How Does Psoriasis Affect The Nails?

Psoriasis is a chronic inflammatory autoimmune condition that can affect not only the skin, but also a person’s joints, fingernails, and toenails. In fact, around half of people with psoriasis have symptoms that affect the nails. For example, people might have symptoms like pits spreading across the nails, which can be large and deep or small and shallow.

These symptoms can cause pain and discomfort. Nail psoriasis that affects the fingernails can make it difficult to work or carry out daily activities. It can also cause embarrassment in social situations².  For example, nail psoriasis on the toenails can make a person feel self-conscious when wearing sandals or going barefoot at the beach or pool³. Nail psoriasis can be hard to treat, but many people find that they are able to manage the symptoms of nail psoriasis and reduce the impact it has on their lives⁴.

The symptoms of nail psoriasis

There are many different symptoms of nail psoriasis. These symptoms can affect all or part of a nail, and one or more nails can be affected. Nail psoriasis occurs more often on fingernails than on toenails.

Each nail actually contains three major parts^3,8:

• The “nail plate” is what we commonly think of as a finger or toenail
• The “nail bed” is the area of skin on which the nail plate rests
• The “nail matrix” is an area at the base of the nail plate where the cells that produce new nail growth are produced

Nail psoriasis can have an impact on all three of these parts. In general, symptoms of psoriasis are caused by rapid, excess growth of skin cells and the same holds true for nail psoriasis: it can cause nails to grow too quickly and/or too thickly, for example.

Pits on the nail plate are the most common symptom of nail psoriasis. This is due to damage in the nail matrix caused by psoriasis, which affects the top of the nail plate. Another common symptom is called distal onycholysis. This happens when the nail plate becomes white or yellowish, and it lifts up and separates from the nail bed below. Some people experience scaling under the nail plate due to the excess cells being produced (also called “subungual hyperkeratosis”)^4,8.

Coloration symptoms

The nail might turn a white, yellow, or brown color in some areas, which is a symptom called leukonychia. Another common symptom is the appearance of a yellowish-brown or red-colored oil droplet or salmon patch on the nail bed.  This is a sign that there is psoriasis in that area. The scientific name for this is dyschromia^5,8.

Texture symptoms

Another set of symptoms can change the way that the nail usually looks. For example, the nail plate might develop lines or ridges in it, or the nail plate might weaken and crumble. When the nail plate weakens, it can also lead to what are known as splinter hemorrhages. These look like long black lines underneath the nail plate^6,8.

People with nail psoriasis are also at a higher risk of developing bacterial and fungal infections in the nails.

How common is nail psoriasis?

Around half of people with psoriasis have symptoms that affect their nails, and most people with some form of psoriasis will have nail symptoms at some point during their lives. Nail involvement is more common among people with psoriatic arthritis, affecting 80-90% of those patients^3,8.

Nail psoriasis usually does not affect people who do not have psoriasis that affects other parts of their bodies. It generally affects people of all ages, genders, and ethnicities at equal rates⁵.

Nail psoriasis treatments

Nail psoriasis can be difficult to treat for a couple of reasons. Topical medicines need to be applied directly to the affected area to be effective. The disease affects the nail matrix where new nail cells are formed, and it is difficult to reach the nail bed and nail matrix with medicine, because they are covered by the nail bed. Another problem is that many medicines for nail psoriasis must be used for a long time (up to 12 months) before they have an effect⁸.

However, there is a range of different treatment options available, and many people are able to improve their symptoms⁸. For patients with relatively mild nail psoriasis, treatment might include:

• Topical calcipotriol solution
• Topical corticosteroids
• Injections of corticosteroids into the affected area of the nail
• Phototherapy

People with more severe nail psoriasis might need more powerful treatment with drugs taken by mouth that affect the entire body, such as immunosuppressants and biologic therapies. Healthcare providers might also recommend that the affected nail be removed entirely and allowed to grow back.

Around one-third of people with nail psoriasis also have fungal infections in their nails, which can be treated with antifungal medicines.

Tips for living with nail psoriasis

Some people have nail psoriasis for a long time, while in others it might go away more quickly (either on its own or due to treatment). There are many strategies that people living with nail psoriasis can use to reduce their symptoms.

Damage or injury to the nails can trigger nail psoriasis and make it worse if you already have it⁴. For this reason, it is important to keep your nails short and protect them from damage, for example, by wearing gloves when working with your hands (vinyl gloves with a cotton liner are recommended, but not latex gloves in case there is an unknown latex allergy)⁵. Keeping the nails dry can also help.

To improve the appearance of the nails during treatment, some people find it helpful to have the nails scraped/filed, to use nail polish, or to apply artificial nails.