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Nail psoriasis

Author
April W Armstrong, MD, MPH
Section Editor
Kristina Callis Duffin, MD
Deputy Editor
Abena O Ofori, MD

INTRODUCTION

Psoriasis is a common, chronic, inflammatory disease that has skin, nail, and systemic manifestations. Nail psoriasis results from psoriatic involvement of the nail bed or nail matrix.

Patients with nail psoriasis can develop a wide variety of nail changes, such as pitting, onycholysis, subungual hyperkeratosis, and nail discoloration. Patients may find the appearance of psoriatic nails psychologically distressing, and extensive cases may confer significant morbidity and functional impairments. Therefore, managing nail psoriasis is an integral part of psoriasis therapy.

The clinical manifestations, diagnosis, and management of nail psoriasis will be reviewed here. The diagnosis and treatment of other manifestations of psoriasis are reviewed separately. (See "Epidemiology, clinical manifestations, and diagnosis of psoriasis" and "Treatment of psoriasis".)

EPIDEMIOLOGY

Nail psoriasis occurs in both adults and children [1,2]. The prevalence of nail psoriasis among patients with psoriasis is estimated to be 10 and 55 percent [3]. In most patients, nail involvement follows or is concurrent with the onset of cutaneous psoriasis [4]. Occasionally, nail psoriasis is the sole manifestation of psoriasis at the time of clinical presentation [5].

Nail psoriasis is also strongly associated with psoriatic arthritis. It has been estimated that 80 to 90 percent of patients with psoriatic arthritis develop nail involvement [6,7]. This finding may be related to the proximity of the nail to the distal interphalangeal (DIP) joint, a site of predilection of psoriatic arthritis (picture 1A). The enthesis of extensor tendon crossing the DIP joint is linked to the nail root and nail matrix [8]. (See "Clinical manifestations and diagnosis of psoriatic arthritis".)

                                

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Literature review current through: Jun 2017. | This topic last updated: Jan 13, 2016.
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References
Top
  1. Mercy K, Kwasny M, Cordoro KM, et al. Clinical manifestations of pediatric psoriasis: results of a multicenter study in the United States. Pediatr Dermatol 2013; 30:424.
  2. Kwon HH, Na SJ, Jo SJ, Youn JI. Epidemiology and clinical features of pediatric psoriasis in tertiary referral psoriasis clinic. J Dermatol 2012; 39:260.
  3. Oram Y, Akkaya AD. Treatment of nail psoriasis: common concepts and new trends. Dermatol Res Pract 2013; 2013:180496.
  4. van der Velden HM, Klaassen KM, van de Kerkhof PC, Pasch MC. Fingernail psoriasis reconsidered: a case-control study. J Am Acad Dermatol 2013; 69:245.
  5. Tan ES, Chong WS, Tey HL. Nail psoriasis: a review. Am J Clin Dermatol 2012; 13:375.
  6. Wilson FC, Icen M, Crowson CS, et al. Incidence and clinical predictors of psoriatic arthritis in patients with psoriasis: a population-based study. Arthritis Rheum 2009; 61:233.
  7. Cohen MR, Reda DJ, Clegg DO. Baseline relationships between psoriasis and psoriatic arthritis: analysis of 221 patients with active psoriatic arthritis. Department of Veterans Affairs Cooperative Study Group on Seronegative Spondyloarthropathies. J Rheumatol 1999; 26:1752.
  8. Tan AL, Benjamin M, Toumi H, et al. The relationship between the extensor tendon enthesis and the nail in distal interphalangeal joint disease in psoriatic arthritis--a high-resolution MRI and histological study. Rheumatology (Oxford) 2007; 46:253.
  9. Gladman DD, Shuckett R, Russell ML, et al. Psoriatic arthritis (PSA)--an analysis of 220 patients. Q J Med 1987; 62:127.
  10. Wright V, Roberts MC, Hill AG. Dermatological manifestations in psoriatic arthritis: a follow-up study. Acta Derm Venereol 1979; 59:235.
  11. Williamson L, Dalbeth N, Dockerty JL, et al. Extended report: nail disease in psoriatic arthritis--clinically important, potentially treatable and often overlooked. Rheumatology (Oxford) 2004; 43:790.
  12. Serarslan G, Güler H, Karazincir S. The relationship between nail- and distal phalangeal bone involvement severity in patients with psoriasis. Clin Rheumatol 2007; 26:1245.
  13. Jiaravuthisan MM, Sasseville D, Vender RB, et al. Psoriasis of the nail: anatomy, pathology, clinical presentation, and a review of the literature on therapy. J Am Acad Dermatol 2007; 57:1.
  14. Trembath RC, Clough RL, Rosbotham JL, et al. Identification of a major susceptibility locus on chromosome 6p and evidence for further disease loci revealed by a two stage genome-wide search in psoriasis. Hum Mol Genet 1997; 6:813.
  15. McGonagle D. Enthesitis: an autoinflammatory lesion linking nail and joint involvement in psoriatic disease. J Eur Acad Dermatol Venereol 2009; 23 Suppl 1:9.
  16. McGonagle D, Palmou Fontana N, Tan AL, Benjamin M. Nailing down the genetic and immunological basis for psoriatic disease. Dermatology 2010; 221 Suppl 1:15.
  17. de Jong EM, Seegers BA, Gulinck MK, et al. Psoriasis of the nails associated with disability in a large number of patients: results of a recent interview with 1,728 patients. Dermatology 1996; 193:300.
  18. Grover C, Reddy BS, Uma Chaturvedi K. Diagnosis of nail psoriasis: importance of biopsy and histopathology. Br J Dermatol 2005; 153:1153.
  19. Rich P, Scher RK. Nail Psoriasis Severity Index: a useful tool for evaluation of nail psoriasis. J Am Acad Dermatol 2003; 49:206.
  20. Parrish CA, Sobera JO, Elewski BE. Modification of the Nail Psoriasis Severity Index. J Am Acad Dermatol 2005; 53:745.
  21. de Vries AC, Bogaards NA, Hooft L, et al. Interventions for nail psoriasis. Cochrane Database Syst Rev 2013; :CD007633.
  22. Crowley JJ, Weinberg JM, Wu JJ, et al. Treatment of nail psoriasis: best practice recommendations from the Medical Board of the National Psoriasis Foundation. JAMA Dermatol 2015; 151:87.
  23. Tzung TY, Chen CY, Yang CY, et al. Calcipotriol used as monotherapy or combination therapy with betamethasone dipropionate in the treatment of nail psoriasis. Acta Derm Venereol 2008; 88:279.
  24. Tosti A, Piraccini BM, Cameli N, et al. Calcipotriol ointment in nail psoriasis: a controlled double-blind comparison with betamethasone dipropionate and salicylic acid. Br J Dermatol 1998; 139:655.
  25. Rigopoulos D, Gregoriou S, Daniel Iii CR, et al. Treatment of nail psoriasis with a two-compound formulation of calcipotriol plus betamethasone dipropionate ointment. Dermatology 2009; 218:338.
  26. Rigopoulos D, Ioannides D, Prastitis N, Katsambas A. Nail psoriasis: a combined treatment using calcipotriol cream and clobetasol propionate cream. Acta Derm Venereol 2002; 82:140.
  27. Zakeri M, Valikhani M, Mortazavi H, Barzegari M. Topical calcipotriol therapy in nail psoriasis: a study of 24 cases. Dermatol Online J 2005; 11:5.
  28. De Simone C, Maiorino A, Tassone F, et al. Tacrolimus 0.1% ointment in nail psoriasis: a randomized controlled open-label study. J Eur Acad Dermatol Venereol 2013; 27:1003.
  29. Cassell S, Kavanaugh AF. Therapies for psoriatic nail disease. A systematic review. J Rheumatol 2006; 33:1452.
  30. Fischer-Levancini C, Sánchez-Regaña M, Llambí F, et al. Nail psoriasis: treatment with tazarotene 0.1% hydrophilic ointment. Actas Dermosifiliogr 2012; 103:725.
  31. Rigopoulos D, Gregoriou S, Katsambas A. Treatment of psoriatic nails with tazarotene cream 0.1% vs. clobetasol propionate 0.05% cream: a double-blind study. Acta Derm Venereol 2007; 87:167.
  32. Scher RK, Stiller M, Zhu YI. Tazarotene 0.1% gel in the treatment of fingernail psoriasis: a double-blind, randomized, vehicle-controlled study. Cutis 2001; 68:355.
  33. Piraccini BM, Venturi M, Patrizi A. Periungual pyogenic granulomas due to topical tazarotene for nail psoriasis. G Ital Dermatol Venereol 2014; 149:363.
  34. Sola-Ortigosa J, Sánchez-Regaña M, Umbert-Millet P. Efficacy of adalimumab in the treatment of psoriasis: a retrospective study of 15 patients in daily practice. J Dermatolog Treat 2012; 23:203.
  35. Leonardi C, Langley RG, Papp K, et al. Adalimumab for treatment of moderate to severe chronic plaque psoriasis of the hands and feet: efficacy and safety results from REACH, a randomized, placebo-controlled, double-blind trial. Arch Dermatol 2011; 147:429.
  36. Rigopoulos D, Gregoriou S, Lazaridou E, et al. Treatment of nail psoriasis with adalimumab: an open label unblinded study. J Eur Acad Dermatol Venereol 2010; 24:530.
  37. Van den Bosch F, Manger B, Goupille P, et al. Effectiveness of adalimumab in treating patients with active psoriatic arthritis and predictors of good clinical responses for arthritis, skin and nail lesions. Ann Rheum Dis 2010; 69:394.
  38. Rudwaleit M, Van den Bosch F, Kron M, et al. Effectiveness and safety of adalimumab in patients with ankylosing spondylitis or psoriatic arthritis and history of anti-tumor necrosis factor therapy. Arthritis Res Ther 2010; 12:R117.
  39. Ozmen I, Erbil AH, Koc E, Tunca M. Treatment of nail psoriasis with tumor necrosis factor-alpha blocker agents: an open-label, unblinded, comparative study. J Dermatol 2013; 40:755.
  40. Saraceno R, Pietroleonardo L, Mazzotta A, et al. TNF-α antagonists and nail psoriasis: an open, 24-week, prospective cohort study in adult patients with psoriasis. Expert Opin Biol Ther 2013; 13:469.
  41. Kyriakou A, Patsatsi A, Sotiriadis D. Anti-TNF agents and nail psoriasis: a single-center, retrospective, comparative study. J Dermatolog Treat 2013; 24:162.
  42. Demirsoy EO, Kıran R, Salman S, et al. Effectiveness of systemic treatment agents on psoriatic nails: a comparative study. J Drugs Dermatol 2013; 12:1039.
  43. Karanikolas GN, Koukli EM, Katsalira A, et al. Adalimumab or cyclosporine as monotherapy and in combination in severe psoriatic arthritis: results from a prospective 12-month nonrandomized unblinded clinical trial. J Rheumatol 2011; 38:2466.
  44. Sánchez-Regaña M, Sola-Ortigosa J, Alsina-Gibert M, et al. Nail psoriasis: a retrospective study on the effectiveness of systemic treatments (classical and biological therapy). J Eur Acad Dermatol Venereol 2011; 25:579.
  45. Ortonne JP, Paul C, Berardesca E, et al. A 24-week randomized clinical trial investigating the efficacy and safety of two doses of etanercept in nail psoriasis. Br J Dermatol 2013; 168:1080.
  46. Luger TA, Barker J, Lambert J, et al. Sustained improvement in joint pain and nail symptoms with etanercept therapy in patients with moderate-to-severe psoriasis. J Eur Acad Dermatol Venereol 2009; 23:896.
  47. Fabroni C, Gori A, Troiano M, et al. Infliximab efficacy in nail psoriasis. A retrospective study in 48 patients. J Eur Acad Dermatol Venereol 2011; 25:549.
  48. Torii H, Nakagawa H, Japanese Infliximab Study Investigators. Long-term study of infliximab in Japanese patients with plaque psoriasis, psoriatic arthritis, pustular psoriasis and psoriatic erythroderma. J Dermatol 2011; 38:321.
  49. Reich K, Ortonne JP, Kerkmann U, et al. Skin and nail responses after 1 year of infliximab therapy in patients with moderate-to-severe psoriasis: a retrospective analysis of the EXPRESS Trial. Dermatology 2010; 221:172.
  50. Torii H, Nakagawa H, Japanese Infliximab Study investigators. Infliximab monotherapy in Japanese patients with moderate-to-severe plaque psoriasis and psoriatic arthritis. A randomized, double-blind, placebo-controlled multicenter trial. J Dermatol Sci 2010; 59:40.
  51. Rich P, Griffiths CE, Reich K, et al. Baseline nail disease in patients with moderate to severe psoriasis and response to treatment with infliximab during 1 year. J Am Acad Dermatol 2008; 58:224.
  52. Rigopoulos D, Gregoriou S, Stratigos A, et al. Evaluation of the efficacy and safety of infliximab on psoriatic nails: an unblinded, nonrandomized, open-label study. Br J Dermatol 2008; 159:453.
  53. Mease PJ, Fleischmann R, Deodhar AA, et al. Effect of certolizumab pegol on signs and symptoms in patients with psoriatic arthritis: 24-week results of a Phase 3 double-blind randomised placebo-controlled study (RAPID-PsA). Ann Rheum Dis 2014; 73:48.
  54. Kavanaugh A, McInnes I, Mease P, et al. Golimumab, a new human tumor necrosis factor alpha antibody, administered every four weeks as a subcutaneous injection in psoriatic arthritis: Twenty-four-week efficacy and safety results of a randomized, placebo-controlled study. Arthritis Rheum 2009; 60:976.
  55. Kavanaugh A, van der Heijde D, McInnes IB, et al. Golimumab in psoriatic arthritis: one-year clinical efficacy, radiographic, and safety results from a phase III, randomized, placebo-controlled trial. Arthritis Rheum 2012; 64:2504.
  56. Patsatsi A, Kyriakou A, Sotiriadis D. Ustekinumab in nail psoriasis: an open-label, uncontrolled, nonrandomized study. J Dermatolog Treat 2013; 24:96.
  57. Rich P, Bourcier M, Sofen H, et al. Ustekinumab improves nail disease in patients with moderate-to-severe psoriasis: results from PHOENIX 1. Br J Dermatol 2014; 170:398.
  58. Vitiello M, Tosti A, Abuchar A, et al. Ustekinumab for the treatment of nail psoriasis in heavily treated psoriatic patients. Int J Dermatol 2013; 52:358.
  59. Igarashi A, Kato T, Kato M, et al. Efficacy and safety of ustekinumab in Japanese patients with moderate-to-severe plaque-type psoriasis: long-term results from a phase 2/3 clinical trial. J Dermatol 2012; 39:242.
  60. Rigopoulos D, Gregoriou S, Makris M, Ioannides D. Efficacy of ustekinumab in nail psoriasis and improvement in nail-associated quality of life in a population treated with ustekinumab for cutaneous psoriasis: an open prospective unblinded study. Dermatology 2011; 223:325.
  61. Gümüşel M, Özdemir M, Mevlitoğlu I, Bodur S. Evaluation of the efficacy of methotrexate and cyclosporine therapies on psoriatic nails: a one-blind, randomized study. J Eur Acad Dermatol Venereol 2011; 25:1080.
  62. Reich K, Langley RG, Papp KA, et al. A 52-week trial comparing briakinumab with methotrexate in patients with psoriasis. N Engl J Med 2011; 365:1586.
  63. Rich P, Gooderham M, Bachelez H, et al. Apremilast, an oral phosphodiesterase 4 inhibitor, in patients with difficult-to-treat nail and scalp psoriasis: Results of 2 phase III randomized, controlled trials (ESTEEM 1 and ESTEEM 2). J Am Acad Dermatol 2016; 74:134.
  64. Nantel-Battista M, Richer V, Marcil I, Benohanian A. Treatment of nail psoriasis with intralesional triamcinolone acetonide using a needle-free jet injector: a prospective trial. J Cutan Med Surg 2014; 18:38.
  65. Goldust M, Raghifar R. Clinical Trial Study in the Treatment of Nail Psoriasis with Pulsed Dye Laser. J Cosmet Laser Ther 2013.
  66. Treewittayapoom C, Singvahanont P, Chanprapaph K, Haneke E. The effect of different pulse durations in the treatment of nail psoriasis with 595-nm pulsed dye laser: a randomized, double-blind, intrapatient left-to-right study. J Am Acad Dermatol 2012; 66:807.
  67. Cannavò SP, Guarneri F, Vaccaro M, et al. Treatment of psoriatic nails with topical cyclosporin: a prospective, randomized placebo-controlled study. Dermatology 2003; 206:153.
  68. Lin YK, See LC, Huang YH, et al. Efficacy and safety of Indigo naturalis extract in oil (Lindioil) in treating nail psoriasis: a randomized, observer-blind, vehicle-controlled trial. Phytomedicine 2014; 21:1015.
  69. Lin YK, Chang YC, Hui RC, et al. A Chinese Herb, Indigo Naturalis, Extracted in Oil (Lindioil) Used Topically to Treat Psoriatic Nails: A Randomized Clinical Trial. JAMA Dermatol 2015; 151:672.
  70. Tosti A, Ricotti C, Romanelli P, et al. Evaluation of the efficacy of acitretin therapy for nail psoriasis. Arch Dermatol 2009; 145:269.
  71. Handfield-Jones SE, Boyle J, Harman RR. Local PUVA treatment for nail psoriasis. Br J Dermatol 1987; 116:280.
  72. Marx JL, Scher RK. Response of psoriatic nails to oral photochemotherapy. Arch Dermatol 1980; 116:1023.