This document provides an overview of nail psoriasis, including its symptoms, classification, diagnosis, management, and treatment options. It begins with an introduction to nail psoriasis and discusses changes in the nail that can occur. It then covers the epidemiology of nail psoriasis and describes clinical features related to the nail matrix and nail bed. The document outlines methods for classifying and diagnosing nail psoriasis, such as the Nail Psoriasis Severity Index (NAPSI). It concludes by discussing various treatment approaches for nail psoriasis, including avulsion therapy, intralesional corticosteroids, systemic therapies, and other physical therapies.

1. The aim of this article is to do a detailed
study about nail psoriasis including its
symptoms, epidemiology, management,
treatment etc.
Department of Research Methodology
By : Shabana Godme
1

2. Acknowledgement
I would like to thanks New Vision
University for initiating Research
Methodology and my Research
Methodology professor Mr. GIA
JGARKAVA for giving me this
opportunity to make an article on
NAIL PSORIASIS.
I am also very thankful to PubMed for
data base review on this topic. I am
writing this project after reading
many of data published through
different references so thanks to all
those publishers and authors too.
I am also very thankful to my parents
for motivating me for writing this
project.
2

3. Contents
Psoriasis in brief ……………………………………………….. 5
Psoriasis diagnosis overview …………………….......... 5
1. Nail psoriasis abstract …………………………………… 6
2. Introduction …………………………………………………. 7
3. Changes in the nail ………………………………………. 9
4. Epidemiology ……………………………………………… 10
5. Clinical features
5.1. Nail matrix signs ...................................... 13
5.2. Nail bed signs ……………………………............ 13
6. Classification ………………………………………………. 14
7. Diagnosis
7.1. NAPSI ……………………………………………………. 15
8. Management ……………………………………………… 17
9. Treatment
9.1. Avulsion therapy……………………………………. 18
9.1.1. Chemical avulsion therapy …………… 18
9.1.2. Surgical avulsion therapy ……………. 18
9.2. Removing an affected nail …………………….. 18
9.3. Intralesional corticosteroids …………………… 19
9.4. Systemic non-biological treatment ……….. 19
9.5. Systemic biological treatment ……………….. 20
9.6. Other physical therapies ……………………….. 20
9.6.1. Photochemotherapy ……………………. 20
9.6.2. Lazer therapy ………………………………. 21
9.6.3. Radiation therapy ………………………… 21 3

4. 9.7. Antifungal therapy ……………………… 23
10. Conclusion ………………………………………. 23
11. References ……………………………………… 24
4

5. Psoriasis in brief
Psoriasis is one of the most baffling and persistent of
skin disorders. It is a long-lasting autoimmune disease
characterized by patches of abnormal skin. It involves
the skin , scalp, joints, mucous membranes and nails.
There are five main types of Psoriasis that is Plaque ,
Guttate , Inverse ,Pustuler & Erythrodermic. It causes
cells to build up rapidly on the surface of the skin. It is
generally thought to be a genetic disease which is
triggered by environmental factors. Diagnosis is
typically based on the signs and symptoms. There is no
cure for psoriasis. However, various treatments can
help control the symptoms. Psoriasis is a multifactorial
disease of unknown origin. These treatments may
include steroid creams, vitamin D3 cream, ultraviolet
light, and immune system suppressing medications
such as methotrexate and about 75% of people can be
managed with creams alone.
The causes of psoriasis is not yet fully discovered but
some theories do exist. It is said to be caused due to
HIV, microbes, medication, genetics and a person’s
lifestyle.
Diagnosis of psoriasis overview
The diagnosis of psoriasis is usually based on the appearance
of the skin. The symptoms of psoriasis vary depending on the
type you have. 5

6. NAIL PSORIASIS
Abstract
Nail psoriasis is common, occurring in up to half of patients
with psoriasis and in 90% of patients with psoriatic arthritis.
Left untreated, it may progress to debilitating nail disease,
which leads to significant functional impairment. The most
common clinical signs of nail psoriasis are nail plate pitting
and onycholysis. Other classical signs include oil drop
discoloration, subungual hyperkeratosis, and splinter
hemorrhages. The modified Nail Psoriasis Severity Index
(mNAPSI) can be used to grade the severity of nail psoriasis,
while the Nail Psoriasis Quality of Life Scale (NPQ10) is a
questionnaire that evaluates the impact of nail psoriasis on
the patient’s functional status and quality of life. Treatment
of nail psoriasis should be individualized according to the
patient’s preferences, severity of nail changes, and
presence of skin and/or joint involvement. Both topical and
intralesional therapies are safe and effective treatment
modalities for nail disease, but are limited by poor
adherence and pain, respectively. Systemic therapy such as
oral retinoids may be considered for widespread nail
disease causing significant morbidity. Among biologic
agents, tumor necrosis factor-a inhibitors and T-cell-
targeted therapies such as ustekinumab may be useful for
refractory severe nail psoriasis. 6

7. Psoriatic nail involvement is common and accompanies
skin lesions on the body surface. Nail psoriasis affects
nearly 80% of patients with plaque psoriasis and is even
more prevalent in patients with psoriatic arthritis. Its
affects the structure and function of the nail. It also has a
negative psychological effect. The characteristics of
psoriatic nails are pitting, discoloration, onycholysis,
subungual hyperkeratosis, as well as crumbling and
grooving of nails and splinter hemorrhages. Adults are
more likely to get this disease compared to children.
Many patients who present with only nail psoriasis later
develop psoriasis of their skin and/or joints. Psoriasis of
the skin, scalp and/or nails often precedes the
appearance of psoriatic arthritis (PsA) by up to 12 years.
The strongest predictor for concomitant PsA was nail
involvement.
Subungual hyperkeratosis of the hyponychium :
Subungual hyperkeratosis affects the nail bed and the
hyponychium. Excessive proliferation of the nail bed can
lead to onycholysis.
Introduction
7

8. a b c
d
f
e
g
8

9. Changes in the nail during nail
psoriasis
a) Pitting on the surface of the nail.
b) Defects in the nail, such as ridges or crumbling nails.
c) Yellowish color to the toenails (and sometimes
fingernails).
d) Thickening of the fingernails or toenails.
e) Spots under the fingernails, such as yellow-red
patches.
f) Separation of the nail from the nail bed.
g) Total loss of the nail bed.
Pitting of the proximal nail matrix :
Pitting is a result of the loss of parakeratotic cells from
the surface of the nail plate.
Nail plate crumbling :
Nail plate weakening due to disease of the underlying
structures causes this condition.
Spotted lunula/distal matrix :
This is an erythematous patch of the lunula.
Leukonychia of the midmatrix :
Leukonychia consists of areas of white nail plate due to
foci of parakeratosis within the body of the nail plate.
9

10. Beau lines of the proximal nail matrix :
These lines are transverse lines in the nails due to
intermittent inflammation causing growth arrest
lines.
Splinter hemorrhage/dilated tortuous capillaries in the
dermal papillae :
Splinter hemorrhages are longitudinal black lines due
to minute foci of capillary hemorrhage between the
nail bed and the nail plate. This is analogous to the
Auspitz sign of cutaneous psoriasis, which is the
pinpoint bleeding seen beneath the psoriatic
plaques.
Epidemiology
Distinctive nail changes occur in about 50% of all
patients with psoriasis and in 80% of patients with
psoriatic arthritis. Psoriatic nail disease mainly occurs
in patients who also have psoriasis affecting the skin.
Fewer than 5% of patients have psoriasis of the nails
without any skin involvement.
Psoriasis tends to run in families. In Farber's
questionnaire study of 2100 patients,[3] 36% of
patients reported the presence of psoriasis in at least
1 relative. Among siblings, 8% are affected if neither
parent has psoriasis. This percentage increases to 16-
25% if 1 parent or sibling has the disease, and it
reaches upto 75% if both parents
10

11. are affected. If 1 twin has psoriasis, the other twin is at
an increased risk of having psoriasis (25% for fraternal
twins, 65% for identical twins). In Scandinavia, the
prevalence rate of nail psoriasis for adults with
psoriasis approaches 5%. The prevalence increases
with the age of the population studied.
Psoriatic nail disease is not associated with mortality.
In severe cases, patients may have functional and
psychosocial impairments.
Clinical features of nail psoriasis
The clinical features of nail psoriasis depend on the
location of the psoriatic Inflammation within the nail
unit.
Nail structure :
11

12. The nail unit is composed of four epithelial structures;
the nail bed, nail matrix, hyponychium and nail folds. Any
or all of these structures can be affected with nail
psoriasis. Generally, psoriasis of the nail matrix and nail
bed result in most of the observed pathologic changes,
whereas psoriasis of the hyponychium and nail folds
contribute less to the pathologic changes.
Signs/symptom Site Features
Oil drop or
salmon patch
Nail bed Translucent yellow-red discoloration
in the nail bed, resembles drop of oil
under nail plate
Pitting Proximal nail matrix Loss of parakeratotic cells from
surface of nail plate
Beau’s lines Proximal nail matrix Transverse lines in nails due to
intermittent inflammation causing
growth arrest lines
Leukonychia Midmatrix disease Areas of white nail plate due to foci
of parakeratosis within the body of
the nail plate
Subungual
hyperkeratosis
Hyponychium and
nail pate
Excessive proliferation of the nail bed
and hyponychium. May lead to
oncholysis.
Onycholysis Nail bed and
hyponychium
Nail plate seperates from its
underlying attachment to nail bed.
Nail plate whitens and may detach.
Nail plate
crumbling
Nail bed or nail
matriix
Nail plate weakens due to disease of
underlying structures
Acrodermatitis
contunua of
Hallopeau
Nail bed, nail matrix,
tips of digits
Nail plate destroyed by pustular
eruption
12

13. Nail matrix signs
It is responsible for the formation of the nail plate. The
effects of psoriasis on the nail matrix involve alterations
in the nail plate, such as cupuliform depressions, also
known as pittings, leukonychia (white spots), red spots
in the lunula and crumbling. Psoriasis of the nail can be
very hard to treat, and treatment is not always
successful. Treatment is aimed at the white half-moon-
shaped root of the nail (the matrix). Foci of psoriasis in
the proximal matrix cause pitting, whereas the same
process in the mid or distal matrix results in psoriatic
leukonychia. The mid and distal areas of leukonychia
resemble pitting, but these abnormal cells are trapped
in the nail plate resulting in white spots (leukonychia)
rather than a pitted surface. Crumbling represents
confluent pitting due to a longer duration of nail
psoriasis in the proximal nail matrix.
Nail bed signs
The nail bed is responsible for the firm attachment of
the nail plate. Effects on the nail bed include
onycholysis, oil-drop or salmon patches, dyschromias,
splinter hemorrhage and nail bed hyperkeratosis.
As nail psoriasis is similar to that observed on the backs
of the fingers, the condition is considered to be a
cutaneous extension of finger lesion.
13

14. Classification of nail psoriasis
Most people with psoriatic arthritis have nail changes
that can be classified as follows:
•Type I - Classic distal interphalangeal joint involvement
(5% of patients)
•Type II - Arthritis mutilans
•Type III - Symmetric polyarthritis
•Type IV - Asymmetric oligoarthritis (the most common
type of psoriatic arthritis, occurring in 70% of patients)
•Type V - Ankylosing spondylitis
Onycholysis of the nail bed and nail hyponychium
Onycholysis is a white area of the nail plate due to a
functional separation of the nail plate from its underlying
attachment to the nail bed. It usually starts distally and
progresses proximally, causing a traumatic uplifting of the
distal nail plate. Secondary microbial colonization may
occur. It leaves an empty space under the nail.
14

15. See the images below:
Diagnosis
The diagnosis of psoriatic nail disease is usually made by
the appearance of the affected nails. Occasionally, a
sample of nail (a biopsy) is needed to confirm the
diagnosis.
Nail Psoriasis Severity Index (NAPSI) :
It is a numeric, reproducible, objective, simple tool for
evaluation of nail psoriasis. This scale is used to evaluate
the severity of nail bed psoriasis and nail matrix psoriasis
by area of involvement in the nail unit.
NAPSI is used to assign a score to each nail for nail bed
and nail matrix psoriasis. The nail plate is divided into
quadrants in presence of lesions by imaginary longitudinal
and horizontal lines. 15

16. M : Nail Matrix
B : Nail bed
Nail plate is assessed for nail matrix psoriasis by the
presence of any feature of nail matrix psoriasis, including
nail pitting, leukonychia, red spots in the lunula, and
crumbling in each quadrant of the nail.
Nail bed psoriasis is assessed by the presence of any
features of nail bed psoriasis, including onycholysis, oil
drop (salmon patch) dyschromia, splinter hemorrhages,
and nail bed hyperkeratosis in each quadrant of the nail.
If the score is 0; the findings are not present, 1 if they are
present in 1 quadrant of the nail, 2 if present in 2
quadrants of a nail, 3 if present in 3 quadrants of a nail, and
4 if present in 4 quadrants of a nail. Thus each nail has a
matrix score (0-4) and a nail bed score (0-4), and the total
nail score is the sum of those 2 individual scores (0-8).
Sum of the total score of all involved fingernails is the total
NAPSI score for that patient at that time.
If a more sensitive scale is needed, the nail can be given a
separate score for all 8 features in each quadrant. The
resulting is a 0 to 32 scale for the nail. A modified version
(mNAPSI) is developed to enhance the face validity and
feasibility of this tool. 16

17. Management
General advice :
•Keep nails short to avoid worse onycholysis and reduce
the accumulation of material under the nail.
•Avoid manicure of the cuticle, which may provoke
infection of the nail bed.
•Avoid artificial nails.
• Abrasive acetone-based nail varnish removers should
be avoided.
•Mild nail disease not causing discomfort or distress
does not need any treatment other than nail varnish to
disguise pitting. Abrasive acetone-based nail varnish
removers should be avoided.
•A patient with painful toenail disease should be
referred to a podiatrist.
•Any patient with nail psoriasis that has a major
functional or cosmetic impact should be referred for
dermatology specialist advice.
• Avoiding minor repetitive nail trauma by wearing
gloves for household chores and gardening.
• Patients should be counselled that nail improvement
occurs slowly and clearing often requires 6 or more
months for fingernails, and up to 12 months for
toenails.
17

18. Treatment
At present, psoriasis of the nails does not have a cure.
The goal of treatment is to improve the function and
appearance of the nails.
Avulsion therapy: Therapy for the forcible tearing away
of a body part by trauma or surgery.
Chemical or surgical avulsion therapy can be used as an
alternative therapy for nail psoriasis disease.
•Chemical avulsion therapy- It includes the application
of ointment to the affected nail under occlusion for
seven days; the nail is removed without any trauma.
Chemical avulsion therapy is painless, involves no blood
loss and is less expensive than surgical avulsion.
• Surgical avulsion therapy- Can be performed for
psoriatic nail disease when other treatments have
failed. The matrix (the part of the nail bed that is
beneath the nail and contains nerves, lymph and blood
vessels) can be electively ablated to prevent regrowth
of the nail. This procedure is performed under local
anaesthesia.
Removing an affected nail: This can be done by applying
a special type of ointment and then covering the nail for
seven days. Otherwise the nail can be surgically
removed using local anaesthetic.
18

19. Intralesional corticosteroids: Intralesional triamcinolone
acetonide injected into proximal nail folds is helpful but
painful in nail matrix psoriasis. It is used when single or
few nails are involved. Intralesional steroid injection
involves a corticosteroid, such as triamcinolone
acetonide or betamethasone suspension. Shorter-
acting corticosteroid preparations, such as
dexamethasone or betamethasone acetate, are
sometimes administered in combination with
triamcinolone.
Systemic non-biological treatment / Systemic therapy
with small molecules : This type of treatment should be
offered to the patient with significant functional
impairment and/or high levels of distress as a result of
severe nail disease.
Traditional small molecule medications- methotrexate,
acitretin , cyclosporine A
Newer small molecules - apremilast, tofacitinib
Methotrexate is recommended as the first choice of
systemic agent for people with psoriasis.
One study found moderate benefit with treatment
using methotrexate or cyclosporine and there were no
significant differences in efficacy between the two
treatments. A significant improvement was detected in
the methotrexate group for the nail matrix findings and
in the cyclosporine group for the nail bed findings.
19

20. Systemic therapy with biologic agents : The biological
therapies adalimumab, efalizumab, etanercept,
infliximab and ustekinumab have shown clinically
important nail psoriasis improvements using the Nail
Psoriasis Severity Index.
More research is needed about the drugs and efficacy of
the group.
Other physical therapies: This includes radiotherapy,
Grenz rays, laser therapy and electron beam therapy.
• Photochemotherapy - Phototherapy with narrow-band
UVB (NB-UVB), and photochemotherapy with UVA in
addition to the photo-sensitizer psoralen (PUVA) are
well established treatments for cutaneous psoriasis.
However, there is a paucity of published literature
evaluating their use in nail psoriasis. In a prospective
series of ten patients with 26 individual nail dystrophies
treated with oral PUVA therapy using 8-methoxy-
psoralen at a dose of 0.6 mg/kg 2–3 times a week,
70%showedimprovement in nail changes such as
onycholysis, subungual hyperkeratosis, nail plate
crumbling, and oil-drop discoloration. None had
improvement in pitting.[55]Another small prospective
study demonstrated considerable improvement in four
out of five patients given topical PUVA 2–3 times a
week using 1%solution of 8-methoxypsoralen applied to
the proximal nail fold up to the terminal phalanx, with
onycholysis showing greater response than pitting. 20

21. There was no incidence of adverse effects in either
study. The degree of UV light penetration in normal
human cadaveric nail plate has been examined. It was
found that the nail plate completely blocked UVB, and
the penetration of UVA was minimal. This may explain
why NB-UVB has not been reported effective while
PUVA has limited efficacy in treating nail psoriasis.
• Laser Therapy- The use of pulsed dye laser (PDL) to
treat nail psoriasis has been explored, driven by
evidence that epidermal hyperplasia in psoriatic
plaques is supported by dermal angiogenesis. In a
study, five patients with psoriatic nails received PDL
(595 nm)once monthly for 3 months, and all had
significant improvement in NAPSI scores. The best
response was observed in onycholysis and subungual
hyperkeratosis. The efficacy of PDL was found to be
comparable to photodynamic therapy using methyl-
aminolevulinic acid and PDL as the light source.
Adverse effects were mainly temporary pain in the
first 24 hours, and slight purpura in the treated nails
resolving within a week.
• Radiation Therapy- While an established therapeutic
modality in the field of oncology, radiation therapy is
not routinely used in the treatment of psoriatic nails.
Superficial radiotherapy and electron beam therapy
may confer temporary benefit in nail psoriasis. A small21

22. 22
series of three patients who received six to eight
treatments of superficial radiotherapy of varying doses
showed clearance of psoriatic nail dystrophies, with no
relapse reported at the time of publication. In a double-
blind, placebo-controlled study involving ten patients,
superficial radiotherapy was ad-ministered to psoriatic
fingernails as three fractionated doses of150 cGy with a
1.00 mm aluminium filter. Significant clinical
improvement was seen in pitting, subungual
hyperkeratosis, onycholysis, and nail thickness at 10
and 15 weeks. However, the improvement in nail
thickness was only temporary, as there was no
difference with the placebo group at 20 weeks post-
treatment. The advantage of electron beam therapy lies
in its ability to effectively penetrate the nail bed. A
prospective study examined the efficacy of electron
beam therapy on psoriatic nails in 12 patients receiving
a weekly dose of 0.75 Gy over 8 weeks. While75%of
patients showed improvement at 3 months, nail disease
relapsed in almost all the patients at 12 months. An
adverse effect observed was the temporary brownish-
black pigmentation of the treated nails. Grenz rays are a
form of ultra-soft, low-energy, ionizing radiation that is
almost fully absorbed within the first 2 mm depth of
skin. In a placebo-controlled trial, 5 Gy of Grenz rays
were administered to 22 patients with psoriatic nails at
weekly intervals for 10 weeks. Moderate improvement
was seen at 3 months, but only in nails of normal
thickness. Therefore Grenz ray therapy should not be 22

23. used in hyperkeratotic nails. Overall, radiation therapy
may be useful for recalcitrant cases of nail psoriasis
where other treatment modalities have failed or are
unsuitable. Nevertheless, it carries the long-term risks of
localized fibrosis and malignancy, which should be
carefully discussed with the patient before commencing
treatment.
Antifungal treatment - This may be required for fungal
nail infection if this is also present.
Conclusion
Despite the frequent occurrence of nail involvement in
patients with cutaneous psoriasis and psoriatic arthritis,
the nails continue to be overlooked by both patients and
their physicians. As nail psoriasis can adversely affect the
patient’s quality of life and lead to significant functional
impairment, its recognition and treatment should be
given greater emphasis. Topical and intralesional
therapies are relatively safe, first-line treatment options,
but are plagued by variable response and poor
compliance to prolonged therapy. Photochemotherapy,
laser therapy, and radiation therapy may be useful in
some refractory cases. Combined therapies are
promising. Systemic therapies, including biologic agents,
23

24. have demonstrated the best outcome compared with
other therapeutic modalities. How-ever, the relatively
higher costs and greater risks of adverse effects remain
a concern, and hence systemic treatment should be
reserved for patients with widespread and severe nail
disease who have failed other therapies. As there is a
paucity of evidence for many of the existing therapeutic
modalities, more studies to investigate the optimal
treatment for nail psoriasis are required.
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http://emedicine.medscape.com
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http://www.clinexprheumatol.org
http://www.gpnotebook.co.uk
www.researchgate.net
http://www.webmd.com
en.wikipedia.org
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