Epidemiology Of Nail Psoriasis
Psoriatic nail disease occurs in 10-55% of all patients with psoriasis, and approximately 7 million people in the United States have psoriasis . Less than 5% of psoriatic nail disease cases occur in patients without other cutaneous findings of psoriasis. About 10-20% of people with psoriasis also have psoriatic arthritis, and nail changes are seen in 53-86% of patients with psoriatic arthritis.
Psoriasis tends to run in families. In Farberâs questionnaire study of 2100 patients, 36% of patients reported the presence of psoriasis in at least 1 relative. Among siblings, 8% are affected if neither parent has psoriasis. This percentage increases to 16-25% if 1 parent or sibling has the disease, and it reaches up to 75% if both parents are affected. If 1 twin has psoriasis, the other twin is at an increased risk of having psoriasis .
In Scandinavia, the prevalence rate of nail psoriasis for adults with psoriasis approaches 5%. The prevalence increases with the age of the population studied.
Psoriatic nail disease is not associated with mortality. In severe cases, patients may have functional and psychosocial impairments.
Males and females are affected equally by nail psoriasis, and the prevalence of nail psoriasis increases with the age of the population studied.
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Miscellaneous Topical Therapies: Allopurinol Intralesional Methotrexate Colloidal Silicic Acid Indigo Naturalis Extract
Allopurinol, intralesional methotrexate, colloidal silicic acid, and indigo naturalis extract have been investigated in nail psoriasis but are not routinely used in clinical practice because of insufficient data, poor study results, or lack of registration. Allopurinol is a purine analog and an often-prescribed urate-lowering drug for the management of gout. It inhibits xanthine oxidase, a key enzyme involved in the oxidation of hypoxanthine and xanthine, reactions that ultimately result in the production of uric acid. Case reports from the early 1970s suggested a positive effect of allopurinol on PP. One placebo-controlled study investigated allopurinol in PP and nail psoriasis . Allopurinol was found to be no more effective than placebo after 8 weeks of treatment.
Methotrexate is a folic acid analog that irreversibly binds to dehydrofolate reductase and blocks deoxyribonucleic acid synthesis. It is usually taken orally or administered by injection and has several indications, including psoriasis. Intralesional use of methotrexate may limit the dose, and hence the side effects, but is not a generally accepted treatment in nail psoriasis. Saricaoglu et al. reported a 26-year-old women who was treated with methotrexate 2.5 mg every week into the proximal nail fold on each side of the nail . Subungual hyperkeratosis and pitting had improved after six treatments.
Recommendations For The Definition Evaluation And Treatment Of Nail Psoriasis In Adult Patients With No Or Mild Skin Psoriasis: A Dermatologist And Nail Expert Group Consensus
- University of Mississippi Medical Center, Jackson, MississippiUniversity of Alabama, Birmingham, Alabama
- Department of Dermatology, Inselspital, University Bern, Bern, SwitzerlandCentro de DermatologÃa, Instituto CUF, Porto, Portugal
- Natalia RompotiCorrespondenceCorrespondence to: Natalia Rompoti, MD, University Hospital of Venereal and Skin Diseases A. Sygros, 5, Ionos Dragoumi, 161 21 Athens, Greece.
- Adam I. RubinAffiliationsDepartment of Dermatology, Hospital of the University of Pennsylvania, Childrenâs Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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How Do You Diagnose Nail Psoriasis
The diagnosis is made much faster in individuals who suffer from plaque psoriasis .
- Fungal infections can also contribute to the symptoms of psoriatic nails. In order to confirm and differentiate, patients are prescribed oral antifungal remedies. If the symptoms do not recede, the diagnosis of psoriasis is confirmed.
- Another alternative is sending nail clippings for a fungal culture.
- In only the most exceptional cases, where only one nail seems to be affected, the nail matrix is biopsied to eliminate the possibility of a tumor.
Medications That Treat Your Skin
Here are some common ways to treat psoriasis on the hands and feet and relieve your symptoms.
In addition to moisturizers, mild soaps, and soap substitutes, your doctor may recommend:
- Coal tar products, like creams, gels, or ointments, to slow skin growth and ease itchy, inflamed, or scaly skin
- Salicylic acid, a peeling agent that softens or reduces thick scales
- Corticosteroids, often creams and ointments
Combinations of these often work better than one treatment alone. Sometimes doctors suggest alternating or using topical corticosteroids with a type of vitamin D called calcipotriene. This medicine should not be used on the face, so be sure to wear gloves when applying to your hands and feet in order to avoid getting it on your face later.
Your doctor might have you use a corticosteroid under a type of dressing called hydrocolloid occlusion. This filmy layer bonds to the cream, helps keep skin moist, and can be worn for several days. Wetting your skin, rubbing on a corticosteroid cream and sealing it in with plastic wrap overnight also is helpful.
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Miscellaneous Systemic Therapies: Fumaric Acid Esters Sulfasalazine And Leflunomide
Fumaric acid esters , sulfasalazine, and leflunomide have also been reported to be effective in nail psoriasis however, based on the current knowledge, they cannot be advised for this indication. FAEs have been used for the treatment of chronic PP since 1959. The commercially available form, containing mainly dimethylfumarate, is currently a first-line systemic therapy for severe chronic PP in several European countries it is not effective in PsA. The general opinion is that it has little efficacy in nail psoriasis, but one case has been reported in which it was effective both on nail bed and nail matrix psoriasis . Side effects are frequent in patients using FAEs, such as episodes of flushing, abdominal pain, and a decrease in lymphocyte count.
Sulfasalazine is an aminosalicylate used as a traditional disease-modifying antirheumatic drug for the treatment of peripheral involvement in PsA. Sulfasalazine is metabolized by gut flora into sulfapyridine and 5-aminosalicylic acid, which act as anti-inflammatory agents. The role of sulfasalazine in cutaneous psoriatic lesions and nail psoriasis is not generally accepted. One case has been reported on the use of sulfasalazine in the treatment of psoriatic nail lesions . After 3 months, nail lesions started to recede and disappeared progressively. No other cases have been reported in literature.
Prevention Of Nail Psoriasis
Good nail care is the best way to treat nail psoriasis. Try these prevention tips:
- Keep your nails trimmed short.
- Use a nail file to keep nail edges smooth.
- Wear gloves to clean and do other work with your hands.
- Moisturize your nails and cuticles every day and after they’ve been in contact with water.
- Wear comfortable shoes with enough room for your toes.
If you’re unhappy with the way your nails look, try nail varnish or artificial nails. They can also protect your nails from more damage. Some people are sensitive to the chemicals in varnish and nail adhesive. Talk to your doctor about whether these are right for you.
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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. Youll find out what dermatologists recommend at: 7 easy-to-follow nail care tips that can reduce nail psoriasis
ImagesImages used with permission of the Journal of the American Academy of Dermatology. J Am Acad Dermatol 2013 69:249.
ReferencesCrowley 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 151:87-94.Dogra A, Arora AK. Nail psoriasis: The journey so far. Indian J Dermatol. 2014 Jul 59:319-33.Lin YK, Chang YC, et al. A Chinese herb, indigo naturalis, extracted in oil used topically to treat psoriatic nails: A randomized clinical trial. JAMA Dermatol. 2015 Jun 151:672-4.Manhart R, Rich P. Nail psoriasis. Clin Exp Rheumatol. 2015 Sep-Oct 33:7-13.van der Velden HMJ, Klaassen KMG, et al. Fingernail psoriasis reconsidered: A case-control study. J Am Acad Dermatol 2013 Aug 69:245-52.
All content solely developed by the American Academy of Dermatology
The American Academy of Dermatology gratefully acknowledges the support from Amgen and .
Natural Moisturizers Like Coconut Oil And Aloe Vera
Seeing as psoriasis dries up the skin, including your nails, keeping affected areas well-moisturized is critical to reducing the redness scaliness. Coconut oil is excellent at moisturizing the nails and cuticles, while aloe vera can replenish and retain moisture.
Apply either of the two on your nails, cuticles, and the base of your fingernails several times a day. If using coconut oil, be sure to massage the area and rinse off after ten minutes. On the other hand, you can leave aloe vera to dry.
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What Treatments Are Available
Mild nail disease which isn’t causing discomfort does not need any treatment. If the nail disease is severe and causing problems then your doctor may refer you to see a skin specialist for advice and treatment. Unfortunately treatment of psoriatic nail disease is difficult and not always successful.
Treatments for nail psoriasis include:
- Treatments applied to the nail, which include steroids, salicylic acid, calcipotriol or tazarotene. Local treatments applied to the nail are often not very effective but are worth trying. If the nail is lifting off then strong steroid scalp application can be trickled under the nail.
- Antifungal treatment – this may be required for fungal nail infection if this is also present.
- A steroid injected into the nail – this may be effective for some types of nail psoriasis but it is painful.
- Light therapy – psoralen plus ultraviolet light A treatment is effective for some types of nail psoriasis but not for pitting of the nail.
- Removing an affected nail – this can be done by applying a special type of ointment and then covering the nail for seven days. Otherwise the nail can be surgically removed using local anaesthetic.
Nail Psoriasis Quick Guide
Learn more about the signs of nail psoriasis, Treatment options and get tips for caring for your nails without making your nail psoriasis worse.
Betteridge, N., Boehncke, W. H., Bundy, C., Gossec, L., Gratacos, J., & Augustin, M. . Promoting patient-centred care in psoriatic arthritis: a multidisciplinary European perspective on improving the patient experience. J Eur Acad Dermatol Venereol, 30, 576-585. doi:10.1111/jdv.13306
Jiaravuthisan, M. M., Sasseville, D., Vender, R. B., Murphy, F., & Muhn, C. Y. . Psoriasis of the nail: anatomy, pathology, clinical presentation, and a review of the literature on therapy. J Am Acad Dermatol, 57, 1-27. doi:10.1016/j.jaad.2005.07.073
Merola, J. F., Li, T., Li, W. Q., Cho, E., & Qureshi, A. A. . Prevalence of psoriasis phenotypes among men and women in the USA. Clin Exp Dermatol, 41, 486-489. doi:10.1111/ced.12805
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Keeping Nails In Good Shape
In addition to following your doctor’s recommendations for treatment of nail psoriasis, there are other ways to take care of your nails:
- Keep your nails trimmed as short as possible.
- Wear gloves when you’re working with your hands.
- Wear shoes with plenty of room in them.
- Avoid scrubbing or scraping underneath your nails.
- Use gentle nail-cleaning tools.
- Soak your nails in tar bath oil mixed with water, then apply nail moisturizer.
- If your nails are intact, consider using a nail hardener to improve their appearance.
Overview Of Treatment Of Nail Psoriasis
Many treatment options are available after the diagnosis of nail psoriasis is made. The treatments focus on improvement of the functional and psychosocial aspects of psoriatic nail disease.
The treatment options for nail psoriasis include topical corticosteroids, intralesional corticosteroids, psoralen plus ultraviolet light A , topical fluorouracil, topical calcipotriol, topical anthralin, topical tazarotene, topical cyclosporine, avulsion therapy, and systemic therapy for severe cases. Onychomycosis requires antifungal therapy for improvement. Laser and light therapies have emerged as possible cost-efficient, in-office treatments however, large-scale trials are needed, particularly in consideration for the effects in combination with other current therapies.
For preventive care, keep the nails dry and protect them from trauma to avoid the Koebner effect and possible secondary microbial colonization. In areas of onycholysis, the nail plate should be trimmed to the point of separation for medications to be effective.
At present, no definitive and curative treatment has been agreed upon by medical experts. Discuss all treatment options for psoriatic nail disease with the patient, and choose the best individually tailored regimen.
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How Is Psoriatic Nail Disease Diagnosed
The diagnosis of psoriatic nail disease is usually made by the appearance of the affected nails. Sometimes scrapings from under the nail, and nail clippings, are sent to the laboratory to be tested for fungal infection of the nail, which can sometimes look like psoriatic nail disease.
Occasionally, a sample of nail is needed to confirm the diagnosis.
Salt Bath To Treat Nail Psoriasis
Soaking affected fingers in salt bath is an effective way to get relief from this condition. For this take warm water in a large bowl. Add required quantity of dead sea salt or Epsom salt or Himalayan pink salt or combination of all three salts to this warm water. Soak fingers or toes in this salt mixed water for half an hour. This softens and cleanse nails and its surrounding area. It also disinfects the affected part. Pat dry nails and massage ayurvedic cream for psoriasis or ayurvedic oil for psoriasis. Salts also help creams or oils to penetrate deep. You can trim nails after this salt bath.
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What Is The Outlook For Psoriatic Nail Disease
Psoriatic nail disease can be difficult to treat and there is no cure. It doesn’t usually grow out without treatment, so can continue to cause problems. The appearance of the affected nails can also sometimes cause distress.
The treatment of severe psoriatic nail disease is now improving with modern medicines.
Psoriatic nail disease can also be mild, not needing any treatment, and able to be hidden with nail varnish.
Comparative Studies With Systemic Therapies
The efficacy of biologics has not only been a matter of research but differences in the occurrence of adverse events have also been investigated. A prospective, randomized, open-label study compared the incidence of onychomycosis in 315 patients with nail psoriasis treated with infliximab, etanercept, and adalimumab, and a statistically positive association between fungal infections and the use of infliximab was shown . At the end of week 24, 33 % of patients receiving infliximab had a positive fungal culture. In patients receiving etanercept and adalimumab, and controls, this percentage was 15.5, 13.3, and 13.9 %, respectively. On the other hand, NAPSI improved more in infliximab-treated patients than in patients receiving etanercept and adalimumab .
The preliminary conclusions that can be drawn from these studies are that conventional therapies are less powerful and are slower-acting treatments for nail psoriasis than biologics, possibly with the exception of cyclosporine. No single biologic appears to be superior above another biologic. Evidence suggests that infliximab may act faster, but after 1 year of treatment these potential differences have vanished. On the other hand, the use of infliximab may result in higher percentages of onychomycosis.
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What Are The Symptoms And Signs Of Nail Psoriasis
Nail psoriasis symptoms affect both toenails as well as finger nails. They can affect either one nail or all of them depending on the severity of the nail disease. The following clinical complaints are observed by nail psoriasis patients:
Apart from this, psoriatic inflammation might make nails brittle and weak.
Nail health is deeply impacted by nail psoriasis. It is often embarrassing and unsightly to suffer from this condition. It is coupled with either one or more of the following complications:
- Tenderness and pain
What Are Medications For Nail Psoriasis
A doctor may prescribe any of the following medications:
- Creams or ointments to rub on and around the nail, including steroid, topical vitamin A or vitamin D derivatives , antimetabolite drugs
- Steroids can applied to the skin under the nail or cortisone injections may be given under the nail injection under the nail may be more effective than when steroids are applied in cream or ointment form.
- PUVA: This therapy is a combination of the prescription medicine, psoralen, and exposure to UVA ultraviolet light.
- Systemic therapy may be appropriate if you have both skin and arthritis symptoms or if the skin and nail symptoms are severe or persisting. Systemic therapy is medication that spreads throughout the body. It is often in pill or injectable form, including methotrexate or cyclosporine tablets, and the injectable biologics etanercept , adalimumab , ixekizumab , secukinumab , and ustekinumab as well as infusible infliximab . An oral medication for both plaque psoriasis and psoriatic arthritis is apremilast .
See the article Understanding Psoriasis Medications for more information.
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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, its 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.
Home Care For Hands And Feet Psoriasis
Some TLC can help ease your symptoms. Some home remedies to try:
- Take care to avoid injury to your hands and feet since even minor trauma can worsen your psoriasis.
- Wash gently in warm, not hot, water with moisturizing soap.
- Apply petroleum jelly to psoriasis plaques on your feet, then put on cotton socks..
- Wear shoes with good cushioning and arch support. Ballet flats or high heels are not great choices
- Get outside. Vitamin D from short stints under sunlight or ultraviolet lights may help tamp down psoriasis symptoms.
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