Psoriasis of the nails L40.8

Author: Prof. Dr. med. Peter Altmeyer

All authors of this article

Last updated on: 29.10.2020

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Synonym(s)

Nail involvement in psoriasis; nail psoriasis; onychodystrophia psoriatica; Psoriasis nail; Psoriasis Nail; Psoriasis nails; Psoriasis of the nail; Psoriasis of the nails; Psoriatic nail; psoriatic nails; Psoriatic onychodystrophy; Psoriatic Onychopathy

Definition
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Frequent manifestation of psoriasis with varying degrees of severity, particularly in severe cases, which places considerable psychological and motoric stress on a patient and which occurs on one or more nails (see nail below). Patients with concomitant psoriatic arthritis are affected by nail changes in up to 80% of cases at diagnosis.

Classification
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Psoriasis of the nail can be divided according to its acuteity.

  • Acute psoriasis of the nail: Intense, often painful inflammation of the distal and/or proximal phalanx with deformation of the nail plate up to loss of the nail.
  • Chronic psoriasis of the nail:
    • Nail matrix psoriasis:
    • psoriasis of the nail bed:
    • Psoriatic crumb nail (parakeratotic crumb nail = extreme variant of nail psoriasis) with simultaneous occurrence of nail matrix and nail bed psoriasis (see also psoriatic pachydermo-periostitis - POPP syndrome).
  • Nail fold psoriasis (psoriatic paronychia).

Occurrence/Epidemiology
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  • Psoriasis is the skin disease that most frequently affects the nails and after nail mycosis probably the most common nail disease.
  • Nail posriasis occurs in about 40%-50% (numbers diverge in the literature) of all psoriasis patients or in 70-80% of all patients with psoriatic arthritis (see below psoriasis arthropathica).
  • Nail psoriasis occurs in about 10-55% of all psoriasis patients with "pure" psoriatic skin symptoms.
  • There is a positive correlation between the presence of psoriasis of the nail, the duration of the psoriasis and the severity of the nail infestation and the severity of the skin and joint changes. The lifetime prevalence is 80%.
  • The close anatomical and pathophysiological connection between the enthesis of the extensor tendon and the nail apparatus is a possible reason (presence of enthesitis) for the closer connection between nail and joint disease.
  • Between 1-5% of patients suffer from isolated nail infestation without other signs of integumentary psoriasis.
  • The connection between nail mycosis and psoriasis of the nail is not certain (Larsen GK et al. 2003).

Etiopathogenesis
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Nails are generally referred to as "simple" skin appendages. There is good evidence that there is a complex relationship between the nail apparatus, distal phalanx and the surrounding tendons and ligaments. This explains the frequent concordant occurrence of psoriasis of the nail and arthritic or enthesitic inflammation.

Clinical features
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Psoriasis of the nail has various clinical manifestations, which can occur in isolation or in combination in individual or all fingernails or toenails.

In a larger cohort

  • 75% of psoriatics have spotted nails
  • at 50% a thickening of the matrix (maximum form = psoriatic crumb nail)
  • in 46%, (distal) onycholysis
  • 30% discoloration due to parakeratosis of the nail plate (oil stain)
  • 50% of those affected complained of pain (mostly pressure pain).

Furthermore:

  • Splinter hemorrhages (smallest oblong bleedings below the nail plate)
  • Subungual hyperkeratosis (caused by psoriatic areas in the distal nail bed and/or the hyponychium; paradoxical nail growth: increased nail thickness growth at the expense of longitudinal growth.
  • Psoriatic paronychia: inflammatory affection of the paronychia with varying degrees of swelling and scaling. Frequent loss of the cuticle (eponychium).
  • Psoriatic crumb nail, the maximum form of psoriatic onychodystrophy.
  • Pustular psoriasis of the nail with formation of sterile pustules. Prone to scarring atrophy. Acrodermatitis continua suppurativa can be considered the maximum form.

Diagnosis
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The clinical picture is conclusive in connection with other psoriatic symptoms. Exclusion of a tinea unguium.

Differential diagnosis
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  • Tinea unguium (most important differential diagnosis!): More often toe nails are affected, slow nail growth, rarely dimples, often onycholysis, microscopic detection of spores and mycelia (careful sampling technique); positive culture!
  • Onychogrypose (common in old age): Strongly arched, thickened, often discoloured, claw-like, hard nail plate. Formation of large, malformed nails grown in the "wrong direction". The nail matrix is hard and not crumbly.
  • Lichen planus: Mostly thinned (!) nail plates with longitudinal distortions of the surface and numerous spots. Complete (atrophying) destruction of the nail plate is possible.
  • Eczema nails: Not clearly assigned term for nail changes in chronic hand eczema. In this respect, the clinical symptoms are of different types: Frequently irregular nail surface with grooves, furrows, pits, splintering, thickening of the nail plate, onycholysis and colour changes. No psoriatic stigmata of the skin.
  • Onycholysis semilunaris: Crescent-shaped incomplete onycholysis with detachment of the nail plate from the free edge. No other psoriatic stigmas
  • Leuconychia (differential diagnosis see there): Polyätiological symptom with punctiform, transversal or longitudinal or homogeneous total white coloration of the nail plate (leading symptom: nail, white) which may affect one or more nails.
  • Yellow-nail syndrome: Thickened nails, yellow throughout the nail area, slow or no growth, scleronychia with peripheral onycholysis.
  • Twenty-nail dystrophy: Often already congenital or developing in the first moons of life. Mostly affects all nails. Nail dystrophies are different, mostly thickened, not crumbly, no spots or oil stains, no integumentary psoriasis.
  • S.a. Nail diseases (overview and classification).

Complication(s)
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About half of the patients with psoriasis of the nail report limitations in their daily functions in everyday life as well as at work. About 50% of those affected report pain.

General therapy
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The treatment of nail psoriasis is extremely difficult and lengthy and therefore requires a lot of patience. Unfortunately, patients have to learn to deal with the different types of nail psoriasis. forms of psoriatic onychodystrophy over a longer period of time. External therapy promises success only in mild forms. The following general rules of conduct must be observed:
  • Avoid provocation factors (aggressive manicure or pedicure, manipulation of the cuticles).
  • Cutting nails short, especially for patients who are confronted with manual activities in their profession/household/hobby.
  • Before cutting the nails, wash and grease them (e.g. Linola fatty ointment) to reduce splintering.
  • If necessary, only cut brittle nails after a lukewarm oil or tar bath (Linola Fat Oil Bath, Balneum Hermal Oil Bath).
  • Have transverse grooves or thickened nails milled off by experienced medical chiropodists.
  • Wear light, wide shoes that do not press on the affected, deformed toenails.
  • Artificial fingernails as an optical embellishment are possible.
  • In case of psoriatic "crumb nails", occlusive treatment with 40% urea paste, e.g. R110 for 10-14 days, soften and have it milled off by a specialist.

External therapy
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  • For lighter forms, try using Calcipotriol solution/ointment (e.g. Daivonex, Psorcutan solution) once/day, preferably in the evening, preferably occlusively (finger cots, gloves) for at least 4-6 months.
  • Alternatively application of topical glucocorticoids e.g. Mometason solution/fat cream in the same way. Alternatively try Sertaconazole Nail Plaster (Zalain Nail Plaster; cut to nail size and change once a week).
  • Alternative: Local treatment with a 0.1% Tazarotene (cream/gel). There are several positive study results (12-24 weeks therapy) (Rigopoulos D et al. 2007)
  • Alternatively (for psoriatic onychogrypose) application of a 15% urea varnish (Onypso). Over a period of >6 months, apply 1 x daily to the affected nails.
  • For more severe forms, the local application of 1% 5-fluorouracil or a solution with 1% 5-fluorouracil + salicylic acid or urea ( off-label use) is recommended. Apply solution once a day, followed by an occlusive dressing. Possible side effects are redness, itching and painful burning.
  • Electrotherapy: Interferential current therapy has also been described as successful for psoriasis of the nail (NEMECTRON; IONTO-COMED).
  • Intralesional injections: medially and laterally below the matrix and below the nail plate a depot of 0.05-0.1 ml triamcinolone acetonide (e.g. Volon A 10 mg/ml) is placed. Strongly painful procedure, conduction anesthesia according to Oberst is necessary. Repeat after 2-4 months if necessary. Under this therapy it was possible in various cases to Clear successes have been proven in various studies (evidence level C).

Radiation therapy
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  • PUVA cream therapy and systemic PUVA therapy have limited effectiveness. More recent controlled data are not available for this form of therapy.
  • In special and justifiable exceptional cases, irradiation with soft X-rays (recognized as a therapy method, dosage 3-4.5 Gy) is recommended. This therapy is well effective, but only to be used by physicians who have experience with this method.

Internal therapy
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For severe therapy-resistant nail psoriasis, systemic therapy is the method of choice.

  • Good successes up to complete freedom from symptoms as part of a long-term internal therapy for psoriasis (> 8-12 months) have been described for fumaric acid ester , Ciclosporin A and Acitretin.
  • Also under the therapy with biologicals (e.g. Etanercept, Infliximab, Adalimumab, Golimumab, Efalizumab) good effects could be proven in different studies. For Infliximab a larger, placebo-controlled blinded study is available in which about half of the patients could achieve a complete clinical freedom of appearance after 50 weeks (Infliximab - EXPRESS study). This result was confirmed in the study by Bianchi L et al. 2005. There is also a larger, positive, phase III study for adalimumab for moderate to severe "psoriasis of the nail" (Elewski et al. 2018).
  • In the case of concomitant psoriatic arthritis, a combination with methotrexate should be considered if necessary.

Note(s)
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Psoriatic onychodystrophy is often seen as a negligible "secondary problem". However, the clinical problem can reach a serious clinical size due to stigmatisation, functional limitations of everyday activities, secondary infections and pain.

With regard to an isolated psoriasis of the nail, the benefit-risk profile of an internal therapy must be considered!

The "Nail Psoriasis Severity Index ( NAPSI) was developed to objectify and monitor nail involvement. Alternative scores are: NPQ10 (Nail Psoriasis Quality of Life - to assess the effect of nail psoriasis on the quality of life of the individual) and NAPPA (Nail Assessment in Psoriasis and Psoriasic Arthritis).

Clinically important is the observation, secured in a multivariate regression analysis, that nail infestation must be considered a negative prognostic factor (Bardazzi F et al. 2017).

Literature
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  1. Bardazzi F et al (2017) Nail involvement as a negative prognostic factor in biological therapy for psoriasis: a retrospective study. J Eur Acad Dermatol Venereol 31:843-846.
  2. Bianchi L et al (2005) Remission and time of resolution of nail psoriasis during infliximab therapy.
    J Am Acad Dermatol 52:736-737.
  3. Elewski BE et al (20189 Adalimumab for nail psoriasis: Efficacy and safety from the first 26 weeks of aphase
    3, randomized, placebo-controlled trial. J Am Acad Dermatol 78:90-99.
  4. Fuchs G (2011) Nail psoriasis. Compendium Dermatology 7:15
  5. Kahl C et al (2012) Stepchild psoriasis of the nail. Dermatologist 63:184-191
  6. Larsen GK et al(2003) The prevalence of onychomycosis in patients with psoriasis and other skin diseases. Acta Derm Venereol 83:206-209.
  7. Reich K (2009) A treatment approach in patients with psoriasis of the nail. JEADV 23 (Suppl):15-21
  8. Rich P et al (2003) Nail psoriasis severity index: a useful tool for evaluation of nail psoriasis. J Am Acad Dermatol 49: 206-212
  9. Rich P et al (2008) Baseline nail disease in patients with moderate to severe psoriasis and response to treatment with infliximab during 1 year. J Am Acad Dermatol 58: 224-231
  10. Rigopoulos D et al.(2007) Treatment of psoriatic nails with tazarotene cream 0.1% vs. clobetasol propionate0
    .05% cream: a double-blind study. Acta Derm Venereol. 2007;87(2):167-8.

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Last updated on: 29.10.2020