Psoriasis of the nails L40.8

Author: Prof. Dr. med. Peter Altmeyer

All authors of this article

Last updated on: 05.01.2023

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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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A frequent manifestation of psoriasis with varying degrees of severity, especially in severe cases, which places considerable psychological and physical-motor stress on the patient and occurs on one or more nails (see nail below). Patients with concomitant psoriatic arthritis are affected by nail changes at diagnosis with up to 80%.

Classification
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Nail psoriasis is subdivided according to its acuity:

  • Acute nail psoriasis: Intense, often painful inflammation of the distal and/or proximal phalanx with deformities of the nail plate up to loss of the nail.
  • Chronic nail psoriasis:
    • Nail matrix psoriasis:
    • Nail bed psoriasis:
    • Psoriatic crumbly nail (parakeratotic crumbly 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 is probably the most common nail disease after nail mycosis.

Nail psoriasis occurs in about 40%-50% (numbers diverge in the literature) of all psoriasis patients and 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 nail psoriasis, the duration of psoriasis, and between the severity of nail involvement and the severity of 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 association between nail and joint disease.

Between 1-5% of patients suffer from isolated nail involvement without other signs of integumentary psoriasis.

The relationship between nail mycosis and nail psoriasis is not confirmed (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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Nail psoriasis has various clinical manifestations that may occur in isolation or in combination on single or multiple fingernails or toenails.

In a larger cohort

  • spotted nails in 75% of psoriatic patients
  • in 50% a thickening of the matrix (maximum form = psoriatic crumb nail)
  • in 46% a (distal) onycholysis
  • in 30% discolorations due to parakeratosis of the nail plate (oil stain)
  • 50% of the patients complained about pain (mostly pressure pain).

Furthermore:

  • Splinter hemorrhages (smallest elongated hemorrhages below the nail plate)
  • Subungual hyperkeratosis (caused by psoriatic areas in the distal nail bed and/or hyponychium; paradoxical nail growth: increased thickness growth of the nail at the expense of longitudinal growth.
  • Psoriatic paronychia: inflammatory involvement of the paronychium with variable degrees of swelling and scaling. Frequent loss of the cuticle (eponychium).
  • Psoriatic crumbling nail, as the maximum form of psoriatic onychodystrophy.
  • Pustular nail psoriasis with formation of sterile pustules. Tends to scarring atrophy. Acrodermatitis continua suppurativa can be considered as 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!): Toenails are more frequently affected, slow nail growth, rarely pits, frequent onycholysis, microscopic detection of spores and mycelia (careful sampling technique); positive culture!

Onychogrypose (common in old age): Highly domed, thickened, often discolored, claw-like, hard nail plate. Formation of large, malformed nails that have grown in the "wrong direction". The nail matrix is hard and not crumbly.

Lichen planus: Mostly thinned (!) nail plates with longitudinal surface distortions and numerous spots. Complete (atrophic) 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, spotting, splitting, thickening of the nail plate, onycholysis and color 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 stigmata.

Leukonychia (differential diagnosis see there): Polyetiologic symptom with punctate, transverse, longitudinal, or homogeneous total whitening of the nail plate (leading symptom: nail, white), which may involve one or more nails.

Yellow-nail syndrome: Thickened, yellow discolored nails throughout the nail area, slow or no growth, scleronychia with peripheral onset onycholysis.

Twenty-nail dystrophy: Often present at birth or developing in the first few months of life. Usually affects all nails. Nail dystrophies vary, usually thickened, not crumbly, no spots or oil stains, no integumentary psoriasis.

See also Nail diseases (overview and classification).

Complication(s)
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About half of patients with nail psoriasis report limitations in their daily functions in everyday life, depending on the extent of the changes.

Around 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 milder forms, try calcipotriol solution/ointment (e.g. Daivonex, Psorcutan solution) 1 time/day, preferably in the evening, preferably occlusive (finger cots, gloves) for at least 4-6 months.

Alternatively application of topical glucocorticoids e.g. mometasone solution/grease cream in the same way. Alternative trial with sertaconazole nail plaster (Zalain nail plaster; cut to nail size and change 1 time/week).

Alternative: Local treatment with a 0.1% tazarotene (cream/gel). Several positive study results (12-24 weeks therapy) are available (Rigopoulos D et al. 2007).

Alternatively (in psoriatic onychogryposis) 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, local application of 1% 5-fluorouracil or a solution containing 1% 5-fluorouracil + salicylic acid or urea is recommended ( off-label use). Apply solution once daily, followed by occlusive dressing. Possible side effects include redness, itching, and painful burning.

Electrotherapy: Interferential current therapy has also been described as successful in nail psoriasis (Fa. NEMECTRON; Fa. IONTO-COMED).

Intralesional injections: medial and lateral injections of 0.05-0.1 ml triamcinolone acetonide (e.g. Volon A 10 mg/ml) below the matrix and below the nail plate. Strongly painful procedure, conduction anesthesia according to Oberst is required. If necessary, repeat several times after 2-4 months. This therapy has been shown to be very successful in various studies. Clear successes have been demonstrated 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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In severe therapy-resistant nail psoriasis, systemic therapy is the method of choice.

  • Good results up to complete freedom from symptoms in the context of a long-term systemic therapy of psoriasis (> 8-12 months) have been described for fumaric acid esters, ciclosporin A and acitretin.
  • Also under the therapy with biologics (e.g. etanercept, infliximab, adalimumab, golimumab, efalizumab) good effects could be found in different studies. For infliximab, a larger placebo-controlled blinded study is available in which about half of the patients achieved complete clinical freedom from symptoms after 50 weeks (Infliximab - EXPRESS study). In the study by Bianchi L et al. 2005, this result could be confirmed. A larger, positive, phase III study in moderate to severe "nail psoriasis" is also available for adalimumab (Elewski et al. 2018).
  • In concurrent psoriatic arthritis, a combination with methotrexate may need to be considered.

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.

Disclaimer

Please ask your physician for a reliable diagnosis. This website is only meant as a reference.

Authors

Last updated on: 05.01.2023