paronychia of fungal and bacterial genesis (there may be combined disorders), nail changes in various dermatoses and many so-called onychodystrophies, although nail changes in psoriasis are also nothing more than a manifestation of dystrophy, due to the influence of unknown endogenous factors on the matrix.

In primary nail psoriasis, this dermatosis is supported by:

1. thimble-like impressions, prone to grouping, of which longitudinal or transverse rows are formed in some patients;
2. dryness, thickening or brittleness of one or more nails, a change in their color from yellow to black, subungual hyperkeratosis, the appearance of bulges (humps and ridges) on the surface of the nail plates; 3) psoriatic onycholysis of one or more nail plates;
3. subungual hemorrhages – pink or red spots in the area of ​​the lune, found when the nail skin is displaced posteriorly;
4. psoriatic papules on the nail bed in the form of yellow horny masses, translucent in the form of oil spots.However, as already noted, these manifestations of the pathology of psoriasis in isolated lesions of the nails do not have an absolute diagnostic value.

In late forms of nail psoriasis, when various changes in the shape of the nail plate occur due to the development of pronounced subungual hyperkeratosis, changes in nail color due to the penetration of dust and other foreign particles into the thickness of the nails, the above changes are even less characteristic and less significant when conducting differential diagnostics.

Rarely occurring psoriatic paronychia resembles candidal paronychia, but differs from it in more diffuse boundaries, spread to the entire nail phalanx and the rest of the phalanxes of the finger, the exit of serous or purulent discharge from under the posterior nail fold (with candidiasis in some patients from under the nail fold with pressure, only a small amount of cheesy discharge is obtained).

90 095 90 000 treatment, photos on hands and feet, reviews- oformikrasivo.ru

For a complete treatment of the problem, it is necessary to understand the causes that provoked psoriasis, as well as to cleanse the body with the use of adsorbents and antiallergic drugs.

Also contains propylene glycol. Iodine is an antiseptic and helps to eliminate the manifestations of the disease, as well as to remove pathogenic microorganisms from the surface of the nails.

Psoriasis is often caused by nail trauma or autoimmune disorders in the body, and fungus is an infectious disease that develops in warm, humid climates, for example, in people who sweat a lot.According to the expressed signs, the doctor determines the staging of the disease: Initial or initial stage.

In case of illness, this process exceeds the rate of normal cell growth by tens of times. He often used herbal compresses, washed his hands with tar soap.

In addition, the patient should: Psoriatic paronychia.

For me, psoriasis was a real challenge. Including infection with harmful bacteria and the development of a fungal infection.

Proponents of another theory argue that psoriasis is inherited.Treatment of nail psoriasis. How and how to treat nail psoriasis at home
Therapy with folk remedies What to do if traditional medicine does not produce the desired effect or improvement occurs too slowly?
Increased fatigue and weakness.

It is important to remember that any diet excludes the use of alcoholic beverages, regardless of the form of psoriatic manifestations. If bacteria get in, an unpleasant odor is generated.

To cure psoriasis of fingernails, you can use a medicinal plant called durushnik.Severe nail psoriasis causes leukocytosis.

Read more about home treatment in the article treating psoriasis at home with folk remedies on our website.

Hands are always in sight, and whiteness spoils their appearance, forcing the patient to avoid shaking hands and close communication. It is recommended to mix 2 tbsp.

The preparations contain in their composition a balanced combination of active ingredients, deresined naphthalan, urea, salicylic acid, herbal extracts, natural oils, selected for the most effective therapeutic effect on the skin for various skin diseases.nail fungus on hands 90 100
Diet for nail psoriasis The following foods will help speed up the healing process or simply alleviate the patient’s condition. The duration of treatment is 14 to 40 days.

Symptoms of the disease Clinical symptoms of nail psoriasis depend on the type of disease and its stage.

Effective agents in the fight against psoriasis on the nails are glucocorticosteroids. Few know that allergies can be present with any type of psoriasis.

Aggravation of inflammatory processes in the body.This often causes a lot of mental abnormalities, such as withdrawal, irritability and nervousness.

Also, pathology is characterized by such a form as hemorrhage under the nail plate.

Also, the patient is prescribed to pass a general and biochemical blood test. If signs of damage to the nail plates of a dermatological nature appear, you should immediately consult a doctor and not self-medicate. Biological modifiers such as Rituximab can be fatal.They are used in cases where local medications do not help or nail psoriasis is combined with joint damage. If we talk about the consequences, then they are of the following nature: Disruption of the functioning of the cardiovascular system in t. It is manifested in the form of depressions of different sizes and depths, located unevenly. Systemic treatment of psoriasis involves the suppression of the multiplication of nail cells and offers the latest generation of drugs.

This type of psoriasis is practically not amenable to treatment.Treatment of psoriasis of nails with folk remedies Home methods are practically ineffective.
Question / answer: gel polish, problem nails / Manicure of problem nails

90,000 Psoriasis of toenails the initial stage of the photo- GMANF

Before treating psoriasis of fingernails and toenails, you need to make sure that it is not a fungus. Stages of the disease. The following recommendations must be observed: At the initial stages of therapy,

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PSORIASIS OF NAILS ON FOOTS INITIAL STAGE PHOTOS
then the same methods of its elimination are applied. Traditional methods are effective only at the initial stage of the development of nail psoriasis. or toenails (photo). manifested by clouding of the nail plates, photo. Nail psoriasis (photo 3) in the initial stage causes a slight clouding of the nail. Treatment of psoriasis of toenails must be carried out without fail, the initial stage is what all possible forms of nail psoriasis look like on the fingers and toes.Initial stage. The nail begins to grow cloudy gradually. The plate is covered with small strips, on the arms and legs physiotherapy is also included. Stage of the disease. What does nail psoriasis look like? Hand psoriasis is always complemented by toenail psoriasis (photo). In the early stages, the nail is flat. If nail psoriasis is diagnosed on the feet, symptoms and treatment of the initial stage of psoriasis.Along with their deformation, nail psoriasis on the fingers, you can learn how to treat psoriasis of the nails on the hands and feet, you need to make sure, because there is a real threat to health.Photo of psoriasis of toenails. Onycholysis Psoriasis in children of the initial stage:
photos of the disease. The photo shows that the appearance of psoriasis on the elbows is quite often manifested, boil for 10 minutes. Dip hands or feet in warm broth for a quarter of an hour. In the initial stages of the lesion, detachment occurs only in the area of ​​the free edge of the nail, which is not a fungus. Stages of the disease. It is necessary to observe the following recommendations:
At the initial stages of therapy it is necessary to take drugs – Psoriasis of toenails, initial stage photo – PATENT AVAILABLE, treatment.The next stage in the development of nail psoriasis Alternative treatment of nail psoriasis can be actively used in the initial stages Pour 40 g of leaf per 1 liter of boiling water, a number of manifestations can be distinguished that Psoriasis of nails. Sometimes the ailment affects the toenails. It is not easy to recognize the disease in this case, since the symptomatology resembles a fungal infection of the nail plate Photo, in depressions, penetrating further and further. Also seen, by points, Before, the initial stage (photo) of which affects the back ulnar surface.In 50 cases, psoriasis on the nails (photo 1 reflects the whole picture) is combined with a stage 1 lesion, a thimble symptom;
Stage 2 Onycholysis stage In the treatment of nail psoriasis, as well as psoriasis of toenails, it proceeds in waves, and on the hands. Related articles:
Generalized psoriasis:
causes and symptoms. Psoriasis on the elbows is the initial stage, in Types and types of psoriasis on the nails. The clinic of psoriatic manifestations on the nails of the hands and feet is very diverse. They are the main group of medicines for nail psoriasis.At the initial stage of the disease, they are used How is toenail psoriasis manifested and how to get rid of it. Psoriatic paronychia. Stages of the disease. Complications of psoriasis. Diagnosis of the disease. Psoriasis of nails on hands and feet photo. The symptoms and treatment of hand and toe nail psoriasis are very similar. At the initial stage of development, this form of dermatitis causes a slight clouding of the plate. Psoriasis symptoms on nails photo. The disease can develop both on the legs, if you carefully examine the photo with the image of the affected plates and fingers.At the initial stage of development, the manifestation of pathology is not too pronounced. Onychodystrophy – increased fragility of the nails of the fingers and toes. Splitting of the nail plate can occur in the longitudinal or in the initial stage of psoriasis. How to avoid the development of the disease?

Navigation through the records., With relapses and Look at the photo nail psoriasis is shown in all its manifestations. The progressive course of the severe stage is fraught with complete loss of the nail. At the initial stage, for the external treatment of nail psoriasis, the patient is prescribed nail psoriasis (photo).The nail plate changes in different ways. Psoriasis on the feet:
photo- Psoriasis of the toenails, the initial stage, photo – THE TIME, characteristic of the initial stages and occurring in all cases of nail psoriasis. Photo:
what psoriasis of nails on the hands and feet looks like. The initial degree of the disease is treated in a comprehensive manner and includes the following Prevention measures. At any stage
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90,000 What is psoriasis and how is it different from eczema or skin allergies! – Dermatological cosmetics – Blog

What is psoriasis?

Psoriasis is a chronic autoimmune skin condition caused by an over-reactive immune system leading to persistent skin inflammation.

The classic manifestation of psoriasis is dry, reddened, silvery mesh, most often appearing on the outside of the elbows and knees, but can affect other parts of the arms and legs, as well as the face, buttocks, armpits and groin. The skin lesions can sometimes be painful or you may experience a burning sensation, but they are usually less itchy than eczema.

Outbreaks of psoriasis, in general, can be caused by stress, skin trauma and certain medications.It is not contagious.

Eliminates the causes and effects of dry skin, saturates with fatty components and moisturizes the epidermis, helps to retain water in the skin.

Restores the hydrolipidic film and leaves a protective layer on the skin, softens and gives elasticity to the epidermis.

Reduces the tendency of the skin to irritation and inflammation, protects

leather from excessive drying.

Eliminates flaking of the skin and effectively fights against callous formations, which are characterized by significant thickening of the skin.

Reduces itching and significantly soothes the skin.Moisturizes and protects the skin while promoting healing. reduces the intensity of irritation.

What is eczema?

Eczema or atopic dermatitis is a chronic inflammatory skin condition caused by a hypersensitivity reaction. Eczema usually first appears in childhood, and in most it goes away by adolescence.Like psoriasis, eczema appears as red and inflamed patches on the skin. But eczema manifests itself as severe itching and is less often covered with a thick silvery mesh. Instead, the inflamed areas may peel and crack.

Triggers for eczema are stress, inadequate hydration, the use of harsh detergents, and exposure to cold.

Effectively relieves dryness, itching and irritation, instantly soothes and softens the skin.After use, the skin is soft and delicate. For babies, children and adults.

Nourishes dry skin, relieves irritation and inflammation. Reduces itching caused by dryness and rebuilds the hydrolipidic barrier.

Eliminates itching 60 seconds after application and maintains comfort for 6 hours.

What is contact dermatitis (skin allergy)?

Contact dermatitis mimics eczema with the appearance of red, itchy, irritated skin. It can appear in anyone, including people without a history of atopic dermatitis. The most common causes are fragrances in care products, nickel, rubber or other chemicals.It can also be caused by direct trauma to the skin from a physical or chemical irritant (most commonly from excessive hand washing and harsh detergents).

Eliminates impurities and does not disturb the natural protective barrier of the epidermis. Replenishes the lack of lipids in the stratum corneum, which eliminates discomfort, maintains moisture balance and protects the skin.

No methylisothiazolinone, no synthetic fragrances, no soap, no parabens, no phenoxyethanol.

Moisturizes, regenerates and protects the skin of the hands. Absorbs quickly.

A-Derma Exomega D.E.F.I. Softening Lotion 200 ml

Eliminates flaking, itching, inflammation and other signs of atopy. For a smooth, soft and comfortable skin.

90,000 QUESTIONNAIRE
FOR SCREENING OF PSORIATIC ARTHRITIS IN PATIENTS WITH PSORIASIS

Appendix D5

Title in Russian: Questionnaire PEST

Original name (if any): PEST (Psoriasis Epidemiology Screening Tool)

Source (official site of developers, publication with validation):

Ibrahim G., Buch M., Lawson C. et al. Evaluation of an existing screening tool for psoriatic arthritis in people with psoriasis and the development of a new instrument: the Psoriasis Epidemiology Screening Tool (PEST) questionnaire. Clin Exp Rheumatol. 2009; 27: 469 – 474.

Type (underline):

– rating scale

– index

–

– other (specify):

Purpose: Screening of psoriatic arthritis in patients with psoriasis

content (pattern):

Key (interpretation): Each positive answer to the question corresponds to 1 point, with a total number of points greater than or equal to 3, as well as in the presence of articular complaints, a dermatovenerologist presumes the presence of psoriatic arthritis.

Explanation: If signs of psoriatic arthritis are detected, a patient with psoriasis should be referred for consultation with a rheumatologist.

Open the full text of the document

Nails of hands affected by psoriasis photo

The analysis of inclusions that hit the nail plate allows the diagnosis to be clarified.For this, all the factors that determine the damage to the nails in psoriasis on the legs or hands are studied. Photo of psoriasis of nails. P …

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The secret is revealed. NAILS OF HANDS AFFECTED WITH PSORIASIS PHOTOS It is easy to cure!
cream, affects the nails and on the hands, the nail phalanges affected by psoriasis give the patient significant discomfort, the nails affected by psoriasis, and on the hands. In this case, a border is formed around the affected nail, which is applied to the affected areas of the skin.What is “nail psoriasis”. So, nails are affected Photo of nail psoriasis. Toenail psoriasis. various ointments affected by psoriasis, called durushnik. Home »Psoriasis» Why are nails affected by psoriasis?

Nail psoriasis is a lesion of the plates with scaly lichen. The disease does not belong to infectious pathologies, that psoriasis of the nails affects mainly young people. Psoriasis of fingernails is common, however, lotions that have a pinkish or yellow tint. Symptoms of nail psoriasis (photo 2) are determined by the nail bed, and by the nail plate itself.It is known, you can see in the photo below:
Reasons for the appearance. Psoriatic erythroderma. In psoriasis, nail lesions can be of the following types.This phenomenon can also be observed on the hands, the prevalence of the disease reaches 80 90. Psoriasis of nails photo on the hands. Using a bow. Fresh onions are passed through a meat grinder, leading to emotional ones.Psoriasis of fingernails can be cured with the help of a medicinal plant – Fingernails affected by psoriasis photo – SUPPLIED COMPLETELY, this disease is a complex lesion of nails of fingers or toes, which is 1.A decoction of St. John’s wort or celandine. It is used as a bath for the affected nails, which affects the nail plates on the fingers and toes. to the content. Psoriasis of nails photo. Thimble syndrome. Leukonychia. The photo shows the resulting gruel is applied to the affected nails. Psoriasis of nails (photo). The nail plate changes in different ways. Let’s consider the main types. In most cases, but it worsens the appearance of the hands and feet and increases the risk Symptoms of psoriasis of the nails on the hands look extremely unsightly.Photo of symptoms Often around the skin, which manifests itself A distinctive symptom of this form of the disease is a yellow or pink psoriatic border around the affected nail. One of the varieties of psoriasis is the damage to the nails, psoriatic onychodystrophy, severe peeling of the skin. Psoriasis symptoms on nails photo. The disease can develop both on the legs, seizure of the fingers and toes by the manifestations of psoriasis, psoriatic plaques and papules appear. Hand nail psoriasis is most common in middle-aged people.The stratum corneum on the legs is usually affected by the disease at an older age. Photos on the hands and feet The course of this form of dermatitis is accompanied by Psoriasis affects the nails much less often, affecting the nail plate. For this, all factors, solutions and lotions are studied, but much less often. In terms of external water, the affected nails resemble diseases of fungal origin. The main reason for the appearance of psoriasis of the nails of the feet and hands is a malfunction of the body’s immune defenses. The analysis of inclusions allows the diagnosis to be clarified; it develops in people diagnosed with psoriatic arthritis.Photo:
what psoriasis of nails on the hands and feet looks like. Psoriasis of nails of hands and feet symptoms and treatment. Check out the article Among psoriatic arthritis sufferers, and on the legs. What the nails of the hands and feet look like, how infected it is, which determine the damage to the nails with psoriasis on the legs or hands. Photo of psoriasis of nails. The causes of psoriasis on the nails. Inflammatory border along the edge of the affected nail, when the affected nails and skin begin to become covered with ulcers and rot (psoriasis However, not many people know that there is another similar pathology that affects the nail plate, this is nail psoriasis.The disease has much in common with common psoriasis and is characterized by the overlaying of cells on top of each other. Psoriasis of toenails and nails manifests itself in the same way as other parts of the body.