Brief overview
- Symptoms: spotted nails, oil spots, crumbled nails, detachment of the nail (onycholysis), nail fold psoriasis
- Treatment: External treatment for mild form, tablets, injections or infusions for severe form (biologics, immunosuppressants and others)
- Causes and risk factors: Hereditary predisposition, trigger factors such as mechanical stimuli, stress or certain medications
- Diagnosis: Typical appearance of the nails, especially if psoriasis also occurs on other parts of the body
- Course of the disease and prognosis: Treatment is usually lengthy and costly
- Prevention: Avoidance of stress, alcohol and nicotine, careful nail care
What is nail psoriasis?
If psoriasis affects the hand or toenails, doctors speak of nail psoriasis. A sole nail psoriasis occurs only rarely. If the joints become inflamed in the course of psoriasis (psoriatic arthritis), psoriatic nail changes are also frequently found.
In nail psoriasis, inflammatory processes occur mainly in the nail bed and in the nail matrix, from which the visible part of the nail develops. This is fused with the skin underneath, the nail bed. If the nail bed and nail matrix change pathologically, the shape, structure and color of the nail (nail plate) also change.
Acute nail psoriasis
Chronic nail psoriasis
More often, nail psoriasis is chronic. In this case, the nails slowly change due to inflammatory processes. They affect the nail matrix, the nail bed and/or the nail fold. Since a nail grows rather slowly, the nail changes are visible for a long time.
What is the initial stage of nail psoriasis?
Nail psoriasis is already noticeable in its initial stage by typical features and nail changes. These sometimes appear on only one, in other cases on several nails at the same time – both on the hand and on the foot.
Nail changes in nail psoriasis
Psoriasis on the fingernail or toenail manifests itself quite differently: some affected persons have several nail changes at the same time, others only a single symptom. The following changes occur in nail psoriasis:
Spotted nails
In this symptom, the nail plate has punctiform indentations that are usually no larger than one millimeter. There are usually several such depressions, also called dimples, on an affected nail. Spotted nails are the most common psoriatic nail change.
Spots
Sometimes nail psoriasis is manifested by white spots in the nail plate (leukonychia). Red spots in the nail crescent (lunula) also indicate psoriasis of the nails.
Psoriatic oil spot
Onycholysis
If the inflammation of the nail bed causes severe scaling, the nail plate often detaches partially or completely. Doctors then speak of partial or total onycholysis.
Splinter hemorrhages
Fine hemorrhages in the nail bed are called splinter hemorrhages. They shimmer through the nail plate as thin, elongated and, depending on the age of the bleeding, red, reddish-brown to blackish lines. Splinter hemorrhages grow along with the nail. When they reach the anterior edge of the nail, they are easily removed.
Crumb nails
In crumb nails, the nail plate of the affected finger disintegrates. This is a particularly severe form of psoriasis on the nail, in which the actual nail structure is completely destroyed. Doctors speak here of onychodystrophy. Crumbled nails develop when psoriasis affects the nail matrix and nail bed at the same time.
Nail fold psoriasis
In some cases psoriasis also affects the skin around the nail. This is called nail fold psoriasis. It often also leads to nail changes, even if the nail itself is not affected. The nails are then strongly grooved or usually have transverse thickenings. These symptoms are also seen in nail psoriasis.
Pain with nail psoriasis
Psychological stress caused by nail psoriasis
Spotted nails, oil stains or onycholysis are psychologically very stressful for many sufferers because damaged or discolored fingernails are quickly associated with a lack of personal hygiene. Therefore, patients with nail psoriasis often try to hide fingernails and hands as much as possible.
Psoriasis on the hand
If sharply defined, reddened and slightly raised patches appear on the skin, which are covered with silvery-white scales, they are most likely psoriasis foci.
How is nail psoriasis treated?
How to successfully treat your psoriasis of the hand and toenails is best discussed with a dermatologist. Both external and internal treatment are possible. Which one to choose depends on the one hand on the nail status, that is, how much the nails have changed due to psoriasis. On the other hand, it depends on how much the disease burdens the patient.
External therapy
Especially in mild forms of nail psoriasis, the doctor usually chooses an external (topical) therapy. Creams, ointments, solutions, plasters or varnishes containing one or more active ingredients are used. These active ingredients include, for example:
- Cortisone
- Urea
- Vitamin D3 (calcipotriol)
- Horsetail
- 5-Fluorouracil (only in very severe cases, usually in combination with urea or salicylic acid).
Especially the external treatment is usually very time-consuming. This is because the active substances hardly or only very poorly penetrate through the nail plate. Sometimes prior softening of the nail plate helps. Most of these preparations work even better under an airtight dressing (occlusive dressing).
In addition to the above-mentioned drug therapies, there are other treatment options. In practice, however, they are rarely used:
- Electrotherapy: Some doctors treat the diseased nails with so-called interference current.
- X-ray therapy: Specialized doctors use X-rays in very rare cases.
- PUVA therapy: The so-called PUVA therapy with UV radiation takes a lot of time and patience. Daily and over several weeks, the nail psoriasis is made photosensitive with the active ingredient psoralen and then irradiated with UV-A radiation.
- Laser: Several studies show promising results in treatment with laser beams, such as those known from eye lasers (excimer laser) or hair and tattoo removal (Nd-YAG laser).
Internal therapy
Nail psoriasis – biologics
These active substances are specially produced proteins that are directed against certain inflammatory messengers or defense cells. In this way they also stop the inflammatory processes in nail psoriasis. Biologics are known to many people from the treatment of rheumatism. The following substances are particularly effective against psoriasis:
- TNF-alpha inhibitors: For example infliximab, adalimumab, golilumab, efalizumab, etanercept
- Ustekinumab: Inhibits the inflammatory messenger interleukin 12/23
- Secukinumab: Blocks the messenger interleukin-17A
- Ixekizumab: Also binds and inactivates interleukin-17A
Other drugs for nail psoriasis
In addition to biologics, other internally active drugs are used to treat nail psoriasis. Under the following medications, nail psoriasis usually regresses well to completely:
- Fumaric acid esters
- Ciclosporin
- The retinoid acitretin
- Methotrexate (especially with concurrent psoriatic arthritis)
- Apremilast
- Tofacitinib
Nail psoriasis home remedies and medicinal plants
Some sufferers rely on home remedies and medicinal plants to treat psoriasis nails. However, the effect is medically hardly secured.
- Aloe vera
- Capsaicin (from chili peppers)
- Indigo naturalis as extract in oil
- Healing earth dressings
- Mahonia creams and ointments
- Wheat and oat bran baths
- Tea tree oil (applied externally)
- Evening primrose oil (applied externally)
- Almond oil (externally applied)
- Black tea dressings and compresses
- Milk thistle tea dressings and compresses
- Pansy tea compresses and compresses
- Curd compresses, packs or rubs
- Calendula ointment for nail bed inflammation
- Camomile extract for nail bed inflammation
Home remedies have their limitations. If the symptoms persist for a long period of time, do not improve or even get worse, you should always consult a doctor.
What causes nail psoriasis?
The exact causes of psoriasis are not yet fully understood. However, it is known that it is a misregulation of the immune system. Like psoriasis of the skin, psoriasis of the nails is therefore not contagious.
In psoriasis, the immune system provokes inflammatory reactions similar to those of a skin lesion. In the process, the defense cells secrete various messenger substances. On the one hand, they accelerate the processes of skin renewal. On the other hand, they maintain the inflammatory reaction.
Doctors assume that several factors interact in the development of nail psoriasis.
Genetic predisposition
Trigger factors for psoriasis
There are several so-called trigger factors. They trigger psoriasis or cause a new episode. These include
- Infections
- Stress
- Certain medications
- Skin injuries
- Sunburn
- Mechanical stimuli such as pressure or scratching
- Hormonal changes (e.g. menopause, puberty)
Nail psoriasis and joint problems
Nail psoriasis and psoriatic arthritis (inflammation of the joints) are closely related. Many people with psoriatic arthritis also have nail psoriasis.
In addition, severe nail psoriasis often results in joint or skin changes. If psoriasis persists for a long time, the risk of further signs of psoriasis increases. If the periosteum is also affected, physicians speak of POPP syndrome (psoriatic onycho-pachydermo-periostitis).
How is nail psoriasis diagnosed?
The dermatologist is responsible for skin or nail diseases. He often recognizes psoriasis on hand and toenails at first glance – especially if a patient is already undergoing treatment for psoriasis or psoriatic arthritis.
In this case, the nail changes are sufficient for the diagnosis of nail psoriasis. Images are often taken by the dermatologist to document and better assess the course of the disease.
Further examinations are usually not necessary.
- Do your parents or siblings suffer from psoriasis?
- Did you once have changes in your skin, such as reddish, sharply defined foci that scaled or itched?
- Do any of your joints hurt?
- Are any of your joints or fingers or toes swollen?
The doctor will also examine the entire skin. He may find psoriasis lesions that the patient has not yet noticed, for example on the scalp covered with hair or in the buttock crease.
A tissue biopsy is very rarely necessary to detect nail psoriasis. Doctors perform it only if all previous examinations have not yielded clear results. As a rule, the tissue sample is obtained from the nail bed.
Nail psoriasis or other nail diseases?
The diagnosis is more difficult if only the nails are pathologically changed. In this case, the physician must distinguish nail psoriasis from other nail diseases, for example from nodular lichen (lichen planus, in this case usually thinned nail plate) or eczema nails (in the case of frequent or chronic skin rashes of the hand).
Nail fungus or nail psoriasis?
However, there are a few distinguishing characteristics between nail psoriasis and nail fungus:
- Psoriasis affects the fingernails more often than the toenails. A nail fungus, on the other hand, mainly affects the toenails.
- The nail grows much slower in nail fungus than in nail psoriasis. In the latter, the growth processes are accelerated by the inflammation.
- Spotted nails are typical for nail psoriasis. In nail fungus they are found rather rarely.
- Especially without treatment a nail fungus smells stern. Nail psoriasis is usually odorless.
To know definitively whether a patient suffers from nail psoriasis or nail fungus, the doctor takes a nail sample. He looks at this under the microscope. In the case of a fungal infection, he then finds fungal spores and filaments (mycelia).
Scoring systems
Various scoring systems record the full extent of nail psoriasis. The result of the scores is a numerical value. This illustrates how severely patients are affected and how much their quality of life suffers from nail psoriasis. This makes it easier for the doctor to choose a therapy for nail psoriasis. In addition, regular calculations help to monitor the course of the disease.
These scores include:
- NAPSI: The NAPSI (Nail Psoriasis Severity Index) assesses how severely damaged the nails are. A high score indicates severe nail changes.
- NAPPA: The NAPPA score (Nail Assessment in Psoriasis and Psoriatic Arthritis) takes into account both the severity and the everyday limitations of nail psoriasis. In addition, previous therapy is part of the NAPPA questionnaire.
What is the course of nail psoriasis?
For the treatment of nail psoriasis you need a lot of patience. This applies to both external (topical) and internal (systemic) therapies. The treatment usually lasts for several months. And often nail psoriasis does not disappear completely despite treatment.
The course of a nail psoriasis is very different. Especially the severe form of nail psoriasis has a worse prognosis. The symptoms of the disease last longer. The accompanying skin and joint inflammations are also more severe.
How can nail psoriasis be prevented?
Even if the development of nail psoriasis cannot be reliably prevented, there are various ways of preventing further episodes or minimizing the symptoms:
- Avoid trigger factors such as alcohol, stress or excessive strain that fuel psoriasis.
- Protect your nails: wear gloves when cleaning or working with harmful substances.
- Take care of your nails: Cut your nails as short as possible and grease them so that they do not split so easily when cut.
