Nail Psoriasis

Updated: Apr 06, 2017

Author: Cindy Li, DO; Chief Editor: William D James, MD

Overview of Nail Psoriasis

Psoriatic nail disease has many clinical signs. Most psoriatic nail disease occurs in
patients with clinically evident psoriasis; it only occurs in less than 5% of patients with
no other cutaneous findings of psoriasis.
An estimated 10-55% of all patients with psoriasis have psoriatic nail disease, and
approximately 7 million people in the United States have psoriasis. About 150,000-
260,000 new cases of psoriasis are diagnosed each year. US physicians see 1.5 million
patients with psoriasis per year.
Severe psoriatic nail disease can lead to functional and social impairments if left
untreated. [1, 2]
See the images of psoriatic nail disease below.

Courtesy of Hon Pak, MD.

Classic distal interphalangeal joint involvement in psoriatic arthritis.

This patient has extensive psoriasis, nail involvement, and joint pain.

Pathophysiology of Nail Psoriasis

The pathogenesis of the psoriatic nail disorder is not completely known. Nail psoriasis
may be due to a combination of genetic, environmental, and immune factors. A well-
known fact is that a familial aggregation of psoriasis exists. Studies have linked
psoriasis with certain human leukocyte antigen subtypes (eg, Cw6, B13, Bw57, Cw2,
Cw11, B27). A T-cellmediated inflammatory process is being investigated as part of
the pathogenesis of psoriasis.

Epidemiology of Nail Psoriasis

Psoriatic nail disease occurs in 10-55% of all patients with psoriasis, and approximately
7 million people in the United States have psoriasis (psoriasis affects 2-3% of the US
population). Less than 5% of psoriatic nail disease cases occur in patients without other
cutaneous findings of psoriasis. About 10-20% of people with psoriasis also have
psoriatic arthritis, and nail changes are seen in 53-86% of patients with psoriatic
arthritis.
Psoriasis tends to run in families. In Farber's questionnaire study of 2100
patients, [3]36% of patients reported the presence of psoriasis in at least 1 relative.
Among siblings, 8% are affected if neither parent has psoriasis. This percentage
increases to 16-25% if 1 parent or sibling has the disease, and it reaches up to 75% if
both parents are affected. If 1 twin has psoriasis, the other twin is at an increased risk of
having psoriasis (25% for fraternal twins, 65% for identical twins).
In Scandinavia, the prevalence rate of nail psoriasis for adults with psoriasis
approaches 5%. The prevalence increases with the age of the population studied.
Psoriatic nail disease is not associated with mortality. In severe cases, patients may
have functional and psychosocial impairments.
Males and females are affected equally by nail psoriasis, and the prevalence of nail
psoriasis increases with the age of the population studied.
Clinical Presentation of Nail Psoriasis
Patient history
Most psoriatic nail disease occurs in people with clinically evident psoriasis. The
diagnosis of psoriatic nail disease without cutaneous psoriasis can be challenging
because of the low index of suspicion and the lack of personal/family history of
psoriasis.
A retrospective study from 2014 reports that nail involvement in psoriasis is a significant
predictor of the patient also having psoriatic arthritis. [4] The study looked at retrospective
data from three German cross-sectional independent national studies on patients with
psoriasis and psoriatic arthritis. Data on the patients history of psoriasis and psoriatic
arthritis, clinical findings, nail involvement, and patient- and practitioner-reported
outcomes were collected from standardized questionnaires. In the results, the
regression model of 4146 patients indicated one of the strongest predictors of
concomitant psoriatic arthritis was nail involvement. Balestri et al also suggest nail
psoriasis as a risk factor for subclinical psoriatic arthritis, reporting that 50% of subjects
with nail psoriasis had interphalangeal stiffness, pain, and swelling. [5]
Choi et al sought to determine whether psoriatic nail features were associated with nail
psoriasis or cutaneous psoriasis disease severity. [6] Studies results indicated nail fold
psoriasis and subungual hyperkeratosis were significantly associated with disease
severity in both cutaneous psoriasis and nail psoriasis.
Physical examination
The clinical findings associated with psoriatic nail disease correlate with the anatomical
location of the nail unit that is affected by the disease. The nail unit is composed of the
nail plate, the nail bed, the hyponychium, the nail matrix, the nail folds, the cuticle, the
anchoring portion of the nail bed, and the distal phalangeal bones (see the images
below). The nail plate is the largest component of the nail unit. The nail matrix gives rise
to the nail plate.
Any defect to the matrix results in onychodystrophy of the growing nail plate. The
proximal nail matrix forms the dorsal portion of the nail plate, whereas the distal matrix
forms the ventral part of the nail plate. The clinical presentation may vary depending on
the location and the severity of inflammation of the affected nail unit. [7] See the images
below.
Anatomy of the nail, superior view.

Anatomy of the nail, sagittal view.

Oil drop or salmon patch of the nail bed
This lesion is a translucent, yellow-red discoloration in the nail bed resembling a drop of
oil beneath the nail plate. This patch is the most diagnostic sign of nail psoriasis. [8]

Pitting of the proximal nail matrix

Pitting is a result of the loss of parakeratotic cells from the surface of the nail plate.
Beau lines of the proximal nail matrix
These lines are transverse lines in the nails due to intermittent inflammation causing
growth arrest lines.
Leukonychia of the midmatrix
Leukonychia consists of areas of white nail plate due to foci of parakeratosis within the
body of the nail plate.
Subungual hyperkeratosis of the hyponychium
Subungual hyperkeratosis affects the nail bed and the hyponychium. Excessive
proliferation of the nail bed can lead to onycholysis.
Onycholysis of the nail bed and nail hyponychium
Onycholysis is a white area of the nail plate due to a functional separation of the nail
plate from its underlying attachment to the nail bed. It usually starts distally and
progresses proximally, causing a traumatic uplifting of the distal nail plate. Secondary
microbial colonization may occur.
Nail plate crumbling
Nail plate weakening due to disease of the underlying structures causes this condition.
Splinter hemorrhage/dilated tortuous capillaries in the dermal papillae
Splinter hemorrhages are longitudinal black lines due to minute foci of capillary
hemorrhage between the nail bed and the nail plate. This is analogous to the Auspitz
sign of cutaneous psoriasis, which is the pinpoint bleeding seen beneath the psoriatic
plaques.
Spotted lunula/distal matrix
This is an erythematous patch of the lunula.
Classification of nail psoriasis
Most people with psoriatic arthritis have nail changes that can be classified as follows
(see the images below):
Type I - Classic distal interphalangeal joint involvement (5% of patients)
Type II - Arthritis mutilans
Type III - Symmetric polyarthritis
Type IV - Asymmetric oligoarthritis (the most common type of psoriatic arthritis,
occurring in 70% of patients)
Type V - Ankylosing spondylitis

Etiology of Nail Psoriasis

Psoriatic nail disease may be due to a combination of genetic, environmental, and
immune factors. A well-known fact is that a familial aggregation of psoriasis exists.
Recent studies have linked psoriasis with certain human leukocyte antigen subtypes
(eg, Cw6, B13, Bw57, Cw2, Cw11, B27). A T-cellmediated inflammatory processing is
being investigated as part of the pathogenesis of psoriasis.

Differential Diagnosis
The differential diagnosis of nail psoriasis includes the following:
Alopecia Areata
Lichen Planus
 Onychomycosis
Pityriasis Rubra Pilaris
Other problems to be considered include idiopathic trachyonychia and punctate
keratoderma.

Skin Biopsy
A nail biopsy is needed to confirm the diagnosis of nail psoriasis in some cases and is
usually taken from the nail bed.

Histologic Findings
Psoriasis can affect any part of the nail unit. Most changes occur in the nail plate.
Histologic findings of nail psoriasis include mild-to-moderate hyperkeratosis,
hypergranulosis, serum globules and hemorrhage in the corneum layer, papillomatous
epidermal hyperplasia, and spongiosis.

Overview of Treatment of Nail Psoriasis

Many treatment options are available after the diagnosis of nail psoriasis is made. The
treatments focus on improvement of the functional and psychosocial aspects of psoriatic
nail disease.
The treatment options for nail psoriasis include topical corticosteroids, intralesional
corticosteroids, psoralen plus ultraviolet light A (PUVA), [9] topical fluorouracil, [10]topical
calcipotriol, [11] topical anthralin, [12] topical tazarotene, [13, 14] topical
cyclosporine, [15] avulsion therapy, [16] and systemic therapy for severe cases.
Onychomycosis (if present) requires antifungal therapy for improvement. Laser and light
therapies have emerged as possible cost-efficient, in-office treatments; however, large-
scale trials are needed, particularly in consideration for the effects in combination with
other current therapies. [17]
For preventive care, keep the nails dry and protect them from trauma to avoid the
Koebner effect and possible secondary microbial colonization. In areas of onycholysis,
the nail plate should be trimmed to the point of separation for medications to be
effective.
At present, no definitive and curative treatment has been agreed upon by medical
experts. Discuss all treatment options for psoriatic nail disease with the patient, and
choose the best individually tailored regimen.

Corticosteroids
Topical treatment with high-potency corticosteroid solution or ointment under occlusion
with cellophane wrap at bedtime can improve nail psoriasis. Avoid long, continuous
therapy with corticosteroids to avoid tachyphylaxis. Also, avoid prolonged occlusion (not
to exceed 2 wk). A topical preparation of a combination of high-potency corticosteroid
and calcipotriol may benefit some patients. [18]

5-Fluorouracil
Topical 1% 5-fluorouracil solution or 5% cream applied twice daily to the matrix area for
6 months without occlusion improves pitting and subungual hyperkeratosis.
PUVA
Psoralen plus ultraviolet light A (PUVA) is very effective for cutaneous psoriasis and can
improve nail psoriasis. Both oral and topical PUVA therapies have improved nail
psoriasis in 3-6 months. A possible adverse effect of PUVA may be nail discoloration.

Triamcinolone
Intralesional triamcinolone acetonide suspension of 2.5 mg/mL into the proximal nail
fold is very helpful for nail matrix psoriasis (eg, pitting, ridging, leukonychia). This
medication may be administered every 4-6 weeks. The proximal nail fold is sprayed first
with a refrigerant spray for anesthesia, and the injection is given with a 30-gauge
needle.

Systemic Therapies
Systemic therapies have been used in patients with severe cutaneous psoriasis. Few
studies have shown significant improvement in nail psoriasis with long-term results.
Three systemic medications are most commonly used for psoriasis and nail psoriasis:
methotrexate, retinoids, [19] and cyclosporine. [20] All three agents have potential serious
adverse effects and toxicities. In most cases, the psoriatic nail disease recurs after the
systemic therapy is stopped. Carefully weigh the risk-to-benefit ratio in the treatment of
nail psoriasis. Systemic therapies are seldom a first-line therapy for nail psoriasis.
Topical treatment with calcipotriol can be used as adjunctive therapy and maintenance
therapy with systemic treatment. Biological therapy for psoriasis and psoriatic
arthritis may have a significant benefit for some patients with psoriatic nail disease. [21]
In 2017, the US Food and Drug Administration (FDA) approved the addition of
moderate-to-severe fingernail psoriasis data to the adalimumab prescribing information,
based on results from a phase 3, multicenter, randomized, double-blind, parallel-arm,
placebo-controlled clinical trial. [22]

Avulsion Therapy
Avulsion therapy by chemical or surgical means can be used as an alternative therapy
for psoriatic nail disease. Chemical avulsion therapy includes the use of urea ointment
in a special compound to the affected nail under occlusion for 7 days, and the nail is
removed atraumatically. Chemical avulsion therapy is painless, involves no blood loss,
and is less expensive than surgical avulsion.
Surgical avulsion therapy can be performed for psoriatic nail disease when other
treatments have failed. During surgery, the matrix can be electively ablated to prevent
regrowth of the nail. This procedure is performed under local anesthesia. Inform
patients of postoperative discomfort, limitations, and possible physical nail
disfigurement.

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