What Is Nail Psoriasis Caused By

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 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 – psoralen plus ultraviolet light A 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.

What Increases Your Risk

Many doctors believe that psoriasis may be passed down from parents to their children . This is because certain genes are found in families who are affected by psoriasis.footnote 2 About one-third of people who have psoriasis have one or more family members with the condition.footnote 3

Other factors that can contribute to the development of psoriasis include:

• Emotional or physical stress. Stress may cause psoriasis to appear suddenly or make symptoms worse .
• Infection. Infections such as strep throat can cause psoriasis to appear suddenly, especially in children.
• Skin injuries. An injury to the skin can cause psoriasis patches to form anywhere on the body, including the site of the injury. This includes injuries to your nails or nearby skin while trimming your nails.
• Smoking. Smoking may make you more likely to get psoriasis and make the symptoms more severe.footnote 4

Impact On Function And Quality Of Life

The clinical signs of nail psoriasis are highly visible and have a significant impact on quality of life. In a survey to evaluate the subjective complaints associated with nail involvement, questionnaires were sent to 7000 patients with psoriasis. One thousand seven hundred twenty-eight patients of mean age 47 years and mean disease duration of 12 years provided evaluable responses. Nail psoriasis was present in 1369 , with both fingers and toes affected in 62.6% of patients, just fingers in 26.8% and only toes in 8.6%. There was a positive association between duration of skin lesions and nail psoriasis. Pitting was reported by 75.3% of patients, upward lifting of the nail by 49.3%, onycholysis by 46.2% and discoloration by 29.2%.

Pain caused by nail changes occurred in 51.8% of patients, and more then 90% were concerned about the cosmetic appearance of their nails. Normal daily activities were negatively impacted in 58.9% of patients and a similar number reported that nail psoriasis inhibited their usual housekeeping activities. Importantly, 47.9% of respondents noted that their nail condition restricted their professional activities.

Another study in 69 patients with PsA found that severe nail disease was associated with functional impairment related to arthritis and with higher depression and anxiety scores on the Stanford hospital anxiety and depression scale .

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Lifestyle Changes To Manage Nail Psoriasis

People with nail psoriasis can make other simple behavioral changes that will help keep their nails healthier and the condition in check.

• Wear gloves when using cleaning products, including when washing dishes. Water and harsh chemicals damage even healthy nails.
• Keep your nails short. The less your nails can catch and tear on other objects, the healthier they will be.
• Moisturize regularly. Keeping skin and nails as supple as possible will help them stay healthier.
• Leave your nails alone. Keep them short, but dont bite or pick at your nails or cuticles. If you have problems with hangnails, find a good manicurist who will understand your concerns, or ask your dermatologist for help.
• Avoid artificial and gel nails, which can damage your already-weak nail beds. Strengthening nail polish or nail-polish strips, as suggested by some MyPsoriasisTeam members may be better alternatives, but you should ask your doctor before investing any time or money in them.

Although nail psoriasis can be uncomfortable and embarrassing, there are plenty of treatments that can make your nails clear and strong. It may take time to find the combination of treatments and lifestyle changes that works for you, but nail psoriasis can be managed.

Home Remedies To Treat Nail Psoriasis

Some MyPsoriasisTeam members use home remedies to manage their nail psoriasis, including incorporating moisturizers that help their nails and skin look and feel healthier. One member swears by an unscented, raw shea butter. I use it on my cuticles and on psoriasis spots on my body. It helps a lot!

Another said their skin and nails dont respond well to any single treatment. I use a variety of lotions and potions on my hands to ease it, they wrote.

A third member recommended Aspercreme with aloe to simultaneously help with pain and moisturizing.

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How To Hide Nail Psoriasis

If you feel self-conscious about your nail psoriasis, there are some things you can do to make it less noticeable.

Cosmetic treatments such as nail filing, buffing, and polish can improve the appearance of your nails while they heal. Just avoid fake nails, which may increase the risk of your nail separating from its bed.

Grenz Ray Climatotherapy Visible Light Goeckerman And Pulsed

Evidence is insufficient to recommend grenz ray therapy for the treatment of psoriasis.

Sufficient evidence exists to recommend climatotherapy for the treatment of psoriasis.

Evidence is insufficient to recommend the use of visible light as a more effective treatment for psoriasis, except in nail psoriasis.

Sufficient evidence exists to recommend Goeckerman therapy for the treatment of psoriasis.

Pulsed-dye laser can be considered for nail psoriasis.

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How Is It Treated

Most cases of psoriasis are mild, and treatment begins with skin care. This includes keeping your skin moist with creams and lotions. These are often used with other treatments including shampoos, ultraviolet light, and medicines your doctor prescribes.

In some cases, psoriasis can be hard to treat. You may need to try different combinations of treatments to find what works for you. Treatment for psoriasis may continue for a lifetime.

What Causes Nail Psoriasis

Researchers believe nail psoriasis like plaque psoriasis and psoriatic arthritis is caused, in part, by inflammation resulting from a faulty immune response. Normally, infections, stress, or trauma trigger the immune system to send white blood cells to the affected area. As the blood cells attack and destroy harmful substances, inflammation occurs an essential part of the healing process. However, a dysfunctional immune system will continue sending white blood cells once an infection is cleared, and theyll attack healthy tissue, causing the inflammation to linger. The resulting inflammation can trigger a number of autoimmune conditions, including all forms of psoriasis.

Some people with plaque psoriasis develop nail psoriasis as an early sign of PsA. If you notice changes in your nails combined with stiffness in your hands or other joints, talk to your doctor right away.

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Social And Emotional Effects Of Nail Psoriasis

Symptoms of nail psoriasis can cause embarrassment and social discomfort. My fingernails and toenails look like a hot mess, lamented one member of MyPsoriasisTeam.

An employer told another members son that their nails reflected poor hygiene.

Being part of a supportive community can help you navigate nail psoriasis and other aspects of living with psoriasis. Im trying not to let it get the best of me, learning a lot from the group, and glad I joined, shared a member of MyPsoriasisTeam.

Causes Of Nail Psoriasis

As in the cases of skin psoriasis, the likelihood of developing nail psoriasis is due to genetic factors. Despite the hard exterior of nails, they are actually surrounded by skin cells. As a result, nails are affected by psoriasis just like the rest of your skin. Generally, symptoms of nail psoriasis are caused by defects at one or more of the three major parts of the nail:

Sometimes, symptoms that appear to result by nail psoriasis causes are actually signs of nail infections. Doctors can test nail samples to determine whether an infection is present or not.

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Main Symptoms Of Psoriasis

Psoriasis typically causes patches of skin that are dry, red and covered in silver scales. Some people find their psoriasis causes itching or soreness.

There are several different types of psoriasis. Many people have only 1 form at a time, although 2 different types can occur together. One form may change into another or become more severe.

Most cases of psoriasis go through cycles, causing problems for a few weeks or months before easing or stopping.

You should see a GP if you think you may have psoriasis.

Assessment And Management Of Nail Disease

Although nail disease is important, it is often overlooked in the clinical management of patients with psoriasis, and in many clinical trials in patients with PsA. Skin plaques are usually the primary motivation for the decision to treat psoriasis, and patients are also sometimes referred to a rheumatologist for assessment of joint involvement. Several possibilities have been proposed for the lack of attention to nail psoriasis. It has been suggested that rheumatologists are poor at detecting nail disease, but this was shown not to be the case, and rheumatologic assessment was found to be highly sensitive in detecting nail involvement, and correlated well with dermatologic assessment.

Another explanation is that therapy for nail psoriasis is perceived to be ineffective, and there is no standard treatment guideline or method for evaluating outcomes. Selecting an appropriate therapy is hampered by a lack of good quality clinical trial evidence using widely accepted objective tools to measure outcomes. Several tools have been used, and these are outlined in .- The Psoriasis Area and Severity Index is commonly used in clinical studies, but only measures skin involvement. The Physician’s Global Assessment is more widely used in clinical practice, but again it does not assess nail involvement. These two tools do not evaluate quality of life in patients with psoriasis. This can be assessed using the Dermatology Life Quality Index , but again nail psoriasis is omitted.

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Generalised Pustular Psoriasis Or Von Zumbusch Psoriasis

This causes pustules that develop very quickly on a wide area of skin. The pus consists of white blood cells and is not a sign of infection.

The pustules may reappear every few days or weeks in cycles. During the start of these cycles, von Zumbusch psoriasis can cause fever, chills, weight loss and fatigue.

Nail Psoriasis Quick Guide

Learn more about the signs of nail psoriasis, Treatment options and get tips for caring for your nails without making your nail psoriasis worse.

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

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

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

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What Are The Symptoms Of Nail Psoriasis

Symptoms of nail psoriasis can be mild or severe. They include:

• Nail discoloration
• Buildup of a chalky substance beneath the nails
• Pitting in the nails
• Blood under the nails
• Nails separating from the nail bed
• Cracking nails
• Deformed nails
• Thickening of the nails from a fungal infection

People with psoriatic arthritis may also experience stiffness in their fingers and hands as part of nail psoriasis. In the most severe cases, nails can disappear entirely, which may hinder a persons ability to use their hands or to walk.

For many people with mild nail psoriasis, the symptoms arent painful even though they may look uncomfortable. However, having nail psoriasis increases your risk for nail infections and fungal infections, so its important that your dermatologist scrape your nails to determine if a fungal infection is present. The infection can recur after being cleared, due to the increased susceptibility.

What Can You Do At Home For Psoriasis

Skin care at home can help control psoriasis. Follow these tips to care for psoriasis:

• Use creams or lotions, baths, or soaks to keep your skin moist.
• Try short exposure to sunlight or ultraviolet light.
• Follow instructions for skin products and prescribed medicines. It may take a period of trial and error until you know which skin products or methods work best for you. For mild symptoms of psoriasis, some over-the-counter medicines, such as aloe vera, may be soothing.

It’s also important to avoid those things that can cause psoriasis symptoms to flare up or make the condition worse. Things to avoid include:

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What Worsens Nail Psoriasis

People with skin psoriasis often track triggers that cause their symptoms, like psoriasis lesions, to worsen or flare up. Because their skin responds to changes within hours, avoiding certain things can cause the appearance of symptoms to diminish. That said, since nails take a long time to grow and cycle through, it can take a few months of psoriasis treatment or trigger avoidance to see improvements. Still, its important to understand what can cause nail psoriasis to worsen so that you can avoid aggravating the condition. Here are a few factors to watch out for:

• Activities that disturb the nail and cause loose nails to peel further
• Dry weather or harsh sun exposure
• Picking or scratching at cuticles
• Scraping out build up underneath the nail
• Stress
• Unhealthy habits like smoking, poor diet, and excessive alcohol consumption
• Wearing artificial nails

Relative Effectiveness Of Treatments

Available studies lack sufficient power to extrapolate a standardized therapeutic regimen.

As of April 2009, an assessment of the evidence for the efficacy and safety of the treatments for nail psoriasis is in progress.

• Infliximab appears to be the most effective treatment for nail psoriasis to date.
• Results from low-dose acitretin therapy show NAPSI score reductions comparable with those studies evaluating biologic drugs for nail psoriasis and suggest that low-dose systemic acitretin should be considered in the treatment of nail psoriasis.

A 2013 meta-analysis showed improvement of nail psoriasis with infliximab, golimumab, superficial radiotherapy, electron beam, and grenz rays compared to placebo. Although systemic therapies have been shown to be beneficial, they may have serious adverse effects.Topical treatments have not been well studied but may be beneficial.

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What Are The Causes Of Nail Psoriasis

The root cause of nail psoriasis is in the nail root which is the skin tissue of the nail bed from where the nail grows. Changes in the growth pattern of the cells in the nail root results in the development of the disease.

Family aggregation studies have linked psoriasis of the nails to genetic factors along with interactions with environmental influences.

Another cause for nail psoriasis is fungal infections like onychomycosis that cause thickening of the nails. This nail fungus produces the symptoms shown in psoriasis.

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 .

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

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