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Psoriatic Arthritis and Nails: Symptoms and Treatment

Posted on March 04, 2021
Medically reviewed by
Kevin Berman, M.D., Ph.D.
Article written by
Nyaka Mwanza

The inflammatory response of psoriatic arthritis (PsA) is systemic, and its symptoms frequently manifest in the skin, joints, and nails. Almost 90 percent of people with PsA develop nail lesions or psoriasis of the nail. Nail psoriasis, fungus, infections, and other problems can affect the nails on the fingers and toes, and one nail or all 20 nails can be affected.

Psoriasis and psoriatic arthritis (PsA), collectively called psoriatic disease, are autoimmune diseases. Autoimmune disorders cause a person’s immune system to overactivate and mistakenly attack its own healthy cells. Approximately 30 percent of people with psoriasis develop PsA. These individuals may experience higher rates of nail disease than people with psoriasis alone. Nail psoriasis usually occurs several years after skin psoriasis appears, and may be among the first symptoms of psoriatic arthritis.

Symptoms of Nail Involvement With PsA

Many nail changes are associated with psoriasis and PsA. These nail changes can include:

  • Beau’s lines — Horizontal ridges in the nail plate
  • Nail deformity
  • Discoloration of the nail — Often yellow-brown, which can look similar to a fungal infection
  • Pitting — Shallow or deep depressions in the nails caused by inflammation of the tendons that anchor the roots of your nails
  • Onycholysis — Separation of the nail plate from the nail bed
  • Onychomycosis — Fungal infection of the nails
  • Splinter hemorrhages — Reddish-brown streaks of blood in the direction of nail growth
  • Thickening of the nail — A feeling like the nails are “heavy”

There is a strong correlation between the severity of nail disease and the severity of both joint and skin disease. Usually, the more severe the symptoms (inflammation, swelling, pain) of the joint where the nail develops (called the distal interphalangeal joint), the more severe the nail involvement will be.

Treating Psoriatic Nail Involvement

Nail symptoms are often treatable. The treatment options available for both PsA and nail psoriasis are more plentiful and better today than ever before. Be patient — nails grow slowly, so it may take six months or longer to see improvements.

Topical Nail Therapies

Topical nail therapies can be helpful in the earlier phases of nail changes. Topical treatments used for psoriasis’ skin symptoms, such as potent corticosteroids and calcipotriol (a vitamin D analog), can help reduce buildup under the nails and other symptoms. In one study, researchers found calcipotriol to be equally effective as potent corticosteroids at treating nail buildup.

Tazorac (tazarotene), a topical cream or gel, may be effective in the treatment of nail pitting, discoloration, and separation.

Topical polyurethane nail treatments help the nail appear more normal, but do not address the inflammation directly.

About one-third of people with nail symptoms also have a fungal infection. Fungal infections of the nail can be treated with antifungal medications. However, the underlying problem of nail psoriasis remains, and the nail is likely to be infected again in the future.

Corticosteroid Injections

Corticosteroid injections into the nail matrix behind the cuticle can be effective for the treatment of nail psoriasis. Injections of corticosteroids are delivered near or directly into the affected nails to treat nail buildup, nail ridges, nail thickening, and toenails or fingernails separating from their digits. If the first treatment shows poor results, your doctor may suggest getting another one in a few months.

Phototherapy

Sometimes, laser treatment can be effective in addressing psoriatic nail involvement. PUVA is a type of phototherapy in which the person ingests or soaks their affected nails in a drug called psoralen. Then UVA rays are directed carefully at the nails. Although PUVA isn’t very effective in treating pitted nails, it can help to address nail discoloration and nails separating from fingers or toes.

Systemic Treatments

Systemic treatments (those that work throughout the body) are a treatment option for severe psoriatic nail problems. Systemic treatments, such as biologics or antirheumatic drugs, are sometimes used to treat systemic inflammation of PsA including nail manifestations.

As with other treatments for nails, it can take months to see results.

Systemic medications for psoriasis that can help clear both the skin and nails include:

Oral nail supplements containing biotin may help the nails grow stronger.

Five Ways To Prevent Nail Problems and Preserve Nail Health

As they say, prevention is better than cure. 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 Association:

  1. Keep your nails short to help prevent nails from lifting off of fingers and toes and to prevent buildup under the nails.
  2. Keep your nails dry and clean to help prevent nail infections.
  3. Wear gloves while washing dishes or gardening to avoid irritating your skin or nails, which may cause flares.
  4. Don’t cut or push back your cuticles to avoid injury that can lead to infection or a psoriasis flare.
  5. Take a pass on artificial nails at your next manicure. Artificial nails can increase the risk of your nails separating from your fingers. Instead, opt for nail polish and gentle buffing.

Find Your Support

Psoriatic arthritis can be tough, but you don’t have to face it alone. MyPsoriasisTeam is the social network for people with psoriasis and psoriatic arthritis and their loved ones. Here, more than 89,000 members with psoriatic arthritis understand what you’re going through and share daily ups and downs in a supportive environment.

Has psoriatic arthritis affected your nails? How are you and your health care team addressing the symptoms? Let us know in the comments below, or start a conversation of your own on MyPsoriasisTeam.

References

  1. Nail Involvement in Psoriatic Arthritis — Rheumatologia
  2. What Your Nails Can Tell Your Doctor About PsA — National Psoriasis Foundation
  3. Psoriatic Arthritis — Symptoms and Causes — The Mayo Clinic
  4. What Is Nail Psoriasis, and How Can I Treat It? — American Academy of Dermatology Association
  5. 7 Nail-Care Tips That Can Reduce Nail Psoriasis — American Academy of Dermatology Association
  6. Managing Skin and Nail Problems of PsA — Arthritis Foundation
  7. Extended Report: Nail Disease in Psoriatic Arthritis — Clinically Important, Potentially Treatable and Often Overlooked — Rheumatology
  8. Enthesitis and Dactylitis in Psoriatic Disease: A Guide for Dermatologists — American Journal of Clinical Dermatology
  9. Psoriatic Arthritis: What Is Happening at the Joint? — Rheumatology and Therapy
  10. Topical Calcipotriol Therapy in Nail Psoriasis: A Study of 24 Cases — Dermatology Online Journal
  11. Treatment of Psoriatic Nails With Tazarotene Cream 0.1% vs. Clobetasol Propionate 0.05% Cream: A Double-Blind Study — Advances in Dermatology and Venereology
  12. Psoriatic Arthritis — Cleveland Clinic
  13. Efficacy and Safety of Continuous Risankizumab Therapy vs Treatment Withdrawal in Patients With Moderate to Severe Plaque Psoriasis: A Phase 3 Randomized Clinical Trial — JAMA Dermatology
Kevin Berman, M.D., Ph.D. is a dermatologist at the Atlanta Center for Dermatologic Disease, Atlanta, GA. Review provided by VeriMed Healthcare Network. Learn more about him here.
Nyaka Mwanza has worked with large global health nonprofits focused on improving health outcomes for women and children. Learn more about her here.

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