Psoriatic onychodystrophy or psoriatic nails is a

nail disease A nail disease or onychosis is a disease or deformity of the nail. Although the nail is a structure produced by the skin and is a skin appendage, nail diseases have a distinct classification as they have their own signs and symptoms which may r ...

. It is common in those with

psoriasis Psoriasis is a long-lasting, noncontagious autoimmune disease characterized by raised areas of abnormal skin. These areas are red, pink, or purple, dry, itchy, and scaly. Psoriasis varies in severity from small, localized patches to complete ...

, with reported incidences varying from 10% to 78%. Elderly patients and those with

psoriatic arthritis Psoriatic arthritis is a long-term inflammatory arthritis that occurs in people affected by the autoimmune disease psoriasis. The classic feature of psoriatic arthritis is swelling of entire fingers and toes with a sausage-like appearance. Th ...

are more likely to have psoriatic nails.James, William; Berger, Timothy; Elston, Dirk (2005). ''Andrews' Diseases of the Skin: Clinical Dermatology''. (10th ed.). Saunders. .

Symptoms

Psoriatic nails are characterized by a translucent discolouration in the nail bed that resembles a drop of oil beneath the nail plate. Early signs that may accompany the "oil drop" include thickening of the lateral edges of the nail bed with or without resultant flattening or concavity of the nail; separation of the nail from the underlying nail bed, often in thin streaks from the tip-edge to the cuticle; sharp peaked "roof-ridge" raised lines from cuticle to tip; or separation of superficial layers of the nail followed by loss of patches of these superficial layers, leaving thin red nails beneath; or nail pitting–punctate changes along the nail plate surface.

Causes

The causes of nail psoriasis are unknown. It has been suggested that fungi may play a role.

Diagnosis

The Nail Psoriasis Severity Index (NAPSI) is a numeric, reproducible, objective, simple tool for evaluation of nail psoriasis. It evaluates several signs separately, each on a 1–3 scale: pitting, Beau's lines, subungual hyperkeratosis and

onycholysis Onycholysis is a common medical condition characterized by the painless detachment of the nail from the nail bed, usually starting at the tip and/or sides. On the hands, it occurs particularly on the ring finger but can occur on any of the fingern ...

. A 2005 study proposed a modified NAPSI scale for persons with psoriasis and named the title of their publication "Modification of the Nail Psoriasis Severity Index". Then, in 2007, a study found that there was a high level of inter-rater variability of the 2003 NAPSI scale and proposed another index which was, like the 2005 article, a modification of the 2003 article, and was named modified NAPSI. A 2008 study found that Cannavo's qualitative system correlated with NAPSI (P<0.001) and is less time-consuming. There is a risk of misdiagnosis with

onychomycosis Onychomycosis, also known as tinea unguium, is a fungal infection of the nail. Symptoms may include white or yellow nail discoloration, thickening of the nail, and separation of the nail from the nail bed. Toenails or fingernails may be affected, ...

Treatment

There exist numerous treatments for nail psoriasis but there is little information concerning their effectiveness and safety. Treatments include topical, intralesional, radiation, systemic, and combination therapies. *

Tacalcitol Tacalcitol (1,24-dihydroxyvitamin D3) is a synthetic vitamin D3 analog. Tacalcitol is marketed under several names, including Curatoderm and Bonalfa. It is on the World Health Organization's List of Essential Medicines. Mechanism Tacalcitol re ...

ointment obtains a significant improvement in all nail parameters, both of the matrix and of the bed. *

Clobetasol Clobetasol is a synthetic glucocorticoid corticosteroid. A propionate ester In chemistry, an ester is a compound derived from an oxoacid (organic or inorganic) in which at least one hydroxyl group () is replaced by an alkoxy group (), a ...

nail lacquer and tacalcitol ointment *

5-fluorouracil Fluorouracil (5-FU), sold under the brand name Adrucil among others, is a cytotoxic chemotherapy medication used to treat cancer. By intravenous injection it is used for treatment of colorectal cancer, oesophageal cancer, stomach cancer, pan ...

. A reported side-effect is yellow nails *

Calcipotriol Calcipotriol, also known as calcipotriene, is a synthetic derivative of calcitriol, a form of vitamin D. It is used in the treatment of psoriasis. It is safe for long-term application in psoriatic skin conditions. It was patented in 1985 and a ...

plus betamethasone dipropionate ointment. *

Efalizumab Efalizumab (trade name Raptiva, Genentech, Merck Serono) is a formerly available medication designed to treat autoimmune diseases, originally marketed to treat psoriasis. As implied by the suffix ''-zumab'', it is a recombinant humanized monoclo ...

Infliximab Infliximab, a chimeric monoclonal antibody, sold under the brand name Remicade among others, is a medication used to treat a number of autoimmune diseases. This includes Crohn's disease, ulcerative colitis, rheumatoid arthritis, ankylosing spon ...

Golimumab Golimumab is a human monoclonal antibody which is used as an immunosuppressive medication and sold under the brand name Simponi. Golimumab targets tumor necrosis factor alpha (TNF-alpha), a pro-inflammatory molecule and hence is a TNF inhibitor. ...

* Low dose methotrexate * Intralesional corticosteroid injection

Relative effectiveness of treatments

Available studies lack sufficient power to extrapolate a standardized therapeutic regimen. As of April 2009, an assessment of the evidence for the efficacy and safety of the treatments for nail psoriasis is in progress. * Infliximab appears to be the most effective treatment for nail psoriasis to date. * Results from low-dose acitretin therapy show NAPSI score reductions comparable with those studies evaluating biologic drugs for nail psoriasis and suggest that low-dose systemic acitretin should be considered in the treatment of nail psoriasis. A 2013 meta-analysis showed improvement of nail psoriasis with infliximab, golimumab, superficial radiotherapy, electron beam, and grenz rays compared to

placebo A placebo ( ) is a substance or treatment which is designed to have no therapeutic value. Common placebos include inert tablets (like sugar pills), inert injections (like saline), sham surgery, and other procedures. In general, placebos can af ...

. Although systemic therapies have been shown to be beneficial, they may have serious adverse effects.

Topical A topical medication is a medication that is applied to a particular place on or in the body. Most often topical medication means application to body surfaces such as the skin or mucous membranes to treat ailments via a large range of classes ...

treatments have not been well studied but may be beneficial.

Research

Active clinical trials investigating nail psoriasis:

Phase IV

* Effects of

Etanercept Etanercept, sold under the brand name Enbrel among others, is a biologic medical product that is used to treat autoimmune diseases by interfering with tumor necrosis factor (TNF), a soluble inflammatory cytokine, by acting as a TNF inhibitor. It ...

. * Effects of

Phase II

* Dose response and safety of topical Methotrexate.

References

External links

Nail psoriasis at Medscape
{{Disorders of skin appendages Conditions of the skin appendages