What should a nail technician know about nail psoriasis?

There are many types of psoriasis, including those that affect the nails.Society is falling ill, and new forms of disease—often incurable—are constantly emerging..Psoriasis is one such disease.Do you know how to recognize psoriasis on your nails??What will you do if you recognize this in one of your clients??The following material will help you gain a better understanding of this topic.

One of the inflammatory skin conditions characterized by involvement of the nail plates is psoriasis.Changes in the nails are usually accompanied by changes in the skin.Sometimes, however, inflammation of the nail apparatus of varying severity can precede the development of skin lesions by as many as several decades.Although less common, changes limited exclusively to the nail plates are also observed during the course of the disease, particularly in cases where the disease affects the distal joints of the hands and feet.

Disorders Associated with Psoriasis

We identify three types of nail disorders associated with psoriasis: thimble nails, onycholysis, and nail plate dystrophy.

Thimble-making

The most commonly observed disorder is digitization.Parakeratosis—a symptom characteristic of psoriatic skin lesions—is considered the cause of this phenomenon.Parakeratosis is characterized by the presence of immature, nucleated cells in the stratum corneum (in healthy skin without parakeratosis, the stratum corneum contains only keratinized, anucleate cells).Similarly, the presence of non-keratinized cells within the nail plates reduces their resistance, which in turn leads to flaking and the formation of tiny indentations—dimples—in the plate.Depending on its severity, this process produces a pattern on the plaque consisting of numerous small pits that are either scattered irregularly or clustered together (a “seamstress’s thimble” pattern).The changes may be symmetrical.It is also possible to use the process to secure a ring.Sometimes this disorder may be the only symptom of the disease.It is also worth noting that pitting is not unique to psoriasis.It also occurs in cases of alopecia areata, and sometimes in healthy individuals.

Onycholysis

Another commonly observed phenomenon in the course of psoriasis is onycholysis, or the separation of the nail plate from the nail bed.This disorder is most likely associated with involvement of the nail apparatus and usually progresses from the free edge of the nail.Beneath the plate, in its distal portion, horn-like material accumulates.If onycholysis does not involve the free edge of the nail plate, it takes the form of seemingly oily, yellowish-brown patches known as “oil spots.”.In addition, a characteristic yellow stripe is very often observed between the white, flaking plate and the pink nail affected by psoriasis.So, just as in the case of bullying—they are symmetrical, and their severity varies from person to person.Due to the Köbner phenomenon observed in psoriasis (which is not unique to psoriasis, as it is also present in m.in.in lichen planus, but very commonly observed during the active phase of the dermatosis), that is, the appearance of lesions characteristic of the disease following exposure to an irritant; the severity of nail lesions in psoriasis also depends on m.in.depending on one's profession, hobbies, or leisure activities, such as gardening (repotting plants with one's hands—including while wearing gloves, etc.).) causes irritation and exacerbates both onycholysis and nail dystrophy.Just as with manicures and pedicures, which—even when performed very gently—can lead to the complete destruction of the nail plate.It is therefore not advisable to apply gel or acrylic to even out the nail plate, as the pre-application procedure is irritating enough to damage the nail plate by exacerbating psoriasis symptoms.

Nail Plate Dystrophy

The most advanced form of nail disorders associated with psoriasis is dystrophic nails.The lesions usually affect all of the tiles, although the severity of the lesions may vary from person to person.This is related to the extent to which the disease process has affected the proximal part of the nail matrix (the area around the posterior nail fold and lunula)..The enamel becomes thickened, discolored, loses its luster, and gradually crumbles.

Nail psoriasis with onychomycosis

Very severe nail deformity associated with one form of psoriasis—Hallopeau's acrodermatitis continua.This form of the disease is characterized by involvement of the distal segments of the extremities, mainly the fingers, with the presence of sterile pustules (containing pus but no bacteria, and therefore non-contagious) and nail plate detachment.Dystrophic psoriatic nails resemble nails affected by a fungal infection in their morphology; therefore, mycological testing is necessary in every case for differential diagnosis.It is worth noting that psoriatic lesions on the nail plates constitute a significant risk factor for fungal infection, and the coexistence of psoriatic nail disease with onychomycosis (a fungal infection) is quite common (10–50% of patients with psoriasis).Differentiating psoriatic nail dystrophy from other conditions that lead to nail destruction is greatly facilitated by the presence of accompanying psoriatic skin lesions and/or a positive family history of the disease.
Nail psoriasis cannot be cured, only managed, and as a result, many patients find it difficult to accept.In every case, a concurrent fungal infection must be ruled out, and if one is detected, appropriate treatment must be initiated.The presence of a fungal infection is also a factor contributing to the worsening of psoriatic lesions, as it acts as an irritant—in accordance with the Köbner phenomenon described earlier.

Treatment Options

In the treatment of psoriatic nail lesions, topical glucocorticosteroid ointments from the strongest class are routinely used (which have not only anti-inflammatory but also antimitotic effects, thus inhibiting cell division), less commonly, vitamin A derivatives (retinoids), with varying degrees of effectiveness.There is also a method of injecting glucocorticosteroids into the nail matrix, which allows the nails to grow back normally.The greatest improvement in nail condition is observed in patients receiving systemic treatment for significantly severe skin lesions.Given the toxicity of systemic medications (oral, intravenous, or subcutaneous) used to treat psoriasis, it appears that lesions confined solely to the nail plates are not a sufficient indication for their widespread use.

Remember that you can't catch psoriasis, but you can catch a fungal infection if you work without protective gear, such as disposable gloves or a face mask..

The material was taken from the book *Dermatology for Nail Technicians*.
The article was written by Lek.med.Agata Maciejewska-Radomska and Dr. n.med.Małgorzata Sokołowska-Wojdyło.

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