Nail Problems Associated with Psoriasis

The number one issue is pitting

women's nails


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Psoriasis is a very common chronic skin disease, affecting about 7.5 million Americans. It can be associated with a variety of other problems including joint pain and destruction and serious illnesses like diabetes, heart attack, and stroke. Psoriasis is also commonly associated with nail disease, and changes and problems with the fingernails, toenails, or both. These nail problems can be very distressing, leading to pain with daily activities, embarrassment with shaking hands or at work, and even difficulty walking. Nail disease can also be quite difficult to treat, sometimes persisting even when all of the skin is better from treatment.

The most common finding in the nails of patients with psoriasis is pitting. There are small dents or pits in the top of the nail, best seen when a small light is shining directly on the nail. Pitting can occur in people without psoriasis, too. If there is psoriasis under the nail, sometimes the tip of the nail can lift off of the skin underneath, which can make the end of the nail white. This is called distal onycholysis and can make the nails painful or easily caught on clothing. When these spots are higher up on the nail, they are called oil drop spots and they look like small orange splotches under the nail. Oil drop spots are very specific to psoriasis and do not usually happen in other conditions or normal nails. When at its worst, psoriasis causes the whole nail to become thick, discolored, and crumbly.

Psoriasis in the nails is often misdiagnosed as nail fungus. Although both are common, nail fungus can sometimes be cured with treatment (although it often recurs). Since nail treatment medications can have serious side effects and be expensive, it is important to have the nails tested by a dermatologist (with a culture or biopsy) to prove fungus is present before embarking on treatment if you have psoriasis. Other skin conditions (like lichen planus or medication reactions) can also cause thick, crumbling nails.

Treatment Options

Treatment of nail psoriasis is slow and often difficult. Since it takes about three months to grow a fingernail and about six months to grow a toenail, even successful treatments will take at least that long before the nail looks normal.

Biotin: Biotin is a B vitamin that is often taken to make the nails grow stronger and more normally at a dosage of 2500 micrograms a day. This dose is more than is usually found in a daily multi-vitamin but it can be purchased at most drug or vitamin stores. As with all nail treatments, you need to be persistent with the vitamin regimen for at least three months to see the benefit (or six months in the case of toenails).

Topical steroids: Topical steroids are often helpful in skin psoriasis but can be difficult to apply in a way that can help the nails. Usually, liquid drops are best and are applied to the underside of the end of the nail (where it meets the skin) and the skin right behind the nail. Overuse of topical steroids can lead to skin thinning (“atrophy”) and stretch marks, which are often permanent.

Injected steroids: Steroid injections underneath and behind the nail can often be quite helpful for nail psoriasis. Unfortunately, they are also very painful and need to be repeated two to four times per year to maintain the good effect. To reduce pain, your doctor can use numbing shots to put the fingers to sleep before giving the injections.

Internal medications: Internal medications seek to calm the parts of the immune system that attack the skin and cause psoriasis. These include older medications like methotrexate and cyclosporine as well as newer pills like apremilast (Otezla) or shots like adalimumab (Humira) or secukinumab (Cosentyx). Most of these can sometimes make nail disease better. For example, secukinumab (Cosentyx) was recently shown to make nail psoriasis substantially better in about 45 percent of patients after four months, and the pill called apremilast (Otezla) was shown to make nail psoriasis on average about 60 percent better when taken for one year. These medications are often expensive and can have side effects that require careful monitoring with your doctor.

Bottom Line

Psoriasis in fingernails or toenails can be disfiguring and disabling. It can be mild or severe and sometimes is not related to the severity of psoriasis of the skin. If you have bothersome nail psoriasis, see a board-certified dermatologist to confirm the diagnosis and help you create a treatment plan. Although it can be slow and difficult to treat, new options are offering hope for nail treatment.

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Article Sources
  • About Psoriasis: Hands, Feet and Nails. National Psoriasis Foundation Website.