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Nail Psoriasis

Specific manifestation of psoriasis affecting fingernails and toenails with characteristic pitting, onycholysis and dystrophy that often signals concomitant arthritis.

Written by: Saygı Hospital Health Guide Editorial Board
Last updated:

This content has been compiled by the Saygı Hospital Health Guide Editorial Board and is periodically reviewed by a specialist physician.

References (5)

This content is for informational purposes only and does not constitute medical advice. You can book an appointment at our Dermatoloji department. Book Appointment →

What is Nail Psoriasis?

Nail psoriasis is a chronic inflammatory disorder affecting the nail matrix and nail bed in patients with cutaneous or articular psoriasis. Prevalence ranges from 10-55% in plaque psoriasis to 80% in psoriatic arthritis, where nail involvement strongly correlates with distal interphalangeal joint disease and enthesitis.

Matrix involvement causes pitting (small depressions from parakeratotic foci), leukonychia (white spots), red lunulae and crumbling. Nail bed involvement causes onycholysis (separation), oil drop sign (yellow-brown discoloration), splinter hemorrhages and subungual hyperkeratosis. Nail Psoriasis Severity Index (NAPSI) is the standard scoring tool.

Differential diagnosis includes onychomycosis (fungal infection), lichen planus, alopecia areata-related nail changes and 20-nail dystrophy. Mycological evaluation is essential before starting biologics. Treatment ranges from topical corticosteroids and vitamin D analogues for mild disease to intralesional triamcinolone injections, biologics (TNF-alpha inhibitors, IL-17/IL-23 inhibitors) and apremilast for moderate-severe disease. Response is slower than skin (6-12 months).

Symptoms

Pitting (small depressions in nail plate)
Onycholysis (separation from nail bed)
Oil drop sign (yellow-brown discoloration)
Subungual hyperkeratosis (thickening under nail)
Splinter hemorrhages
Crumbling and dystrophy
Leukonychia (white spots)
Pain and functional impairment

Risk Factors

Plaque psoriasis (especially severe disease)
Psoriatic arthritis (especially DIP joint involvement)
Family history of psoriasis or psoriatic arthritis
HLA-Cw6 positivity
Nail trauma (Koebner phenomenon)
Onychomycosis as trigger
Smoking and obesity
Long disease duration

When to See a Doctor?

If you experience any of the following symptoms, seek medical attention promptly:

  • Persistent nail changes lasting >3-6 months
  • Multiple nails affected with characteristic features
  • Concurrent skin or joint psoriasis
  • Pain and functional impairment
  • Failure of antifungal therapy
  • Cosmetic concerns affecting quality of life
  • Suspicion of psoriatic arthritis with DIP involvement
  • Need for systemic therapy in moderate-severe disease

Treatment Methods

01
Topical clobetasol or calcipotriol-betamethasone for nail folds
02
Topical tacrolimus for nail matrix involvement
03
Intralesional triamcinolone (2.5-10 mg/mL) into nail folds
04
Apremilast for mild-moderate disease
05
TNF-alpha inhibitors (adalimumab, infliximab) for severe nail disease
06
IL-17 inhibitors (secukinumab, ixekizumab) — high efficacy
07
IL-23 inhibitors (guselkumab, risankizumab) — sustained response
08
Mycological exclusion of onychomycosis before biologics

Which Department to Visit?

You can visit our Dermatoloji department for these complaints. Our specialist physicians will create the most suitable treatment plan for you.

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Health Disclaimer: The information on this page is prepared for general informational purposes only. It does not replace medical diagnosis and treatment. Please consult your physician for your complaints. Saygı Hospital does not accept responsibility for actions taken based on the information on this page.