What is nail psoriasis, and how can I treat it?

If you have psoriasis, it’s important to check your fingernails and toenails for signs of nail psoriasis. Common signs include:

• Tiny dents in your nails (called “nail pits”)

• White, yellow, or brown discoloration

• Crumbling nails

• Nail(s) separating from your finger or toe

• Buildup beneath your nail

• Blood under your nail

If you notice any of these signs or another problem with a nail, tell your dermatologist. Treatment can help clear nail psoriasis and reduce pain. Without treatment, nail psoriasis may worsen. Some people develop “disappearing” nails. This can affect people’s ability to use their hands or walk. Treatment can prevent this. 

Nail changes can also be a sign of psoriatic arthritis, so you want to see your dermatologist to find out. Treating psoriatic arthritis can prevent it from getting worse.

What nail psoriasis looks like

Nail psoriasis causes changes to your fingernails and toenails

This fingernail shows 3 signs of nail psoriasis: Crumbling, roughness, and blood under the nail (arrow).

Common signs of nail psoriasis

This nail also has 3 signs of nail psoriasis: Tiny dents in the nail (pits), white discoloration, and lifting (the nail is separating from the finger).

Most people who have plaque psoriasis develop nail psoriasis

Discoloration (blue arrow), nail lifting from the finger, and a thin line of blood (black arrow) are common signs of nail psoriasis.

Nail psoriasis usually begins years after psoriasis first appears on the skin

This patient’s nail has 3 common signs of nail psoriasis: Grooves, blood beneath the nail (arrows), and lifting of the nail from the finger.

Nail psoriasis can be mild

If you have psoriasis, ridges and a thin line of blood beneath the nail (black arrow) can be signs of nail psoriasis.

Improvement from treatment happens slowly

Nails grow slowly, so it will take 6 months or longer to clear debris, a common sign of nail psoriasis, beneath the nail.

What treatments are available for nail psoriasis?

There are many treatments for nail psoriasis. Your treatment plan may include one or more of the following. Treatment you apply to the nails: This can be helpful for mild or early nail psoriasis. Nails grow slowly, so you’ll need to apply these treatments for several months, often once or twice a day. Because nail psoriasis can be stubborn, you may need to use more than one treatment. Sometimes, two medicines are combined to give you a faster response. 

Treatment that you apply to your nails includes the follow.

• A potent or very potent corticosteroid: This can be helpful for most signs and symptoms of nail psoriasis. It’s safe to use this medicine once or twice a day for up to nine months.

• Calcipotriol: In one study, researchers found this to be as effective as a potent corticosteroid at treating the buildup beneath the nail.

• Tazarotene: This treatment can be especially helpful for treating pitting, a separating nail, and discoloration.

If you need stronger treatment, your dermatologist may recommend treatment given in a dermatologist office or clinic. This treatment may include one of the following.

• Injections of corticosteroids (or another psoriasis medicine): This involves getting injections directly into or near your nails with psoriasis. If the first treatment shows poor results, you may get another one in a few months. Corticosteroid injections can be effective for treating buildup under the nail, nail ridges, nail thickening, and nails separating from fingers or toes.

• Laser treatment: Some lasers can be effective.

• PUVA: This involves first soaking in (or taking) a medicine called psoralen. Afterwards, you are carefully exposed to UVA rays. PUVA can be effective for treating discolored nails and nails that are separating from fingers or toes. It does little to treat nail pitting.

• Treatment that works throughout the body: If you have severe psoriasis and nail psoriasis, your dermatologist may prescribe medicine that can treat both your skin and nails. As with other treatment for nail psoriasis, it can take months to see results. 

Psoriasis medicine that can help clear the skin and nails includes: 

• A biologic

• Methotrexate

• Retinoid

• Cyclosporine

• Apremilast

Nail infection needs treatment, too

A nail infection can develop if you have nail psoriasis. Because a nail infection can look a lot like nail psoriasis, it’s important to find out if you have an infection. Testing, which usually consists of scraping the nail, can find an infection.  If you have a nail infection, treatment can get rid of it. 

For best results from treatment

Treating nail psoriasis can be a challenge. It often takes time to treat. To get results, you need to treat your nails as directed and for as long as directed. Some patients need to try a few treatments to find one that works. 

The right nail care can help you get the best results from treatment. You’ll find out what dermatologists recommend at: 7 easy-to-follow nail care tips that can reduce nail psoriasis

Images
Images used with permission of the Journal of the American Academy of Dermatology. J Am Acad Dermatol 2013;69(2):249.

References
Crowley JJ, Weinberg JM, et al. Treatment of nail psoriasis: Best practice recommendations from the Medical Board of the National Psoriasis Foundation. JAMA Dermatol. 2015 Jan;151(1):87-94. Dogra A, Arora AK. “Nail psoriasis: The journey so far.” Indian J Dermatol. 2014 Jul;59(4):319-33. Lin YK, Chang YC, et al. “A Chinese herb, indigo naturalis, extracted in oil (Lindioil) used topically to treat psoriatic nails: A randomized clinical trial.” JAMA Dermatol. 2015 Jun;151(6):672-4. Manhart R, Rich P. “Nail psoriasis.” Clin Exp Rheumatol. 2015 Sep-Oct;33(5 Suppl 93):7-13. van der Velden HMJ, Klaassen KMG, et al. “Fingernail psoriasis reconsidered: A case-control study.” J Am Acad Dermatol 2013 Aug;69(2):245-52.