Nail psoriasis: The journey so far

Abstract

Nail involvement is an extremely common feature of psoriasis and affects approximately 10-78% of psoriasis patients with 5-10% of patients having isolated nail psoriasis. However, it is often an overlooked feature in the management of nail psoriasis, despite the significant burden it places on the patients as a result of functional impairment of manual dexterity, pain, and psychological stress. Affected nail plates often thicken and crumble, and because they are very visible, patients tend to avoid normal day-to-day activities and social interactions. Importantly, 70-80% of patients with psoriatic arthritis have nail psoriasis. In this overview, we review the clinical manifestations of psoriasis affecting the nails, the common differential diagnosis of nail psoriasis, Nail Psoriasis Severity Index and the various diagnostic aids for diagnosing nail psoriasis especially, the cases with isolated nail involvement. We have also discussed the available treatment options, including the topical, physical, systemic, and biological modalities, in great detail in order to equip the present day dermatologist in dealing with a big clinical challenge, that is, management of nail psoriasis.

Ungueal Psoriasis: A Single Nail Affected

“…Nail involvement is an extremely common feature of psoriasis and affects approximately 10-78% of psoriasis [1].…”

Therapeutic challenges in a case of psoriasis with nail onset

“…Most patients with psoriasis develop nail lesions during the course of the disease, the prevalence of nail psoriasis among patients with psoriasis ranging between 10 and 78%, with a mild male predominance (3).…”

“…is the most commonly used index for assessing the severity of nail psoriasis. The method involves the division of the nail into four quadrants by drawing imaginary lines (a vertical and a horizontal line) and the evaluation of the matrix and nail bed lesions in each quadrant (3,9).…”

Clinical Manifestations and Management Considerations of Psoriasis Affecting The Nail Unit

“…12 Psoriatic involvement of the nail matrix causes aggregation of parakeratotic cells in the nail plate and other areas of the nail unit, thereby disrupting the normal process of keratinization and causing characteristic nail changes seen in psoriasis including pitting, leukonychia, crumbling, red spots in the lunula, transverse grooves, and trachyonychia. 13 These changes are summarized in Figure 2.…”

“…12 Psoriatic involvement of the nail bed leads to the development of onycholysis, salmon patches (oil drops), subungual hyperkeratosis, and splinter hemorrhages. 13 These changes are summarized in Figure 3. Aside from an obvious value early diagnosis and treatment has in preventing nail deterioration and long-term sequelae, there is also growing evidence that psoriatic nail changes may be a predictor of psoriatic arthritis.…”