Fact Sheet

Nail Psoriasis

Nail psoriasis?
Psoriasis can affect both finger nails and the toe nails. The percentage of those with psoriasis who have nail involvement is thought to be 50%. In psoriatic arthritis this may rise to 80%. For some unknown reason the finger nails are more often involved than toe nails. The nails are part of the skin so it is perhaps not surprising that a skin disease such as psoriasis can affect the nails. No one knows why some people get nail involvement and others don’t. Nails grow from the nail plate which is just under the cuticle. In people who develop psoriasis of the nails it is involvement of the nail plate that causes pitting and ridging of the nails. Onycholysis,subungual hyperkeratosis and splinter haemorrhages are due to disease of the nail bed. The nail itself is totally inert, being composed of modified, tightly packed dead skin cells, and therefore any treatment must be directed to the nail plate itself or the nail bed. The severity of nail involvement does not follow the severity of psoriasis elsewhere in the body. Rarely, the nails can be the only site of the body affected. More usually, if the nails are involved there will be areas of psoriasis elsewhere on the body. You can, however, develop severe nail changes with only minimal psoriasis elsewhere on the body.

Commonly it appears as pits in the nails of various size, shape, and depth. Sometimes the nails develop a yellowish colour and become thick. The nails may crumble easily and be surrounded by inflammation. Another possible symptom is detachment of the nail from the nail bed. Psoriasis can affect the connective tissue that forms the nails. Pitting of the nails may be an early sign of nail psoriasis, although pitting can also occur in other diseases. Other signs of nail psoriasis include the appearance of dark spots resembling oil droplets on the nails, the build-up of flaky skin cells under the nails, and separation or loosening of the nails from their beds (onycholysis). One or more nails may be affected.

Nail changes in psoriasis fall into general categories that may occur singly or all together:

• The nail plate is deeply pitted, probably due to defects in nail growth caused by psoriasis.
• The nail has a yellow to yellow-pink discoloration, probably due to psoriatic involvement of the nail bed.
• White areas appear under the nail plate. These are air bubbles marking spots where the nail plate is becoming detached from the nail bed (onycholysis). There may be reddened skin around the nail.
• The nail plate crumbles in yellowish patches (onychodystrophy), probably due to psoriatic involvement in the nail matrix.
• The nail is entirely lost due to psoriatic involvement of the nail matrix and nail bed.

Remember that nails grow extremely slowly and what you are influencing is not the existing nail but new nail that is developing from the nail plate. It may, therefore take up to a year for finger nails, and two years for toe nails to grow out normally. So you must be patient with any treatment because of the slowness of growth, so any benefits from such treatments you apply may take up to a year or more to be seen. Nails on the hand in psoriasis can be painful and often restricts dexterity of the fingers. If the toe nails are affected attention and care from a chiropodist may be helpful and may be able to pare down the nail to remove the pressure from excess thickening of the cosmetic problem. The nails are distorted and this can be embarrassing. Nail varnish can be used to conceal some of the damage. Application of a good nail hardener or artificial nails if the nails are mostly intact can improve their appearance and also aids to protect them. Be careful to avoid sensitivities to glues with chemicals that may be used to apply artificial nails. It is always advisable to tell your manicurist about your psoriasis so that he/she can be extra careful.

About one-third of people with nail psoriasis may have a fungal infection, which, if treated, could help their nails to improve. Some treatments used for skin psoriasis also may improve the condition of the nails. Consult with your physician to learn which treatment may be best for you.

Nail psoriasis is frequently associated with psoriatic arthritis.

Onycholysis is when the nail bed develops a build up of keratin causing the nail to appear white when it is viewed from above. It usually starts from the end of the nail and works back. This may be the only sign of psoriasis and may affect only one finger or toenail alone and there may be no other skin rash of psoriasis. Onycholysis may affect only one fingernail and never become more extensive, but in some people it can affect more than one nail. There is no way of predicting this. The nail can lift off from the nail bed and the nail can sometimes be lost. It may or may not grow back normally.

Occasionally the build up of keratin beneath the nails in psoriasis can be very marked and lead to the affected nail becoming thickened and raised. When this happens it is called Onychodystrophy. This can be sore and painful and some sufferers may also find the appearance embarrassing due to comments made by others. The other diagnosis could be a fungal infection of the nail in which case clippings of the crumbly keratin beneath the nail should be sent for culture. Sometimes it can be difficult to tell between the two

What can help ?
The basic strategy for both hands and feet should be to keep the nails short. Try to trim them back to the point of firm attachment and gently file them down with an emery board.
Try to protect your nails from damage because this can worsen the problem. Consider wearing gloves to protect your nails whenever you are doing something that may damage your nails.
Rubbing moisturisers into the nail and cuticle or soaking them in emollient oils may help.
If your nails are pitted but mainly intact, nail hardeners or artificial nails may improve their appearance. It is a sensible precaution to rule out the possibility of any sensitivity to glues and chemicals by first applying a small sample to the skin.
Toe nails can benefit by being soaked for at least 10 minutes in a bowl or bath of warm water which softens the nails before gently filing the thickened part of the toe nails with an emery board, and using good sharp scissors to trim off small pieces of the nails. You should cut straight across the toe nail, which helps it from becoming ingrown. It helps to always wear comfortable shoes, which gives room for the toes, avoiding any friction to the toe nails causing thickening to occur. It may be of benefit to consider when buying shoes to select a size up from your normal size.

If your nails are affected by psoriasis, try the following:

• Trim your nails to reduce the risk of injuring them; trauma can worsen nail psoriasis.
• Try soaking affected nails and follow up with moisturizer. Carefully file thickened toenails with an emery board after soaking.
• Reduce toenail pressure and friction – which can cause toenails to thicken -- by wearing well-fitted, roomy shoes.
• Consider using nail hardeners or artificial nails that can help to improve the appearance of intact nails.
• Talk to your physician if deformed nails are a problem for you. They may be surgically removed and replaced with artificial nails.

Disclaimer

While every effort has been made to ensure that the information given in this leaflet is accurate, not every treatment will be suitable or effective for every person. All content within Pure and Gentle SkinCare is provided for general information only, and should not be treated as a substitute for the medical advice of your own doctor or any other health care professional. Pure and Gentle SkinCare is not responsible or liable for any diagnosis made by a user based on the content of Pure and Gentle SkinCare website or advisers. Always consult your own GP if you're in any way concerned about your health as he or she will be able to advise in greater detail.

Other helpful information sites

www.psoriasis-association.org.uk - A charitable site which provides some factual information on Psoriasis to give you a better understanding of what psoriasis is, what causes it and what treatments are available.

www.psoriasisblog.org - Psoriasis information and support web site for psoriasis sufferers and their families living with the difficulties of psoriasis. Psoriasisblog.org is an independent blog for people suffering from psoriasis written by people suffering from psoriasis.

www.psoriasisgroup.com - Psoriasis Group is a Psoriasis community built by people with Psoriasis for people with Psoriasis.

www.psoriasis-help.org.uk - A non profit site which is dedicated to helping people suffering from the Chronic Skin Disease Psoriasis. This site contains information about Treatments, Handy Tips for living with the Psoriasis and other topics

www.psoriasis-support-trust.org - Formerly the Psoriasis Youth Foundation, to assist sufferers of Psoriasis, through grants and research sponsorship.
www.nhsdirect.nhs.uk - telephone 0845 4647 to speak to an adviser or nurse
www.britishskinfoundation.org.uk - helpful advise on many different types of skin problems
www.bbc.co.uk/health - information site