Is Psoriasis Damaging Your Nails?

If you have psoriasis, you’re used to having red, patchy, dry and itchy skin and stiff joints. But when psoriasis starts to thicken, pit, ridge and discolor your nails, it can be hard to overlook. This is called ‘nail psoriasis.’

Nails can tell us a lot about our health. People often consider nail psoriasis a cosmetic issue, but “nail psoriasis is a medical disorder that can be managed with various medications and often with favorable results,” says dermatologist Amy Kassouf, MD.

This is especially important for anyone who works with their hands (surgeons, hairdressers, landscapers, etc.) or those who constantly type on a computer—the more your hands are in use, the more diminished the functionality of your psoriatic nails.

What does nail psoriasis look like?

Nail psoriasis can affect your fingernails and toenails and will often manifest in these ways:

• Discoloration. Your nails are starting to brown, yellow or turn completely white.
• Damaged nail surface. You will notice lines, cracks, pits, holes or ridges. Basically, any nail surface that isn’t smooth.
• Lifted nails. With nail psoriasis, white debris can begin to form under your nail, pushing it up and away from your skin. This is usually painful.
• Thinning or thickening texture. If your nails feels brittle or too thick, this can be the buildup of psoriatic skin cells under the nails, or it can be a fungal infection that can more easily invade the already-lifted nail. You will need a culture to determine the best treatment.
• Nail separation. Again, pretty painful. Depending on the severity of your nail psoriasis, your nail may start to separate itself from the nail bed.

How topical medicine and injections work to fight nail psoriasis

If your psoriasis is confined to the nail bed (below the “nail plates” you may polish), topical steroids, vitamin D3 analogue ointments and retinoid creams or gels can be effective.

But psoriasis typically goes deeper, affecting the nail matrix (below the nail plate, cuticle and nail fold skin). While topical treatments don’t penetrate the matrix of the nail, steroids can be safely injected around the nail with good efficacy.

“These injections are both safe and effective in reducing the pitting, hardening, ridging and discoloration, as well as nail separation caused by nail psoriasis,” says Dr. Kassouf.

Dermatologists usually administer injections monthly, then reassess the nails to see if further treatments or dosage changes are needed.

If you can’t tolerate or don’t respond to injections, oral medications (such as cyclosporine, acitretin, otezla and methotrexate) are occasionally used — especially when you have psoriasis-related (psoriatic) arthritis or significant skin changes.

Newer ‘biologics’ available to treat nail psoriasis

“Beyond that, we can offer biologic drugs,” says Dr. Kassouf. “A systemic approach to treatment can be worthwhile, because many patients with skin psoriasis also have nail psoriasis, and both conditions increase the risk of psoriatic arthritis.”

More recently, a two-year study of the oral drug tofacitinib in over 1,800 patients with moderate-to-severe nail psoriasis showed significant improvement at four months that continued through one year. (One-quarter of these patients had psoriatic arthritis as well.)

Treat your nails to some TLC

Whatever treatment you receive, it’s important to avoid irritating or injuring your nails. “Irritation and injury can drive the inflammation that drives psoriasis,” explains Dr. Kassouf.

Avoid picking at your nails and manipulating them, and steer clear of harsh chemicals, such as those found in acetone and non-acetone nail polish removers.

Follow these nail-care tips at home, too:

• Keep your fingernails and toenails trimmed short and filed evenly (but not too short, otherwise you can develop an infection).
• If you have damaged nails, wear gloves when cleaning or doing work around the house.
• Always wear socks with shoes and make sure your shoes fit properly, so as not to irritate toenails further.

“The progress for your nails may be slow. It can take three to six months before you see any improvement,” Dr. Kassouf says. “But most people do improve with the therapies available today.”