The 8 million people with psoriasis in the United States also run the risk of developing psoriatic arthritis (PsA).
This chronic disease can cause pain, stiffness, and swelling in the joints and areas where tendons and ligaments connect to bone — as well as sometimes painful nail symptoms for about 80 percent of folks who live with PsA.
The nail effects of psoriatic arthritis
Here are some nail symptoms associated with PsA:
- pitting or teeny holes
- discolored red, pink, or orange patches
- white spots
- brittle, broken nails
- separation from the nail bed
- buildup of skin cells under the nail
- blood spots under the nails
- bacterial and fungal infections
Why does PsA cause nail symptoms?
Docs don’t fully understand why some people with PsA have nail symptoms and others don’t, or why some develop skin psoriasis symptoms before signs of PsA or vice versa. But research is ongoing.
In fact, skin symptoms show up before joint inflammation in 75–80 percent of people with PsA — sometimes as early as 10 years before! Still, psoriasis and PsA, like some other autoimmune conditions, remain as mysterious as Bigfoot.
Can you treat PsA?
Yep! Options include:
- topical creams
- steroid injections
- disease-modifying antirheumatic drugs (DMARDs)
- biologic therapy
You can also manage the symptoms at home in the following ways:
- gentle exercise, like yoga and swimming
- a balanced diet
- over-the-counter (OTC) pain relief
PsA affects around 30 percent of people with psoriasis, an autoimmune, inflammatory skin condition that causes your body to be a little too enthusiastic about skin cell production. As a result, the skin cells build up, forming itchy, sore, discolored patches of skin that docs call plaques.
Here’s a PSA on the nail symptoms of PsA and what to do when you notice them.
There isn’t a one-size-fits-all answer to this. If you’re living with PsA, you may see a variety of changes in your nails, depending on where the inflammation is. PsA is different for everyone. In the initial stages, you may notice only fatigue and joint pain, and your doctor might not yet diagnose PsA.
- Pitting. Pitting is the most common PSA nail symptom, popping up for around 68 percent of folks with PsA. As the name suggests, it causes the nail surface to look uneven, bumpy, and pitted, or indented.
- Discolored patches. Red, pink, or otherwise discolored patches can develop under the nails. Some folks call them oil drops because the nail appears to have yellow or golden-brown oil trapped underneath.
- White patches. These can be a sign of psoriatic changes to the nail matrix (the area from which your nails grow).
- Brittle nails. Docs call this onychorrhexis. It causes your nails to crumble and break easily, and they may split along their length.
- Separation. Also called onycholysis, this means that the nail lifts away or separates from the nail bed. The nail then turns yellow or white. Because of the gap, your nail becomes more prone to infection.
- Hyperkeratosis. Your skin cells build up under the nail.
- Splinter hemorrhages. If damage occurs in the capillaries under the nail, you may notice tiny blood spots that spread. They can also lead to split nails.
- Infections. If your nails are damaged and brittle, bacteria and fungi love to jump in and cause infections. You may notice inflammation and skin changes around the nail bed or in the nail itself.
If you live with PsA, nail changes are pretty darn common, affecting around 8 in 10 people with the condition, compared to just 4 in 10 of those with psoriasis. Nail changes may be your first clue that PsA is developing.
Any part of your nail structure or the surrounding area can change as a result of PsA. The nail unit is made up of the matrix, plate, bed, and folds. The matrix is the part responsible for nail growth, and if psoriasis inflammation affects this area, it can cause ridges, lines, dots, and separation.
If PsA affects the nail bed, you may see nail detachment, oil drop patches, splinter hemorrhages, and cells building up.
The relationship between nail psoriasis and the inflammatory joint changes of PsA is complex. But docs recognize the physical connection between the nail matrix and the end of the last finger bone and joint. They’re linked in a not-at-all-catchily-named system called the joint-entheseal-nail apparatus.
The enthesis is the point at which a ligament or tendon meets the bone. All the daily stuff you use each finger for (eww, not that, gross) applies force to its nearest enthesis, which might allow PsA lesions to develop in those joints. And because that enthesis is linked to the nail… yep, you guessed it. Nail symptoms occur.
In a 2015 study of 180 people with PsA, the researchers found that a higher number of swollen joints had links to nail changes — especially in people who had swollen joints on the same finger as the nail.
PsA affects the last finger joint more than most others in your bod. This *might* explain why there’s a much higher incidence of nail changes in folks with PsA than in those with just plain ol’ psoriasis.
Psoriatic arthritis nail ridges
Folks living with PsA may develop psoriatic lesions directly on the nail matrix, leading to ridges in the nails that run up and down vertically. They look like delicate little railway tracks running from your cuticle and on into oblivion.
These ridges may be prone to splitting at the ends, leaving your nails at risk of infections.
You can also develop transverse grooves and ridges called Beau’s lines. These rather romantic-sounding symptoms typically occur on every finger and toenail and can eventually lead to the nail crumbling. So, not romantic at all, then.
Because there’s no cure for psoriasis or PsA, treatment aims to ease your symptoms, reduce nail damage, and prevent progression. There are medications to treat generalized PsA and to target its nail symptoms specifically.
A healthcare pro might advise these options for PsA’s nail symptoms.
Creams contain various active ingredients. Some may slow down cell turnover and reduce hyperkeratosis, while others, such as steroids, reduce inflammation.
Other valuable ingredients include:
- vitamin D-like compounds to reduce the thickness and scaliness of psoriasis plaques
- salicylic acid to remove a buildup of skin cells
- antifungals to get rid of fungal nail infections
- antibiotics to banish bacterial infections
Sometimes a doctor will recommend cortisone injections that target one joint. Although these are not usually the first line of treatment, injections may relieve inflammation in specific joints.
But the wearing off of steroid injections *can* trigger psoriasis flare-ups and cause issues with nail weakness. These injections are usually a fail-safe for instances when other psoriasis treatments don’t work.
Phototherapy involves using UV light to slow down skin cell growth, which may ease some nail symptoms. (Nope, not taking photos for Insta to make you feel better. Disappointing, we know.)
You may need to visit the clinic to have your nails zapped, or you might be able to get your hands on some equipment for home use.
If these options aren’t working for you, then your doctor may recommend generalized PsA drugs to reduce the severity and frequency of flare-ups.
Disease-modifying antirheumatic drugs (DMARDs)
DMARDS like methotrexate (Trexall) act as anti-inflammatories and immunomodulators, meaning that they help limit the permanent damage PsA can cause.
You may need to take oral tablets or receive weekly injections.
Biologics are newer, potent medications that target particular parts of the immune system. Because they are highly specific in how and where they work, there’s a lower risk of the adverse effects to the liver, kidneys, and other organs that might happen with other strong psoriasis medications.
Doctors may recommend biologics if you haven’t seen results with other treatments.
Although prescription medication is likely the most effective option, some home and natural remedies may help ease your symptoms, including:
- Over-the-counter (OTC) pain relievers. If your nails are feeling sore and inflamed, then taking meds like ibuprofen (Advil) and naproxen (Aleve) could help, and OTC topical forms (like Voltaren gel) are now available. Additionally, OTC creams or soaps containing salicylic acid, tar, or both may help limit infections. But talk with your doctor before adding anything new to your treatment regimen.
- Exercise. Gentle, low impact exercise like yoga or swimming may help manage PsA. Plus, you’ve probably heard by now that exercise improves your overall well-being, so what’s to lose?
- Diet. Because psoriatic inflammation may increase your risk of health issues like heart disease and high blood pressure, following a balanced diet is a good idea. It could also reduce the inflammation affecting your nails.
- Keep your nails short. You’re less likely to damage or injure your nails if they’re short. Psoriasis flares can occur at new sites of even mild injury — a process called the Koebner phenomenon. Short nails are also less likely to develop a buildup of cells underneath them or to lift away from the nail bed.
- Wear gloves. Doing housework, gardening, or DIY? Reach for the gloves to minimize PsA-triggering irritation. If you’re washing the dishes, car, or dog, wear cotton gloves under the waterproof gloves. This will both protect your nails and keep them dry, making infections less likely.
- Avoid the nail salon. Although it’s tempting to cover affected nails with acrylics or other artificial nails, it’s not a good idea. The grinding and harsh chemicals in these processes damages the nails.You can use nail polish or hardener to conceal and protect your nails if you like — but check with a healthcare pro first.
- Try to avoid biting your nails. The same applies to cutting and pushing back your cuticles. This can damage your skin and cause infections.
- Resist cleaning under your nails. It may feel impossible to ignore the buildup under your nails, but removing it can loosen the nails and increase your infection risk. Instead, soak your nails in warm, soapy water to remove any junk.
- Choose unscented, natural products. Avoiding some chemicals in cosmetic products may help you sidestep any nasty PsA reactions.
When to see a doctor
If you notice anything suspicious going on with your nails, it’s probably time to chat with a healthcare pro, because nail psoriasis could be an early symptom of PsA. Either way, you may need treatment if something like a fungal infection has developed.
Likewise, if you’re living with PsA and you develop new nail symptoms, it’s time for a checkup. You may need to change up your treatment dose or ask about other options.
Keep in mind that your nails grow slowly, so any medications you’re using may take time to show their positive effects. Be a patient patient and remember to keep your doc updated with any changes.
Finding the right treatment to ease your symptoms may involve a hefty dose of trial and error. But working with your doctor gives you the best chance of getting the results you want.
PsA is a form of inflammatory arthritis that can cause a whole bunch of nasty nail symptoms like pitting, separation, discoloration, and flakiness. Up to 80 percent of people with PsA develop nail problems.
Although there’s no cure for PsA, you can work with your doctor to find a suitable treatment plan. Treatments such as corticosteroid injections, phototherapy, DMARDs, biologics, and various creams can help you reduce nail flare-ups and manage PsA.