Nail psoriasis is a common type of psoriasis that is often overlooked. This type of psoriasis can significantly impact your daily life. Studies show that 80-90% of people with psoriasis will have nail problems at some point (1).

What Is Nail Psoriasis?

Nail psoriasis happens when psoriasis affects your fingernails and toenails. This causes various changes in how they look and feel. Studies show that 80-90% of people with psoriasis will have nail problems at some point (2).

The condition affects all parts of the nail and surrounding structures. In a large study of psoriasis patients, 81.8% had nail involvement at baseline (3).

Treatment Options for Nail Psoriasis

Treating nail psoriasis can be challenging, but various options are available. These range from topical treatments to advanced biologics. The effectiveness of treatments varies, and what works for skin psoriasis may need adjustment for nail involvement.

Nail psoriasis often requires different treatment approaches than skin psoriasis (4).

Who Gets Nail Psoriasis?

Nail psoriasis affects a large percentage of people with psoriasis, regardless of age or gender.

Prevalence in Psoriasis Patients

In a large study involving nearly 1,000 people with psoriasis, about 1 in 5 (19.7%) also had psoriatic arthritis. Having nail psoriasis was found to be a major risk factor (5).

Another study found that about 7 out of 10 (71.1%) people with psoriasis had nail problems (6).

Connection to Psoriatic Arthritis

Having nail psoriasis makes you more likely to develop psoriatic arthritis. About 6 out of 10 people (60%) with psoriatic arthritis have nail problems (7).

Fact
Nail psoriasis affects up to 90% of people with psoriasis at some point in their lives, making it one of the most common manifestations of the disease outside of skin involvement.

Symptoms and Appearance

Nail psoriasis can affect your nails in many different ways. Changes range from mild cosmetic issues to severe functional problems.

Common Nail Changes

The most frequent signs include pitting (small dents in the nail), onycholysis (separation of the nail from the nail bed), and discoloration. Pitting and onycholysis were identified as the most common lesions (3).

Advanced imaging studies reveal additional features. Nail psoriasis typically shows onycholysis, salmon patches, and splinter hemorrhages when examined with special magnification (8).

Nail Matrix vs. Nail Bed Involvement

Understanding which part of your nail is affected helps doctors choose the best treatment. The nail matrix is where the nail grows from. The nail bed is the skin under the nail.

Different treatments work better for different nail areas (9).

How Nail Psoriasis Is Diagnosed

Doctors typically diagnose nail psoriasis by examining your nails and looking for characteristic changes. Several scoring systems help measure severity and track treatment progress.

The NAPSI Score

The Nail Psoriasis Severity Index (NAPSI) is the most widely used tool for assessing nail psoriasis. This scoring system evaluates both nail matrix and nail bed features.

Studies have validated NAPSI as an effective measurement tool (10).

Topical Treatments

Topical medications applied directly to affected nails are often the first treatment approach. This is especially true for mild to moderate nail psoriasis.

Corticosteroid Preparations

Strong topical corticosteroids can help improve nail psoriasis when used consistently. Clobetasol nail lacquer at 8% concentration was effective and safe for treating nail psoriasis (11).

Patients using clobetasol propionate ointment experienced meaningful nail improvements over several months (12).

Vitamin D Analogs

Calcipotriol (a form of vitamin D) offers another topical option. Calcipotriol reduced nail thickness by about 49% after 5 months of treatment (13).

Combining calcipotriol with urea improved results. This combination had a mean improvement of 57.1% (14).

Other Topical Options

Several other topical treatments have shown promise. Tacrolimus ointment, typically used for eczema, can help nail psoriasis too.

Tacrolimus 0.1% ointment applied for 12 weeks showed significant improvement compared to untreated nails (15).

Tazarotene, a vitamin A derivative, reduced onycholysis (nail separation) in both covered and uncovered nails (16).

Warning
Topical treatments for nail psoriasis require patience and consistent use. Because nails grow slowly, it may take 3-6 months to see significant improvement. Don’t stop treatment early if you don’t see immediate results.

Systemic Treatments

When topical treatments don’t work well enough, pills that work throughout your body may help nail psoriasis.

Methotrexate

Methotrexate is one of the oldest systemic treatments for psoriasis. It can improve nail involvement, particularly nail matrix problems.

Methotrexate achieved a 43.3% improvement in nail scores (9).

Cyclosporine

Cyclosporine is particularly effective for nail bed problems. It reduced nail scores by 37.2% (9).

Topical cyclosporine has also been tested. Three out of 8 patients achieved complete resolution of nail lesions after 12 weeks (17).

Acitretin

Acitretin is an oral vitamin A derivative. It provided the longest duration of remission, averaging 9 weeks (18).

Biologic Treatments

Biologic medications target specific parts of the immune system. These injectable medications often provide dramatic improvements for nail psoriasis.

TNF Inhibitors

Tumor necrosis factor (TNF) inhibitors were among the first biologics used for psoriasis. Multiple TNF inhibitors have proven effective for nail disease.

Infliximab

After 24 weeks, 57.2% of people saw their nails improve with infliximab. By week 50, almost half (44.7%) had completely clear nails (3).

Adalimumab

Almost half (46.6%) of people saw major improvement in their nails after 26 weeks of adalimumab. After 52 weeks, 54.5% achieved at least 75% nail improvement (19, 20).

Etanercept

Etanercept significantly decreased nail scores by 4.3-4.4 points at week 24 (21).

Golimumab

Golimumab showed 33% improvement with 50 mg doses and 54% improvement with 100 mg doses (2).

Infliximab works fastest among TNF inhibitors, showing significant improvement by week 14. Adalimumab and etanercept took until week 24 for similar results (22).

IL-17 Inhibitors

Interleukin-17 (IL-17) inhibitors have shown exceptional results for nail psoriasis.

Ixekizumab

Over 50% of patients achieved complete nail clearance by week 60 with ixekizumab (10).

Ixekizumab had the highest probability (46.5%) of achieving complete nail clearance compared to other biologics (23).

Secukinumab

Patients achieved 45.3% nail improvement with secukinumab 300 mg at week 16. After 2.5 years, patients maintained 73.3% nail improvement (24, 25).

Brodalumab

Brodalumab ranks second only to ixekizumab for achieving complete nail clearance, with a 37.0% probability (23).

IL-23 Inhibitors

Medications targeting interleukin-23 offer another effective approach for nail psoriasis.

Guselkumab

Guselkumab shows about 27.7% probability of achieving complete nail clearance. After treatment withdrawal, nail improvements lasted longer than skin improvements (23, 26).

Risankizumab

Patients experienced mean improvements of over 81% in nail indices after 256 weeks of risankizumab treatment (27).

IL-12/23 Inhibitors

Ustekinumab

Ustekinumab achieved 46.5% nail improvement with the 45 mg dose and 48.7% with the 90 mg dose at week 24 (6).

Fact
Modern biologic treatments can achieve complete nail clearance in many patients. Studies show that up to 50% or more of patients on certain biologics achieve completely normal-appearing nails with continued treatment.

Other Treatment Approaches

Apart from medications, several other treatment methods can help improve nail psoriasis.

Intralesional Injections

Injecting medication directly into the nail area provides targeted treatment. Triamcinolone injections showed significant improvement compared to topical treatments, though benefits decreased after stopping (12).

Phototherapy

Light therapy can help nail psoriasis. Pulsed dye laser treatment significantly reduced nail severity scores after 6 months (28).

Superficial radiotherapy showed significant improvement compared to sham treatment. The treated nails demonstrated a significant fall in clinical rating scores at weeks 10 and 15 compared to baseline and sham-treated nails (29).

Combination Approaches

Combining treatments often provides better results. Fractional CO2 laser combined with tazarotene gel showed significantly better results than tazarotene alone (30).

Combining laser therapy with methotrexate gel also improved outcomes. Patients receiving combination treatment maintained better results 3 months after stopping therapy (31).

Comparing Treatment Effectiveness

Several large studies have compared different treatments to help doctors and patients make better treatment choices.

Network Meta-Analyses Results

Ixekizumab consistently ranks highest among biologics for achieving complete nail clearance (46.5%), followed by brodalumab (37.0%) and adalimumab (28.3%) (23).

Tofacitinib and ixekizumab showed the most significant effect sizes in treating nail psoriasis (32).

Speed of Response

How quickly treatments work matters for quality of life. Among TNF inhibitors, infliximab works fastest, showing significant improvement by week 14. Adalimumab and etanercept typically take until week 24 (22).

IL-17 inhibitors generally work faster than other biologics. Ixekizumab and secukinumab often show improvement within the first month of treatment.

Tip
When choosing a treatment, consider both effectiveness and speed of response. While some medications may ultimately achieve similar results, faster-acting treatments can provide quicker relief from symptoms that affect daily activities.

Special Considerations

Several factors should guide treatment selection for nail psoriasis beyond just effectiveness.

Treatment Duration and Maintenance

Nail psoriasis needs long-term treatment because nails grow slowly. Fingernails take 4-6 months to completely regrow. Toenails take up to 12 months.

Continuing treatment maintains improvements. Patients who continued secukinumab for 2.5 years maintained excellent nail improvements (25).

Safety Considerations

All treatments have possible side effects. Strong systemic treatments may have serious side effects (4).

Topical treatments generally have fewer side effects but may be less effective. Biologics require regular monitoring but often have favorable safety profiles with long-term use.

Cost and Access

Treatment costs vary dramatically. Topical treatments and traditional systemic medications like methotrexate are generally less expensive than biologics.

If you have moderate to severe psoriasis affecting both skin and nails, biologics may be covered by insurance. Consider discussing all options with your healthcare provider, including patient assistance programs.

Future Directions

Research continues to advance nail psoriasis treatment. New medications and approaches show promise.

Emerging Therapies

JAK inhibitors represent a new class of oral medications. Tofacitinib had one of the highest effect sizes for nail improvement among all treatments analyzed (33).

After 52 weeks, patients maintained significant improvements in nail psoriasis with tofacitinib (34).

Improved Assessment Methods

Better ways to measure nail psoriasis continue to develop. Dermoscopy provides more detailed assessment of nail changes (35).

Standardized outcome measures help compare treatments more effectively (36).

Living with Nail Psoriasis

While waiting for treatments to work, several strategies can help manage symptoms and improve appearance.

Nail Care Tips

Proper nail care helps minimize damage:

  • Keep nails short to reduce trauma and prevent lifting
  • File nails gently instead of cutting to avoid injury
  • Moisturize nails and cuticles regularly
  • Wear gloves during wet work to protect nails
  • Avoid picking or pushing back cuticles

Cosmetic Options

While treating the underlying condition, cosmetic approaches can help:

  • Nail polish can hide discoloration and minor surface irregularities
  • Artificial nails should be avoided as they can worsen nail lifting
  • Professional manicures are fine but inform technicians about your condition

Lifestyle Modifications

Keeping a healthy weight, managing stress, and eating an anti-inflammatory diet may help control the disease better. Some people find that certain vitamins and minerals or supplements help their psoriasis.

Disclaimer
Treatment decisions should always be made with your healthcare provider based on your specific situation. What works best varies between individuals, and some treatments may not be suitable for everyone due to other health conditions or medications.

When to See a Doctor

Seek medical attention for nail changes if you have psoriasis or suspect nail psoriasis. Early treatment can prevent permanent nail damage.

See a doctor if you experience:

  • New nail changes with known psoriasis
  • Nail changes without skin psoriasis (nail-only disease occurs)
  • Pain or functional impairment from nail problems
  • Signs of infection around nails
  • Nail changes affecting work or daily activities

Nail psoriasis can occur without skin involvement and may be an early sign of psoriatic arthritis. Early recognition and treatment are important for best outcomes.

Conclusion

Nail psoriasis is a common and challenging manifestation of psoriasis that significantly impacts quality of life. While treatment can be difficult, many effective options now exist. From topical treatments for mild disease to powerful biologics for severe involvement, most people can achieve significant improvement with proper treatment.

The key to successful management is patience. Nail improvements take months to become visible due to slow nail growth. Working closely with your healthcare provider to find the right treatment approach, whether exploring natural options or advanced biologics, can lead to clearer nails and improved quality of life.

With newer treatments showing the ability to achieve complete nail clearance in many patients, the outlook for nail psoriasis continues to improve. Don’t let embarrassment prevent you from seeking help. With the right approach, you can achieve healthier nails and better overall disease control.

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