Psoriasis of the Nails
Content from presentations and scholarly articles by Dr. Phoebe Rich
Nail psoriasis occurs in up to 80% of patients with plaque psoriasis and is more prevalent in patients with psoriatic arthritis. Nail psoriasis is far more than just a cosmetic problem. Psoriasis of the fingernails is psychologically distressing and can cause pain, functional deficits in fine motor manipulation of small objects, and when toenails are involved, can cause difficulty with ambulation. Although nail psoriasis can be extensively destructive to the nail plate, it is a non-scarring process. If treated effectively, nails with psoriasis can return to a normal or close to normal condition. Nail psoriasis takes a vast toll on patients, but with treatment and hopefully clearing of nail psoriasis quality of life can greatly increase.
There are a few key factors by which the disease is characterized. Pitting is a common factor in which the keratin of the nail loses cells and it starts to form pits in the fingernail or toenail. It can range anywhere from one pit to a dozen from patient to patient. Oil drop discoloration is when it looks like there is a drop of oil under the nail-bed. It may range from yellow-red to a yellow-brown in color. The nails start to turn white when crumbling starts to occur. When the nail starts to lift away from the bed on either the fingers or toes, it's called onycholysis. Other characterizations include subungual hyperkeratosis and splinter hemorrhages.
"50% of people with Psoriasis have the disease on their nails, but only 5% have it limited to their nails"
Nail psoriasis is diagnosed by having also toe nail fungus, Reiters', parakeratosis pustulosa, subungual hyperkeratosis or fingertip eczema with subungual hyperkeratosis and onycholysis. Some secondary effects might also occur sych as fungus. Sometimes psoriasis is secondarily infected with yeast or dermatophytes. The fungus can add to the Koebner reaction. The doctor will do a KoH test or culture on the nail and view it under the microscope to classify it.
There are many options for treating nail psoriasis. Topicals, injectable medications, oral meds and physical modalities such as PUVA light therapy and Grenz Ray are among the treatments. Clinical features of psoriasis are in a site on the nail remote from where the pathology resides however. Challenges arise from the fact that the nail plate prevents the delivery of medication to the site of the pathology. Drugs only work when they can get to where they need to go. If medications don't work then many patients choose to camouflauge or simply try to cover it up.
When trying to cover up nail psoriasis, be cautious about potential koebner reactions. If one does choose to go this route avoid anything irritating or potential allergies. Just as nail cosmetics can sometimes cause trouble in non psoriatic nails, the same is true in psoriatic. Millions of women use nail cosmetics with absolutely no adverse events pertaining to their psoriasis.
GET A SUPPORT SYSTEM!
It is important to have a supposrt system with any disease. Optimism and encouragment can go a long way. There is constantly new research being done and possible trials to get involved with.
The Oregon Dermatology and Research Center is a proud supporter of the National Psoriasis Foundation. They are a great resource for individuals and families to find support in the community, events, ways to get involved and lots of education for both adults and children alike.