The Treatment of Nail Psoriasis: A Review

Abstract

Nail disease affects most patients with psoriasis and has a substantial medical and psychological impact on the lives of those affected. Frequently, nail psoriasis is associated with severe pain, restriction in daily activity, and emotional agony that require the dermatologist to know the most up-to-date therapies. Unfortunately, no single treatment is paramount, and the choice of therapy must be individualized to disease severity, patient tolerability, cost, and risk of adverse events. Some clinical manifestations include nail pitting, discoloration, onycholysis, subungual hyperkeratosis, and splinter hemorrhages. Currently, no standardized therapeutic regimen exists; and, given the variability in clinical manifestations, multiple modalities may be needed for adequate results. More recently added to the armamentarium of topical and injectable therapies for nail disease are systemic agents, such as biologics, and photochemotherapeutic treatments. These therapies have been used with varying degrees of success. This review highlights the current treatments available for the treatment of nail psoriatic disease.

Psoriatic Nail Changes Are Associated With Clinical Outcomes in Psoriatic Arthritis

“…12 Clinically, the white free edge of the nail plate extends proximally to the area that remains attached. 12 Subungual hyperkeratosis occurs when there is an increase in the number of keratinocytes in the nail bed. 10,12 Finally, splinter hemorrhages can form when longitudinal ridges in the nail plate grow distally and disrupt nearby capillaries, causing red blood cells to leak into the grooves between the ridges of the nail bed.…”

“…9,10,13,14 Pitting is the result of abnormal keratinization causing parakeratotic cells to deposit in the developing nail plate. 12 The pits form when the parakeratotic cells fall off as the nail plate grows out from the nail matrix. 9,10 When psoriatic lesions are present in the intermediate nail matrix, white transverse discolourations (leukonychia) can develop.…”

“…9,10 When psoriatic lesions are present in the intermediate nail matrix, white transverse discolourations (leukonychia) can develop. 12 Severe inflammation of the nail matrix can cause nail plate crumbling. 9 The lunula is the white, crescent-shaped area at the proximal portion of the nail plate.…”

“…15 Lastly, longitudinal psoriatic lesions in the nail matrix cause corresponding longitudinal ridges and splitting in the nail plate (onychorrhexis). 10,12 Nail beading is scarcely described but is suggested to be related to increase nail matrix cell turnover. 14…”

“…[9][10][11] Inflammation at the hyponychium can lead to separation of the nail plate from the nail bed (onycholysis), allowing air to enter this newly formed space. 12 Clinically, the white free edge of the nail plate extends proximally to the area that remains attached. 12 Subungual hyperkeratosis occurs when there is an increase in the number of keratinocytes in the nail bed.…”