Nail Psoriasis

Nail Psoriasis

 Psoriasis can affect the nails in up to 50 percent of patients, and this number can be higher if psoriatic arthritis is present. Some people might have only nail psoriasis with no apparent skin changes on the rest of the body. Psoriasis of the fingernails is more common than psoriasis of the toenails. Several changes can occur in the nail with psoriasis.

 

Pitting: The most common finding in nail psoriasis is pitting. Pits are shallow depressions or dents, less than 1 mm in diameter, and look like pin holes. They can affect all nails, some or none.

 

Thickening or lifting of nail plate: The affected nail might thicken or lift away from the skin attached to the nail. When the nail lifts away from the nail bed it is called onycholysis. It usually begins at the edge or at the end of the nail and may continue backward under the nail until it is completely loosened from the nail bed.

 

Color change: The nail can develop a yellow-brown discoloration that might involve the entire nail. The discoloration can also occur in only one or a few localized areas in a spotlike manner and resemble an oil droplet.

 

Other changes: Other changes in nail psoriasis include depressions in the nail, roughness and grooving of the nail. If severe, patients may lose their nails, making it difficult to grasp objects! Bacterial and fungal infections may also develop in a nail already affected with psoriasis.

 

Fungal infections of the nails: A fungal infection of the nails (which may occur along with nail psoriasis) can also cause thickening of the nails. It is not uncommon for nail psoriasis to be misdiagnosed as a fungal infection. Fungal infections should be treated, if possible, because they can worsen psoriasis.

 

In order to make a proper diagnosis, a doctor takes nail clippings and a fungal culture. Once an infection is confirmed, treatment is most effective with oral antifungals. Topical treatment of nail fungus is usually ineffective, although new nail lacquers may be effective in certain patients.

 

Nail psoriasis is difficult to treat; both patients and dermatologists are often disappointed with the results. Treatment can take prolonged periods before improvement is seen. Topical treatments are generally ineffective in treating nail disease. Systemic treatments (oral or injectable medications) can improve nail psoriasis. Methotrexate and cyclosporine can be particularly effective, but it is important to compare the risks of therapy with the benefits of treatment. If only the nails are affected, systemic medications are rarely used because the risks of therapy usually outweigh the benefits. If extensive areas of the body are affected, systemic therapy may be a reasonable option. Also, intralesional injections of corticosteriods can be effective, but because it is painful, few patients tolerate this treatment.

 

If you receive an oral or injectable medication and the psoriasis elsewhere on the body shows improvement, the nail psoriasis may also improve. Scarring or permanent nail loss does not occur in nail psoriasis even in the most severe cases, but it can take 6 to 12 months for a fingernail, and 12 to 18 months for a toenail to be replaced.

How to Treat Scalp Psoriasis

Scalp Psoriasis

 The scalp is one of the most common and persistent areas affected by psoriasis (occurring in about 50 percent of all patients) and can be one of the most difficult places to treat. The scales on the scalp can be thick and silvery-white, and can stick together tightly to form dense crusts that can be very itchy. Picking at the scales and scratching the scalp can worsen the psoriasis.

 Scalp psoriasis can be localized, involving only a few discrete areas or can affect the entire scalp. The lesions often appear behind the ears and along the hairline, but can spread beyond the hairline. If the ear canal is affected and accumulates enough scales, hearing may be impaired. Hair loss is uncommon because psoriasis does not affect the hair root, but in severe cases hair loss can occur. Hair usually regrows once the psoriasis is controlled.

 Mild outbreaks of scalp psoriasis that remain hidden by the hair might not be noticed by an observer; however, severe forms can be extremely itchy and highly visible. Silvery-white scales (resembling dandruff) flake onto shoulders and collar, which can be embarrassing and emotionally stressful for the patient. Successful treatment is important to minimize the emotional stresses and physical discomforts.

 Treatment of scalp psoriasis is challenging, but there are many therapies that can help. Sometimes, the best treatments are arrived at by trial and error, so it is important to be patient when treating and awaiting results. The following are some common forms of treatment.

 Shampoos: Shampoos that contain active ingredients such as tar, salicylic acid, zinc pyrithione or selenium sulfide can be very helpful in reducing the scaling and thickness of scalp psoriasis. Recently, shampoos that contain steroids have been developed and can be quite helpful for patients.

 Topical steroids: Steroid-containing scalp preparations can be very effective at reducing redness (inflammation) in psoriasis of the scalp. Steroids are usually prescribed either as a lotion, solution or foam for hair-bearing areas (creams and ointments are difficult to apply to the hair-bearing scalp, often causing the hair to become matted). Alcohol-based lotions can cause stinging, so a water-based lotion can be substituted (amcinonide).

 Salicylic acid: Salicylic acid (keratolytic) is an ingredient found in certain over-the-counter shampoos. It is helpful in removing excessive scale, which in turn allows for the penetration of other medications (such as steroids) into the site of inflammation. Salicylic acid can be mixed in low concentrations in mineral oil or provided in combination with a topical steroid (betamethasone dipropionate/salicylic acid) or combined with tar in a shampoo.

 Topical vitamin D analogues (calcipotriol): Topical calcipotriol scalp solution can be used alone or in combination with other topical treatments.

 Anthralin: Anthralin can reduce the turnover of skin cells that cause the excessive buildup of scale, and reduce inflammation. As a result, it can be highly effective in treating scalp psoriasis. However, Anthralin can be messy and cause staining of the skin, blonde or gray hair, and clothing.

 Anthralin can be applied directly to the skin for short periods (Short Contact Anthralin Therapy or SCAT) of 15 to 30 minutes. It should then be washed off to prevent irritation. Lower strengths of anthralin can be used and left on the skin for longer periods.

 If your skin is tender and sore from psoriasis, anthralin might not be the best choice as it can cause irritation of the scalp.

Plaque Psoriasis

Plaque Type Psoriasis

 The most common form of psoriasis is known as plaque-type psoriasis (or psoriasis vulgaris). As previously explained, the term “plaque” is used to describe a raised area of skin that is greater than 1 cm in diameter. By definition, many of the areas affected are greater than 1.0 cm in diameter, although smaller areas of raised skin less than 1.0 cm (papules) might be present. Smaller papules may join to form a larger plaque. The affected area is usually raised, red and scaling. The lesions are usually well defined, meaning that the border between involved skin and uninvolved skin is remarkably sharp. The lesions of psoriasis are normally round to oval in shape. Scales can appear as silvery-white and powdery, and in some cases can be quite thick, even resembling an oyster shell (ostraceous). Scales can flake or peel off in thin transparent sheets. Plaque-type psoriasis occurs in 80 to 90 percent of all cases and tends to persist for long periods of time. It affects mostly the elbows, knees, scalp and lower back. It can, however, involve any part of the body.

 The condition commonly appears in a symmetrical pattern (e.g., if the right elbow is affected the left elbow might also be affected) and can also involve the scalp. When the scalp is affected, it can be intensely itchy. Scalp psoriasis can be one of the most frustrating and difficult areas to treat.

 Plaque-type psoriasis can affect the genitals. Men are more likely to be affected in this location than women. Genital lesions can cause embarrassment during sexual relations, especially if the penis is affected. Affected areas of skin can become redder and more noticeable after intercourse. It is important that affected people are aware that lesions are not contagious, to reassure themselves and advise sexual partners.

 Many times, patients are too embarrassed to tell their doctors that genital areas are affected. However, it is important to tell your doctor as there are treatments to help control psoriasis in these locations. Topical corticosteroids are usually effective in treating genital psoriasis. However, thinning of the skin (atrophy) and stretch marks (striae) can occur when potent steroids are applied for prolonged periods to such sensitive areas. In general, lower potency topical steroids are used in areas where the skin is thin. Higher potency topical steroids generally should be avoided on the genitals.

 Newer, non-steroidal treatments known as calcineurin inhibitors or topical immunomodulators are being investigated for use in psoriasis. Calcineurin inhibitors offer the advantage of being steroid free, with no risk of stretch marks or thinning of the skin. Applying anthralin or coal tar products to genital lesions is not recommended as they can cause irritation.

 The palms of the hands and soles of the feet can also be affected, although less frequently in plaque-type psoriasis. The lesions can be commonly noted on the pressure-bearing areas of the hands and feet.