Navigating the Challenges of Nail Changes with Psoriasis

Psoriasis is a chronic autoimmune condition that primarily affects the skin. But it can also cause changes to your nails like pitting, discoloration, and crumbling.

Plaque psoriasis (PsO) is commonly known for the silvery, itchy scales on your skin. But this condition can affect your fingernails and toenails, too.

These nail changes can range from mild to quite severe, including potentially losing a nail.

Nail changes are quite common — they’re seen in up to 80% of people with PsO lesions. Usually, nail symptoms are associated with more severe psoriatic disease and may be a sign of earlier onset and a higher risk of developing psoriatic arthritis (PsA).

Join the free Psoriasis community!

Connect with thousands of members and find support through daily live chats, curated resources, and one-to-one messaging.

Sign up

Types of nail changes seen in psoriasis

Nail PsO can present in a variety of ways:

Pitting (punctate nail depression)

Pitting is the most common nail change seen in PsO. Your nail may appear either studded or have linear depressions in the nail plate, causing an uneven surface, and sometimes uneven growth.

The areas of the pitting may be weaker and more prone to breakage.

Nail discoloration (oil drops)

If you experience nail discoloration, you may notice a circular area of discoloration. Your nail bed might be pink, red, or purple.

This is sometimes called the “oil drop sign” because the discoloration looks similar to an oil drop on a piece of paper.

Splinter hemorrhages

Splinter hemorrhages are red to brown linear streaks that look like a tiny amount of blood on, in, or under your nail.

Subungual hyperkeratosis

Sublingual hyperkeratosis is when a layer of white keratin debris lays on top of your nail bed. This debris may look fluffy or even crumbly. This causes thickening and weakening of the nail itself, which can be quite noticeable and also prone to breakage and uneven edges.

Onycholysis

Onycholysis is when the far end of your nail separates from the underlying nail bed, appearing thick and white. Often, there’s a line where the separation ends, causing it to have a “half-and-half” dipped appearance.

Nail crumbling

When the tip of your nail disintegrates due to thickening and cracking, it may be caused by subungal hyperkeratosis, onycholysis, or something else. It may be worsened by nail trauma.

Nail crumbling can result in losing your entire nail, leaving the hyponychium (the skin under your nail) exposed. This can be painful and even limit some daily activities like bathing, eating, household chores, and typing.

Leukonychia

Leukonychia is when white spots or lines develop on your nail and can vary from 1 to 2 small dots to lines that cover the majority of your nail.

Many of these nail symptoms are not necessarily specific to PsO. If you notice any nail changes, be sure to talk with your healthcare team.

Diagnosis

Nail changes in psoriasis are evaluated and diagnosed by healthcare professionals using a variety of tools. These tools include:

• the Nail Psoriasis Severity Index (NAPSI)
• the modified NAPSI
• Physician’s Global Assessment of Fingernail Psoriasis (F-PGA)

Outlook

Nail PsO can be a challenge to manage. If you’re living with nail PsO, you may have periods of improvement and then periods of worsening nail health.

Right now, there’s limited data on nail PsO treatments when compared with skin PsO treatments. Nail trauma is not uncommon, either, because your nails are often already damaged. This can worsen your quality of life due to both pain and appearance.

While there are many treatment options available, they may take a long time to work.

Treatment options

Treatment for nail psoriasis is not as well studied as the treatments for plaque psoriasis of the skin. However, there are quite a few options.

Treatment is usually chosen based on disease severity, which is classified as either mild or moderate to severe.

Mild nail psoriasis treatment

Mild disease treatment options include topicals, special lasers, and intralesional injections. Common options include:

• high-potency topical steroids
• vitamin D analogs (calcipotriol)
• topical tacrolimus
• topical tazarotene (Tazorac)
• topical tofacitinib
• fractional CO2 laser treatment, in addition to topical tazarotene
• intralesional corticosteroids injections

Moderate to severe nail psoriasis treatment

Moderate to severe treatment options usually involve a biologic agent but may include oral options, injectables, and lasers as well.

First-line therapy for moderate to severe nail PsO is a biologic. These can be divided into 4 categories:

• Tumor necrosis factor-α inhibitors: adalimumab (Humira), infliximab, etanercept, certolizumab (Cimzia), and golimumab (Simponi)
• Interleukin-17 inhibitors: secukinumab (Cosentyx), ixekizumab (Taltz), and brodalumab
• Interleukin-23 inhibitors: guselkumab (Tremfya), risankizumab (Skyrizi), tildrakizumab (Ilumya)
• Interleukin-12 and interleukin-23 inhibitors: ustekinumab (Stelara)

If your nail psoriasis doesn’t improve after using a biologic (even after switching between classes) or you cannot use a biologic in general, the second-line treatments include the same topical therapies used in mild cases or a pulsed dye laser.

Other treatments to consider for moderate to severe nail PsO include:

• acitretin
• cyclosporine
• fractional CO2 laser
• excimer laser treatment
• narrowband UVB phototherapy

Typically, these treatments require a long time to work. You may require multiple sessions with re-treatments in the future. This can often mean a long-term, if not lifetime, commitment.

Other considerations

Treatment for nail PsO typically requires you to see a specialist, such as a dermatologist.

All treatments for nail PsO should be decided on a case-by-case basis and be specific to your symptoms.

Your doctor will consider how many nails are involved and if your joints are affected, as seen in psoriatic arthritis (PsA).

Lifestyle changes

Medical treatments aren’t the only way to improve the health of your nails. You can also try at-home care like:

• Nail care: Keeping your nails trimmed and moisturized helps manage symptoms.
• Protection: Wearing gloves when doing household chores and avoiding nail trauma can prevent further damage.
• Diet and supplements: A balanced and anti-inflammatory diet, along with supplements like biotin, may help support your nail health.

The bottom line

Nail changes due to psoriasis can occur alongside plaque psoriasis or independently. These nail changes can be challenging to treat at times and usually require specialty therapies.

If you notice any changes in your nails, be sure to bring these up to your doctor so they can find the best treatment option for you.