Nail psoriasis results from psoriatic involvement of the nail bed or nail matrix. Patients with nail psoriasis can develop a wide variety of nail changes, such as pitting, onycholysis, subungual hyperkeratosis, and nail discoloration. Splinter hemorrhages: Nail bed involvement resulting in capillary rupture in the dermis beneath the nail plate. These are the most common changes in nail psoriasis:. Subungual hyperkeratosis of the toenails can be particularly uncomfortable because when wearing shoes the nail may be put under constant pressure. Some nail changes are caused by using systemic retinoid medication, which can help the skin but may result in formation of very thin nails which do not appear normal. In addition to these changes you may get longitudinal ridging of the nails and reddish marks under the nails, called splinter haemorrhages, due to tiny burst blood vessels under the nails. Results from psoriasis affecting the distal nail bed or hyponychium or extension of oil spots distally. (a) Nail plate thickening with discoloration and subungual hyperkeratosis (arrow) of the toenail (b) Subungual hyperkeratosis affecting toenails. Diagnosis of nail psoriasis can be made easily in a patient with concomitant skin psoriasis.
In psoriasis can see a yellowish-brown margin between the margin between the normal nail (pink) and the detached parts (white). Most commonly results from the compulsive habit of a patient picking at a proximal nail fold thumb with an index fingernail. Can sometimes be seen in nail bed ‘oil spot’, distal onycholysis, distal subungual hyperkeratosis, splinter haemorrhages and false nail following spontaneous separation of nail plate. Psoriasis can change the nail bed as the results in onycholysis, discoloration, splinter hemorrhage and subungual hyperkeratosis. The main treatment of psoriatic nails is using topical high- potent steroids however topical steroids are limited their ability to penetrate deep nail matrix or nail bed which are the main pathology. Nail psoriasis can occur at any age and all parts of the nails and the surrounding structures can be affected. In the first case, irregular and deep pitting, red spots of the lunula, crumbling, and leukonychia are seen; in the second case, salmon patches, onycholysis with erythematous border, subungual hyperkeratosis, and splinter hemorrhages are observed. The most severe changes are observed when the disease affects the nail matrix, a germinative epithelium that produces the nail plate. Alterations of the nail bed due to nail psoriasis include onycholysis, subungual hyperkeratosis, oil drop or salmon spots, dyschromias, and splinter hemorrhages (Figure 2).
Psoriatic fingernail and toenail damage can be one of the most distressing features of an already difficult to bear skin disease. 1 They also found that fingernail changes were more associated with psoriatic onychopathy while toenail changes were more frequently the result of fungal infection. This review is the result of a systemic approach to the literature and covers topical, intralesional, conventional systemic, and biologic systemic treatments, as well as non-pharmacological treatment options for nail psoriasis. Nail psoriasis can be treated effectively using topical treatments, intralesional treatments, and systemic treatments, but an optimal effect may take up to 1 year. Psoriasis of the nail bed presents as oil-drop discoloration, splinter hemorrhages involving the distal third of the nail plate, subungual hyperkeratosis, and/or detachment of the nail plate from the nail bed (onycholysis). Nail bed features a oil-drop discoloration, b onycholysis, c subungual hyperkeratosis, d splinter hemorrhages. Thin dark red lines 1-3 mm in length, representing small hemorrhages at the junction of the nail plate and the nail bed.
Nail Disorders And Abnormalities. Medical Information
Now research suggests that the fingernails may be the window to the joints at least in people with psoriatic arthritis. Previous studies have found that at least 80 percent of people with psoriatic arthritis also have fingernail psoriasis, which can cause many different nail changes, including crumbling nails, ridges on the nails or discoloration. Primary dermatologic disorders present a broad spectrum of nail changes. Psoriatic nail lesions in order of frequency are pits, discoloration of the nail bed, onycholysis, subungual keratosis, nail plate abnormalities, and splinter hemorrhages. Although the nail matrix and nail bed normally keratinize without a keratohyaline granular layer, the psoriatic changes seen in these structures can be well differentiated from the normal process. A psoriatic lesion only affecting the deeper matrix areas will not result in a pit but rather a leukonychi area of the deeper nail plate area (Fig 14-9). Onychomycosis affects toenails more often than fingernails because of their slower growth, reduced blood supply, and frequent confinement in dark, moist environments. It may occur in patients with distorted nails, a history of nail trauma, genetic predisposition, hyperhidrosis, concurrent fungal infections, and psoriasis. Begins distally at the hyponychium and spreads to the nail plate and bed; hyperkeratotic debris accumulates and results in onycholysis; nails thicken, chip, become dystrophic, and turn yellow-white or brown-black; infection can progress proximally, causing linear channels or spikes that can make treatment difficult; associated with paronychia. Oncholysis, ingrown toenails, subungual keratosis, nail plate discoloration and irregularities; caused by friction against the shoe. Treatment results for nail psoriasis are almost always unsatisfactory and until now there is no standardized treatment regimen. One study by Tham et al 7 showed that pitting was the most common sign of psoriasis, followed by onycholysis then subungual hyperkeratosis and nail bed discoloration as the least common. Simply put, live assessment of each quadrant of the nail is graded for the presence or absence of nail matrix disease (score 0-4) consisting of pitting, leukonychia, red spots in lunula, and nail plate crumbling and nail bed psoriasis (score 0-4) for the presence of oil drop salmon patch discoloration, onycholysis, nail bed hyperkeratosis, splinter hemorrhage and nail bed hyperkeratosis. Psoriasis can change the nail bed as the results in onycholysis, discoloration, splinter hemorrhage and subungual hyperkeratosis. The main treatment of psoriatic nails is using topical high- potent steroids however topical steroids are limited their ability to penetrate deep nail matrix or nail bed which are the main pathology.
Current Concepts In Treating Psoriatic Nails
Psoriatic nails are one of the most difficult management problems faced by dermatologists. 2 Common changes on physical examination are pitting and surface ridging, onycholysis, oil spots, yellowish discoloration, thickening, splinter hemorrhages, subungual hyperkeratosis, pustules, and partial or complete loss of the affected nails (Figures 1-4). The various manifestations of nail psoriasis are a result of inflammation in different parts of the nail unit, including the matrix, nail bed and periungual tissues. However, prolonged steroid application can result in thinning of the periungual skin; as a result, patients need to be monitored carefully for signs of atrophy. Moderate periungual psoriasis with nail ridging will respond to potent topical corticosteroid applied to the affected nail under polyethylene occlusion, used in combination with practical measures to protect the hands such as gloves and avoidance of mechanical or chemical trauma. Local application of corticosteroid for psoriatic onycholysis. The use of intralesional corticosteroids is the mainstay treatment for dystrophic changes in psoriatic nails.12 William Gerstein of Montreal, while training with P. More generalized dystrophy warrants deeper injection into the matrix, and nail bed injection is helpful for subungual hyperkeratosis and some forms of nail thickening. Local disorders affecting the nail apparatus can result in a spectrum of chronic nail diseases. (apparent nail plate thickening due to subungual hyperkeratosis of nail bed). Splinter hemorrhages. Skin swelling with blue/red discoloration of proximal nail fold. The presence of splinter hemorrhages suggests psoriasis (Figure 10).