Psoriatic onychia is a rare form of psoriasis that affects the natural appearance of the nails, causing changes in the matrix, bed, and nail plate. It is a non-contagious autoimmune condition that appears more often in the nails of the hands than the feet, with characteristic alterations in one or more nails. It is often associated with psoriatic arthritis and primarily affects individuals with a personal or family history of psoriasis, negatively impacting their quality of life.
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Symptoms
Psoriatic onychia causes a range of characteristic symptoms:
Discoloration: Yellow or brown spots beneath the nail surface, known as “oil drop” spots.
Pitting: Small holes or depressions on the nail surface.
Transverse lines: Black or red streaks (splinter hemorrhages).
Leukonychia: White marks or opaque coloration on the nail plate.
Subungual hyperkeratosis: Thickening of the skin under the nail, which may lead to nail detachment or loss.
Onycholysis: Separation of the nail from its bed.
Brittle nails: Weakness and tendency to break easily.
Redness: Congestion of capillaries at the base of the nail.
Finger arthritis: Often accompanies nail changes, affecting up to 86% of patients with psoriatic arthritis.
Causes
Psoriatic onychia is caused by a combination of immunological, genetic, and environmental factors. It is a chronic inflammatory condition that is often triggered or worsened by psychological stress, certain medications, or infections.
Diagnosis
Diagnosing psoriatic onychia is often complicated as symptoms resemble those of other nail diseases. The difficulty increases in cases of onycholysis without the presence of characteristic yellowish spots that aid recognition. In isolated onycholysis cases without accompanying psoriasis signs, dermoscopy of the nail bed is the most effective method for accurate diagnosis. Differential diagnosis is critical to avoid confusion with other conditions. Detailed investigation includes microscopic examination and cultures, as nails affected by psoriasis are prone to fungal and bacterial infections.
Treatment
Treatment depends on the severity of the condition and its impact on the patient’s quality of life.
Topical Treatment:
Includes corticosteroids, vitamin D derivatives, and tazarotene. Effective in mild cases but requires long-term compliance.
Intralesional Therapy
Injection of low-dose corticosteroids directly into the lesion, used for cases resistant to topical treatment.
Laser and Phototherapy
Use of Excimer Light, Pulsed Dye Laser (PDL), and ND-YAG Laser offers immediate and safe results, especially in difficult cases. Laser therapy, such as Excimer Light and PDL, is considered the safest and most effective method, surpassing conventional pharmaceutical treatments.
Systemic Therapy
Applied in severe cases or when psoriatic arthritis or extensive plaque psoriasis coexist. Medications such as methotrexate, cyclosporine, and new biologic agents with high efficacy and safety are administered. Low-dose acitretin has also shown good results.
