Introduction:
Psoriasis is an inflammatory condition that primarily affects the skin, nails, and joints. Nails are affected in the majority of psoriasis patients. This is seen as a significant psychological and societal issue. In addition to being a cosmetic flaw, nail alterations can cause various problems with daily tasks, including employment and a lower quality of life.
Psoriasis-related nail involvement also results in severe pain, depression, and anxiety. Because of its resistance to medication, nail psoriasis can be very difficult to treat. There is a strong link between psoriatic arthritis and nail psoriasis.
Nail disease affects about 40% of patients with skin psoriasis, but up to 80% of patients with psoriatic arthritis have nail involvement. Strong data suggests that nail psoriasis can even develop a few years before signs of arthritis and is a predictor of joint illness.
What Components Make up a Nail Structure?
The nail unit comprises the nail folds, nail bed, nail plate, and matrix. The matrix is in charge of nail growth. It is separated into sections that are proximal and distal. In the nail bed, nails develop toward the distal end. The hyponychium connects the distal portion of the nail plate to the nail bed. The proximal region of the nail plate contains lunulae which is white and semicircular in appearance. The proximal nail fold (PNF) and lateral nail folds surround the nail. The primary purpose of the nail unit is to shield the digits from severe harm. Also, having manicures improves the fingers' ability to move precisely, essential for handling small objects. Individuals suffering from nail illnesses may have pain and discomfort frequently and difficulty moving precisely.
How Does Psoriatic Arthritis Affect the Nails?
Clinically, nail psoriasis can present with various symptoms, depending on where the inflammatory process is located. Nail pitting, Beau's lines, trachyonychia, leukonychia onychomadesis, and nail dystrophy are caused by nail matrix involvement, whereas nail bed psoriasis causes onycholysis, subungual hyperkeratosis, oil drop patches, and splinter hemorrhages.
1. Nail Pitting:
According to the Psoriasis and Psoriatic Arthritis Alliance, nail depressions are the most prevalent sign of PsA, accounting for over two-thirds of cases. They might have a large, deep, or small size.
2. Onycholysis:
This is the gradual separation of a nail from the underlying nail bed, which is generally painless. The formed pocket may provide a channel for fungus or bacteria to infect the nail bed. Fungal infections affect almost one-third of those who have nail psoriasis.
3. Subungual Hyperkeratosis:
Under the nail, skin cells gather and produce a flaky or chalky substance known as debris. It is more of a problem in toenails because the continual pressure from wearing shoes may become painful.
4. Ridging:
The lengthwise grooves and ridges, called Beau's lines, can be caused by matrix inflammation, which is the area at the base of the nail where the cells responsible for new nail development are generated. Usually, they develop on each fingernail or toenail.
5. Thickening:
The uncontrolled growth of skin cells causes the nails to grow in excess resulting in thickening of skin. It is because the skin and nails are composed of the same protein.
6. Crumbling:
A crumble-like appearance can result from chronic inflammation of the nail matrix.
7. Color Changes:
Psoriatic arthritis patients frequently have reddish markings (also known as splinter hemorrhages, which are caused by microscopic burst blood vessels under the nails) and/or discoloration that can be white, yellow, or brown
There are numerous options for treating nail psoriasis. Topical steroids and calcipotriene, a vitamin D-based medication, are the mainstays. Skin and nails can be treated with body-wide therapies like retinoids and biologics. Unfortunately, nail psoriasis can be difficult to treat. One might need multiple treatments because the problem might be hard to treat. Because nails develop slowly, even if a therapy is effective, it may take some time to show complete results. This might take up to a year for fingernails, and for toenails, it can take up to two years. When your nails are distorted, that can be a lengthy period. One can take various steps to preserve and enhance the look of the nails and exercise patience.
How Is It Treated?
The management of nail psoriasis is clinically difficult. Systemic and biological medications, topical treatments, and procedural interventions are all potential forms of therapy.
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Topical products are recommended in individuals with psoriasis of the nails, minor or no skin illness, and no indications of arthritis. The recommended course of treatment in these situations is to use strong topical corticosteroids alone or in conjunction with calcipotriol. Corticosteroid injections intralesionally may be a useful treatment, but there are potential side effects as well, including injection discomfort, skin atrophy, depigmentation, secondary infection, and subungual bleeding. The most commonly used injection is Triamcinolone acetonide at a concentration of 0.1 to 0.2 ml or 5 to 10 mg/ml. To minimize pain during treatments, topical anesthetics or nerve blockers are required.
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Systemic medication is extremely beneficial in nail psoriasis and is suggested to be used if topical therapy cannot treat skin disease or psoriatic arthritis. The nail lesions may get better with methotrexate and cyclosporine. Methotrexate is more successful than cyclosporine in addressing alterations in the nail matrix, although cyclosporine is more effective in improving nail bed scores. Acitretin may cause more onycholysis and pitting but can also lower the NAPSI score.
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Biological therapy has made significant advances in the treatment of nail psoriasis. The recommended therapeutic agents are Apremilast, Etanercept, Adalimumab, Infliximab, Ustekinumab, and Golimumab, listed in order of preference.
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The secondary infection of dermatophytes in psoriatic nails can make treatment more difficult. Consequently, fungal nail infections should be ruled out in patients with psoriasis.
Conclusion:
There needs to be more standardization in evaluating treatment for nail psoriasis. The therapy must be modified based on the severity of nail alterations, psoriatic arthritis, skin illnesses, and quality of life impairment. Nail lesions may persist even when psoriasis, arthritis, and skin psoriasis are under control.
