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As many as 90 percent of people with psoriatic arthritis (PsA) develop nail lesions or psoriasis of the nail. Nail psoriasis, fungus, infections, and other problems can affect the fingernails and toenails, and one nail or all of them can be affected.
Psoriasis and PsA — collectively called psoriatic disease — cause a person’s immune system to mistakenly attack its own healthy cells. According to the National Psoriasis Foundation, approximately 33 percent of people with psoriasis develop PsA.
People with PsA and psoriasis may experience higher rates of nail disease than people with psoriasis alone. Nail psoriasis may be among the first symptoms of PsA. Below are some of the nail changes associated with psoriasis and PsA.
Grooves and ridges may appear on the nails when you have PsA. Ridges can be horizontal (also called Beau’s lines) or vertical. “Does anyone else have ridges in their nails?” one MyPsoriasisTeam member asked.
Another replied, “I have ridges and pits in my fingernails.”
Some people with PsA find that their nails turn color. Different hues may appear, but yellow-brown is common and can look like a fungal infection.
Shallow or deep depressions in the nails may appear, known as pitting. “I’ve noticed my fingernails have started pitting. Could this be linked to my condition?” one member asked.
Another replied, “I also have nail pitting on my fingernails off and on.”
Separation of the nail plate from the nail bed is called onycholysis. Because of the gap between the skin and the nail, more bacteria can enter the area, raising the risk of developing an infection.
Fungal infection of the nails, called onychomycosis, may occur in people with PsA. This symptom should be reported to a dermatologist — your doctor can pinpoint a treatment to help eliminate the infection.
Reddish-brown streaks of blood in the direction of nail growth are known as splinter hemorrhages. “I have splinter hemorrhages, ridges, and nail lifting on my toenails,” one MyPsoriasisTeam member wrote. “I am seeing my rheumatologist tomorrow to see if there’s anything they can do.”
A feeling of heavy nails may affect people with PsA. This thickness may make it challenging to clip your nails. “I can’t even get the toenail clippers around my fingernails,” one member wrote.
There’s a strong connection between the severity of nail disease and the severity of both joint and skin disease in people with PsA. Usually, the more severe the symptoms of the joint where the nail develops (called the distal interphalangeal joint), the more the nails will be affected.
There are more treatment options than ever for both PsA and nail psoriasis. But be patient — nails grow slowly, so it may take six months or longer to see improvements.
Treatments applied directly to the nails can be helpful in the earlier stages of nail changes. Topical treatments for psoriasis skin symptoms, such as corticosteroids and calcipotriol (a form of vitamin D), can help reduce symptoms such as buildup under the nails.
Tazarotene (Tazorac), a topical cream or gel, may be effective for treating nail pitting, discoloration, and separation.
About one-third of people with nail symptoms also have a fungal infection. Antifungal medications can treat the infection but not the underlying problem of nail psoriasis, so the nail is likely to get infected again.
Corticosteroid injections into part of the nail called the nail matrix can effectively treat nail psoriasis. The medication is delivered near or directly into affected nails to treat buildup, ridges, thickening, and separation. If the first corticosteroid treatment shows poor results, your doctor may suggest getting another in a few months.
Sometimes, phototherapy can be effective in improving psoriatic nail problems. Psoralen plus ultraviolet A (PUVA) is a type of phototherapy in which a person either takes a drug called psoralen orally (by mouth) or soaks their affected nails in it. Then UVA rays are directed carefully at the nails. Although PUVA isn’t very effective in treating pitted nails, it can help address discoloration and separation from fingers or toes.
Systemic treatments (those that work throughout the body) are an option for severe psoriatic nail problems. Nail changes can also be addressed using PsA treatments, such as biologics or antirheumatic drugs. These medications include methotrexate and biologic drugs such as adalimumab (Humira), etanercept (Enbrel), and risankizumab-rzaa (Skyrizi), which are also used to treat skin psoriasis.
As with other treatments for nail problems, it can take months to see results.
In the case of psoriatic nail problems, protection and prevention are key. You’re more likely to see faster improvement when your PsA treatment is coupled with a nail care plan to make sure your nails stay healthy.
To protect your nails, try these tips from the American Academy of Dermatology:
MyPsoriasisTeam is the social network for people with psoriasis and psoriatic arthritis and their loved ones. On MyPsoriasisTeam, more than 125,000 members come together to ask questions, give advice, and share their stories with others who understand life with psoriasis.
Has psoriatic arthritis affected your nails? How are you and your dermatologist or rheumatologist addressing the symptoms? Let us know in the comments below, or start a conversation of your own on your Activities page.
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