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How Does Psoriasis Affect Nails

Diagnosing Toenail Psoriasis What To Expect

Does nail psoriasis go away?

Toenail psoriasis is often misdiagnosed as a fungal infection under the toenail the symptoms of these conditions are often the same and can be difficult to distinguish, particularly if your doctor does not have a background in dermatology.

Differential diagnosis of toenail psoriasis from toenail fungus is further complicated by the fact that toenail psoriasis can often cause onychomycosis.

One test that is frequently employed to distinguish fungal infections from other skin disorders is the KOH wet mount. This involves taking a specimen from under the nail and examining it under a microscope.

Potassium hydroxide is applied to the sample, which dissolves hair, skin cells, and other debris, leaving behind any fungus that may be present. If the KOH test is inconclusive, your doctor may take a sample of your nail for biopsy.

Should You Take Psoriasis To The Nail Salon

Psoriasis could affect your nails, but a safe manicure and pedicure may help you feel better about your hands and feet.

For some people living with psoriasis, showing off painted fingers and toes may seem out of the question. From nails that are pitted, thickened, and discolored to ones that are separated from the nail bed, it can be embarrassing.

According to the National Psoriasis Foundation, about half of all people with psoriasis have nail problems. A trip to the nail salon may be the perfect feel-good strategy for you.

If you treat psoriasis, the appearance of your nails will improve. Depending on the severity of your symptoms, treatment may involve topicals, , or biologic drugs. In a study published in March 2010 in the journal Archives of Drug Information, researchers found that the drug efalizumab was more effective in treating nail psoriasis than topical treatments and light therapy.

Even if the treatment is effective, you still may want to polish your nails to make them look better and to help you feel better about yourself. But is it safe to get a pedicure or manicure when you have psoriasis?

Most definitely, says Marlene Reid, doctor of podiatric medicine with Family Podiatry Center in Naperville, Illinois, and past president of the American Association for Women Podiatrists. Its not going to help, but its not going to make it worse, either, she says. Getting polish to cover up is fine.

How Successful Are The Treatments

Anti-inflammatory drugs can help to reduce pain, swelling and stiffness. Unfortunately, however, they can make skin symptoms worse in some people. Steroid injections to joints may give relief. Disease-modifying drugs such as methotrexate can damp down both skin and joint symptoms, as can targeted biologic agents.

In some cases, surgery to remove a thickened synovial membrane , realign a joint or to fuse a joint may stop pain which results from movement.

Sometimes it is possible to remove the painful end of a bone .

Remember: All treatments may have unwanted side effects or require special precautions . Always make sure you have all the information before embarking on any course of therapy this includes reading the patient information leaflets provided with your medicines.

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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.

See the images of psoriatic nail disease below.

See 15 Fingernail Abnormalities: Nail the Diagnosis, a Critical Images slideshow, to help identify conditions associated with various nail abnormalities.

For patient education information, see the Psoriasis Center and Arthritis Center, as well as Psoriasis, Types of Psoriasis, Understanding Psoriasis Medications, and Psoriatic Arthritis.

When To See A Doctor


Nail psoriasis is not contagious, and treatment can reduce or help control the symptoms.

If the nails show symptoms of psoriasis or a fungal infection, see a doctor. This is especially important for people who already have a type of psoriasis.

A person may have to try several treatments before finding one that works.

Symptoms can take time to improve, and they may take up to a year to clear. One reason for this is that the nail plate grows very slowly. The symptoms may also return at a later date.

With new drugs appearing on the market, more effective treatments for nail psoriasis may be on the horizon.

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Impact On Quality Of Life

Nail psoriasis has a profound negative influence on all aspects of quality of life as well as on daily, sports, and professional activities. Women try to hide their nails and cover them with nail lacquer although common nail varnishes are not harmful, artificial nails, particularly when long, increase the mechanical stress and strain to the nail plate nail bed attachment acting as a Köbner phenomenon and worsening nail psoriasis. Similarly, professional activities with particular use of the fingers may have a deteriorating effect on the disease. Matrix involvement scores higher than pure nail bed affection as it results in more obvious nail plate damage.

How Often Does Psoriatic Arthritis Affect The Nails

Psoriasis limited to the nails is uncommon and estimated to occur in only 5-10% of people with psoriasis, although many people who first present with psoriasis only in their nails later develop psoriasis of the skin and/or joints. Nail psoriasis is more likely to occur in adults than children.1

Psoriasis of the skin, scalp and/or nails often occurs before the appearance of PsA, and psoriasis of the nails has been associated with a greater likelihood of developing PsA. Nail lesions occur in about 87% of people with PsA.2

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Clinical Characteristics Of Nail Psoriasis

Psoriasis causes a variety of both specific as well as ambiguous nail lesions. Fingernails are more frequently affected than toe nails, probably because they grow faster. Particularly, for scientific purposes, nail psoriasis is often divided into matrix and nail bed involvement or both, which is also reflected in many trials differentiating the response into general, more on matrix or nail bed psoriasis. Pits are the most characteristic and most frequent signs and are seen as small, sharply delimited depressions in the nail surface. They are of remarkably even size and depth. Their distribution may be haphazard or they may sometimes be arranged in parallel transverse or short longitudinal lines. They are the result of tiny psoriatic foci in the apical matrix producing parakeratosis, which breaks off when it grows out from under the proximal nail fold then leaving these depressions. Sometimes, the para-keratosis remains and is seen as an ivory-colored spot in the proximal half of the nail plate. Pits may be single, which is not yet psoriasis specific, or multiple. Ten pits in one nail or > 50 pits on all nails are regarded as proof of psoriasis. Red spots in the lunula usually represent a very active psoriasis lesion with dilatation of the capillaries and thinning of the suprapapillary plate. Red or mottled lunulae are due to the dilatation of matrix blood vessels.

How Is Toenail Psoriasis Treated

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Unfortunately, not many good treatment options exist for toenail psoriasis. Conservative treatment usually begins with topical corticosteroid creams or ointments, or non-steroidal alternatives such as Tazorac and Dovonex.

The drawback to these creams and ointments is that they may not penetrate the nail plate adequately. Also, long-term steroid use can cause the skin and nails to thinwhich takes months to grow out.

Another treatment option is phototherapy. This involves treating the nails with topical or systemic psoralen compounds, which cause the nail to respond to ultraviolet light.

According to some experts, the best treatment involves intralesional steroid injections. This means injecting cortisone into the base of the nail and into the nail folds alongside it. This treatment can be effective, and when done properly it is not as painful as it sounds.

Proper care of your feet and nails is vitally important if you have psoriasis. Avoid getting pedicures, as nail salon personnel often treat the nails roughly, and many of them trim cuticles, , which allows bacteria to enter the nail , and is especially bad for persons affected with toenail psoriasis.

Keep your toenails short to avoid injury, and try to keep the nail folds clean and dry. Above all, one of the best treatments for psoriatic nails is control of your overall psoriasis.

Medical References:

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Infliximab In Nail Psoriasis

Possibly the most robust scientific best evidence for the efficacy of a TNFα antagonist in nail psoriasis comes from the well-controlled EXPRESS trial . This was a phase III, multicentre, double-blind, placebo-controlled trial designed to evaluate the long-term efficacy and safety of infliximab in patients with moderate-to-severe plaque psoriasis. The primary endpoint of the study was the proportion of patients achieving at least 75% improvement in PASI compared with baseline. The percentage improvement in NAPSI at weeks 10, 24 and 50 was also specifically investigated.

Three hundred seventy-eight patients were randomly assigned in a 4 : 1 ratio to receive infliximab 5 mg/kg at weeks 0, 2, 6 and every 8 weeks through to week 46 , or placebo at weeks 0, 2, 6, 14 and 22, then crossing over to infliximab at weeks 24, 26, 30, 38 and 46 . Nail psoriasis was present in 240 of the infliximab group and in 65 of the placebo group, with corresponding mean NAPSI scores at baseline of 4.6 and 4.3 based on the most severely affected target nail. The mean number of affected nails was 7.4 and 7.5, respectively, and the right thumb was most often selected as the target nail. The clinical signs of target nail psoriasis in each group are shown in .

Infliximab group

Clearance of nail psoriasis with infliximab in the EXPRESS study. .

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 , topical fluorouracil, topical calcipotriol, topical anthralin, topical tazarotene, topical cyclosporine, avulsion therapy, and systemic therapy for severe cases. Onychomycosis 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.

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.

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How Does Psoriatic Arthritis Affect Your Toenails


Almost all people with PsA have nail symptoms. One common problem is pitting, or tiny indentations in the surface of your nail. Another problem is nail separation, when the nail lifts from the toe.

National Psoriasis Foundation: Classification of Psoriatic Arthritis, About Psoriatic Arthritis, “5 things you didnt know about PsA.”

Seminars in Arthritis and Rheumatism: “Dactylitis: A hallmark of psoriatic arthritis.

Arthritis Foundation: Anatomy of the Foot, “Arthritis & Diseases that Affect the Foot, 10 Hand- and Foot-Care Tips for Psoriatic Arthritis.”

Rheumatic and Musculoskeletal Diseases: “Psoriasis and the risk of foot and ankle tendinopathy or enthesopathy in the absence of psoriatic arthritis: a population-based study.

Rheumatology: “Metatarsophalangeal joint pain in psoriatic arthritis: a cross-sectional study. Psoriatic arthritis .

Hospital for Special Surgery: Synovitis.

Expert Review of Clinical Immunology: “Focusing on the foot in psoriatic arthritis: pathology and management options.”

Mayo Clinic: Psoriatic arthritis.

National Psoriasis Foundation: Classification of Psoriatic Arthritis, About Psoriatic Arthritis, “5 things you didnt know about PsA.”

Seminars in Arthritis and Rheumatism: “Dactylitis: A hallmark of psoriatic arthritis.

Arthritis Foundation: Anatomy of the Foot, “Arthritis & Diseases that Affect the Foot, 10 Hand- and Foot-Care Tips for Psoriatic Arthritis.”

Features Associated With Nail Psoriasis

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Nail inflammation in psoriasis may be a predisposing factor for secondary fungal infections. The association between these two conditions is estimated to occur in 4.6-30% of patients with nail psoriasis, and the morphology of the lesions caused by these two diseases can be similar. 3131. Natarajan V, Nath AK, Thappa DM, Singh R, Verma SK. Coexistence of onychomycosis in psoriatic nails: a descriptive study. Indian J Dermatol Venereol Leprol. 2010 76:723. The presence of onychomycosis in patients with nail psoriasis may lead to more intense clinical manifestations through the Koebner phenomenon, which occurs as a result of continuous fungal infections.2626. Szepietowski JC, Salomon J. Do fungi play a role in psoriatic nails? Mycoses. 2007 50:437-42.

The presence of nail psoriasis is also associated with the severity of the skin condition. Hallaji and colleagues described the relationship between these two variables through the following equation: for each one-point increase in the severity of cutaneous psoriasis, 10 points are added to the severity of the nail condition.3232. Hallaji Z, Babaeijandaghi F, Akbarzadeh M, Seyedi SZ, Barzegari M, Noormohammadpour P, et al. A significant association exists between the severity of nail and skin involvement in psoriasis. J Am Acad Dermatol. 2012 66:e12-3.

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Group Gr And Group It Epidemiological Data

A total of 68,839 children aged 6-17 years were seen in pediatric skin consultation over a period of 10 years at both clinics . The number of patients/year is shown in figure 2. The total number of patients at the pediatric age affected by skin psoriasis was 406 , 284 in Group GR and 122 in Group IT, corresponding to 0.9 and 0.31% of the pediatric population, respectively. Furthermore, a total of 74 out of the 68,839 children had involvement of the nails: 55 out of 30,044 in Greece and 19 out of 38,795 in Italy, which equals 0.18 and 0.05% of all pediatric skin consultations, respectively . With regard to the children with skin psoriasis, the rate of children affected by nail psoriasis was 19.4% in Group GR and 15.5% in Group IT.

Table 2

For additional information:

How Did I Get Toenail Psoriasis

It is not known exactly what causes psoriasis. The disease is known to have a strong genetic componenta third of all sufferers have a family history of psoriasis, and if an identical twin develops the disease it is 70% likely that the other twin will also develop itbut other factors also seem to have an effect.

Certain drugs and medications have been reported to cause psoriasis, and lifestyle factors such as drug and alcohol abuse, stress, smoking, and obesity are all known to exacerbate existing cases. Environmental factors such as excessive heat or dryness can also have this effect.

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Changes In Nail Shape Or Thickness

In addition to pitting, you might notice other changes in the texture of your nails. Psoriasis can cause lines called Beaus lines to form across your nails.

Weakness of the structures that support nails can cause your nails to crumble. Nails can also become thicker due to a fungal infection called onychomycosis, which is common in people with psoriasis.

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Psoriasis/Nail Psoriasis Healing Introduction

If you have psoriasis and you notice some changes in your nails, there are many treatments you can turn to for help.

Nail psoriasis alters the way your toenails and fingernails look. They may get thick, develop pinprick holes and change color or shape. They also can feel tender and hurt.

You can treat these problems with medicine. Cosmetic repairs can make your nails look better.

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Conditions With Similar Symptoms

Nail psoriasis can resemble a fungal infection, such as onychomycosis. This also causes the nails to thicken. Moreover, onychomycosis often occurs alongside nail psoriasis. This can make diagnosis difficult.

Getting a correct diagnosis is important because the treatment for a fungal infection is different from the treatment for nail psoriasis. Anyone with psoriasis and changes in their nails should make sure that their doctor is aware of their psoriasis.

Nail psoriasis does not always cause physical pain, but some people may find it unsightly, and it can cause embarrassment. Treatment can prevent it from worsening.

Treatments include:

  • topical medicines, such as creams applied directly to the nails
  • systemic medications, which affect the whole body
  • intralesional therapies, which involve a doctor injecting medication into the nail bed

What Are Medical Treatments For Nail Psoriasis

A doctor may recommend that a part of the nail be removed, either chemically or surgically. Chemical removal of the nail involves putting an ointment on the nails for seven days. The nail comes off by itself with no bleeding.

Even with effective treatment, an improvement in symptoms may take a long time, since eight to 12 months can be needed to generate a new fingernail.

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Importance Of The Nail In Psoriasis

Despite its frequent occurrence, nail psoriasis is often overlooked and not treated effectively. This has important implications for the management of patients with psoriasis, since nail involvement has a serious negative impact on functioning and quality of life. Furthermore, it may be a predictor of future inflammatory joint damage, a precursor to PsA, and a visible indicator of disease activity.

What Causes Nail Psoriasis

Nail Psoriasis

Psoriasis is a multifactorialsystemic disease including inflammation and epidermalhyperproliferation.

Nail psoriasis can involve the nail bed, nail matrix, hyponychium, and nail folds.

Theories include:

  • Activation of the antimicrobialpeptide LL-37 by Candida and the cytokine overflow theory
  • Increased expression of interleukin-10 in the affected nail bed compared to downregulation of IL-10 in psoriatic skin lesions
  • Koebnerisation of psoriasis in onychomycosis or nail trauma.

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