Understanding Psoriatic Arthritis and Nail Health: A Comprehensive Guide

Psoriatic arthritis (PsA) is a chronic autoimmune disease of the skin and joints. It is a type of inflammatory arthritis that occurs in some people who have psoriasis, a skin condition characterised by red, scaly patches. PsA can result in joint pain, swelling, stiffness, and nail changes. Psoriatic arthritis often affects nails, which can range from mild to severe.  Understanding the link between PsA and nail health is critical for effectively managing the condition. This blog is a comprehensive guide that will explain the link between PsA and nail changes, as well as strategies for nail health and symptom management.

Managing nail health in psoriatic arthritis (PsA) entails understanding the relationship between the two conditions and implementing targeted interventions. PsA is a chronic autoimmune disorder that causes joint inflammation and psoriasis, and it can have a variety of effects on the nails. Understanding nail changes, early detection, comprehensive assessment, treatment approaches, nail care practices, lifestyle modifications, regular follow-up, and patient education and support are some insights and interventions for managing nail health in PsA. Healthcare providers can effectively navigate nail health in PsA patients and improve their overall quality of life by implementing a comprehensive approach that combines medical interventions, nail care practices, lifestyle changes, and ongoing support.

Psoriatic Arthritis and Its Impact on Nails

Psoriatic arthritis (PsA) can have a serious impact on nail health, often resulting in nail psoriasis. Let us take a closer look at how PsA affects nails.

• Nail psoriasis is a common symptom of PsA, affecting up to 80% of people who have the disease.  It can cause a variety of nail changes, including pitting, nail plate thinning, onycholysis, discoloration, nail thickening, subungual hyperkeratosis, and nail fissuring.

• Nail psoriasis in PsA can cause pain, discomfort, and functional limitations.  Severe nail involvement may make it difficult to perform daily activities like gripping objects and buttoning clothes.

• The visible changes in the nails can have a significant psychological impact on people with PsA, causing embarrassment, self-consciousness, and a lower quality of life.  Nail psoriasis can also impair social interactions and relationships.

• Nail changes can sometimes occur before the onset of joint symptoms in PsA, providing an early diagnostic clue.  Healthcare providers should carefully examine the nails of patients with suspected PsA for signs of nail psoriasis.

• The severity of nail involvement in PsA has been linked to a poor prognosis, including more extensive joint damage and disability.  As a result, monitoring nail health is critical for determining disease severity and directing treatment decisions.

• Nail psoriasis in PsA can be difficult to treat because the nail unit is relatively inaccessible to topical therapies.  Systemic medications, such as traditional DMARDs (disease-modifying antirheumatic drugs) and biologics, are frequently used to treat nail psoriasis. 

• To manage nail psoriasis in PsA, dermatologists, rheumatologists, and other healthcare providers must work together.  Treatment plans should address both joint and nail symptoms to achieve complete disease control.

Identifying the Signs: Common Nail Changes in Psoriatic Arthritis

Identifying common nail changes associated with psoriatic arthritis (PsA) is critical for its early detection and treatment. Here are the common nail changes seen in PsA:

1. Pitting: One of the distinguishing features of nail psoriasis in PsA is the presence of tiny, shallow pits or dents on the nail surface.  These pits can vary in size and number and are commonly found in multiple nails.

2. Nail Plate Thinning: Nail psoriasis can cause thinning of the nail plate, making it more fragile and susceptible to breakage.  The nails may appear brittle and grow less thick or strong than healthy nails.

3. Onycholysis: The splitting of the nail plate from the nail bed is referred to as onycholysis.  This may cause the nail's damaged portion to lift, exposing a white or yellowish patch beneath. One or more nails may experience onycholysis, a common sign of nail psoriasis.

4. Discoloration: Under the nail plate, there may be tiny oil spots known as "salmon patches" or a yellowing or brownish discoloration due to nail psoriasis.  The entire nail may be discoloured, or just a small area may be affected.

5. Thinning of the Nails: Psoriatic arthritis can cause hypertrophy, or thickening of the nails over normal.  This may cause the nails to appear irregular and bulbous, especially at the tips.

6. Subungual hyperkeratosis: The accumulation of keratin fragments beneath the nail plate is known as subungual hyperkeratosis.  This may result in pain or discomfort, particularly when pressure is applied, as the nail may lift or become deformed.

7. Fissures in the nails: Psoriatic nail involvement can appear as vertical or horizontal lines or fissures in the nails.  The nail may split or weaken as a result of these fissures, which may run the full width or length of the nail plate.

8. Nail Clubbing: Nail clubbing is a condition where the nails curve around the fingertips and the tips of the fingers enlarge. It can happen in some severe PsA cases.  However, this is less common and usually associated with more advanced diseases.

The Science of Psoriatic Nail Damage: What Happens Underneath

Psoriatic nail damage in psoriatic arthritis (PsA) is characterised by complex pathological processes that occur beneath the nail plate and within the nail unit. Understanding the science of psoriatic nail damage provides insight into the mechanisms that cause these changes. Here's what happens under the nail in PsA:

• Immune Dysregulation: The primary cause of psoriatic nail damage is immune dysregulation, which is defined as abnormal immune system activation.  In PsA, immune cells, specifically T-cells, infiltrate the nail matrix and surrounding tissues, causing inflammation and tissue damage.

• Nail Matrix Involvement: The nail matrix, which is located beneath the cuticle at the base of the nail, is responsible for producing the cells that make up the nail plate.  In PsA, inflammation in the nail matrix disrupts normal nail cell production, causing changes in nail growth and morphology.

• Keratinocyte Proliferation: Psoriatic nail damage is linked to increased keratinocyte proliferation, which is the predominant cell type in the epidermis (outer layer of the skin) and nail plate.  This hyperproliferation results in the formation of thickened, disorganized nail plates, characteristic of nail psoriasis.

• Vascular Changes: Inflammatory processes in PsA can affect the blood vessels that supply the nail unit, causing dilation and increased permeability.  These vascular changes contribute to the appearance of distinct nail findings such as oil spots and splinter haemorrhages.

• Dermal Remodelling: Chronic inflammation in PsA causes remodelling of the dermal tissue beneath the nail unit.  Fibroblasts and other cells involved in tissue repair and remodelling are activated, resulting in collagen deposition, fibrosis, and structural changes to the nail bed. 

• Nail Bed Involvement: PsA can affect both the nail matrix and the nail bed—the tissue beneath the nail plate.  Inflammation and vascular changes in the nail bed contribute to onycholysis (separation of the nail plate from the nail bed) and subungual hyperkeratosis.

• Interplay with Joint Involvement: Psoriatic nail damage frequently coexists with joint involvement in PsA, implying common pathogenic mechanisms.  Both nail and joint manifestations of PsA are caused by inflammatory cytokines and immune-mediated processes, emphasising the disease's systemic origin.

Differentiating Between Nail Psoriasis and Fungal Infections

Differentiating between nail psoriasis and fungal infections is critical for proper diagnosis and treatment. Here are some key differences to help you distinguish between the two conditions:

1. Clinical Presentation:

• Nail Psoriasis: Nail psoriasis is distinguished by characteristic nail changes such as pitting, onycholysis (separation of the nail plate from the nail bed), nail plate thickening, discoloration (yellowing or brownish), nail bed hyperkeratosis (thickening), and crumbling.  These changes frequently affect multiple nails and may be accompanied by skin psoriasis or other symptoms of psoriatic arthritis.

• Fungal nail infections: Nail plate discoloration (yellow, white, or brown), thickening, brittle or crumbly texture, hyperkeratosis of the nail bed, and occasionally an unpleasant stench are all common symptoms of fungus-related nail infections, such as onychomycosis.  Fungal infections can affect one or more nails and spread to adjacent nails if not treated.

2. Distribution:

• Nail Psoriasis: Nail psoriasis typically affects multiple nails at the same time, including fingernails and toenails.  The severity of nail involvement varies, but it typically follows a symmetrical pattern, affecting the same nails on both hands or feet.

• Fungal Nail Infections: Fungal nail infections can affect one or more nails, but they may begin in one nail and spread to other nails over time.  The distribution may be asymmetrical, and the severity varies according to the degree of fungal colonisation.

3. Associated Symptoms:

• Nail Psoriasis: Nail psoriasis is frequently associated with skin psoriasis, psoriatic arthritis joint symptoms, or a psoriatic disease family history.  Patients may feel nail pain, tenderness, or discomfort, especially if onycholysis or inflammation is present.

• Fungi Infections: Fungal nail infections can cause discomfort, itching, or mild pain in the nails as they spread, though they may not show any symptoms at first.  Fungal infections can cause functional impairment and nail deformity in severe cases.

4. Risk Factors:

• Nail Psoriasis: Although nail involvement can sometimes occur without cutaneous symptoms, risk factors for nail psoriasis include a personal or family history of psoriasis or psoriatic arthritis.  A few other risk factors could be obesity, smoking, and certain medications.

• Fungal Infections: A history of athlete's foot (tinea pedis), prior fungal infections, trauma to the nails, inadequate nail hygiene, diabetes, immunodeficiency, peripheral vascular disease, and extended exposure to moist environments are risk factors for fungal nail infections.

5. Diagnostic Tests:

• Nail Psoriasis: A complete medical history and a clinical examination are the main methods used to diagnose nail psoriasis.  In atypical cases, a nail biopsy and dermoscopy may be used to confirm the diagnosis.

• Fungal Infections: Diagnosis of fungal nail infections typically involves microscopic examination and culture of nail clippings or a nail plate biopsy to identify fungal elements. Dermoscopy may also aid in the diagnosis by revealing characteristic findings such as subungual debris and longitudinal striations.

6. Response to Treatment:

• Nail Psoriasis: Nail psoriasis may respond to treatments that target the underlying inflammatory process, such as topical or systemic corticosteroids, vitamin D analogues, calcineurin inhibitors, systemic medications (e.g., methotrexate and biologics), and phototherapy.

• Fungal Infections: Antifungal therapy is usually required for fungal nail infections, which can be topical (e.g., ciclopirox, amorolfine) or oral (e.g., terbinafine, itraconazole). Treatment may need to last several months to achieve complete resolution.

Strategies for Managing Psoriatic Arthritis in Nails

Managing psoriatic arthritis (PsA) in the nails requires a multifaceted approach that addresses both the joint and nail manifestations of the disease. Early diagnosis and assessment, a multidisciplinary care team, treatment tailored to disease severity, topical therapies, systemic medications, combination therapy, patient education and self-management, and regular monitoring and follow-up are all effective strategies for managing PsA in the nails. Healthcare providers can effectively manage PsA in the nails and improve patient outcomes by using a tailored treatment approach that includes topical therapies, systemic medications, patient education, and regular monitoring.

Topical Treatments: A First Line of Defense for Psoriatic Nails

Topical treatments are an important first line of defence for managing psoriatic nails, especially in cases of mild to moderate involvement. These treatments seek to reduce inflammation, normalise keratinocyte proliferation, and improve the appearance and function of the nails. Here are some popular topical treatments for psoriatic nails:

• Corticosteroids: Topical corticosteroids are frequently prescribed as a first-line treatment for nail psoriasis. They work by reducing inflammation and inhibiting immune responses in the affected area. Corticosteroid formulations vary in potency, and the appropriate formulation is determined by the severity and location of nail involvement. Low-to-medium potency corticosteroids are commonly used to treat nail psoriasis because they reduce the risk of skin thinning and other side effects. Corticosteroid creams, ointments, gels, or solutions are applied directly to the infected nails and skin. The medication should be applied to the entire affected nail and gently massaged into the nail bed and surrounding tissue.

• Calcineurin Inhibitors: Topical calcineurin inhibitors, such as tacrolimus (Protopic) and pimecrolimus (Elidel), are another option for treating nail psoriasis, particularly in sensitive areas like the nail folds. Calcineurin inhibitors regulate immune responses by inhibiting T-cell activation and cytokine production, which reduces inflammation. These medications are typically applied twice a day to the affected nails and surrounding skin. They are generally well tolerated and can be used for extended periods without causing skin thinning or atrophy. 

• Vitamin D Analogues: Topical vitamin D analogues, such as calcipotriol (calcipotriene) and calcitriol, have anti-inflammatory and antiproliferative effects and can be effective in treating nail psoriasis. Vitamin D analogues regulate keratinocyte differentiation and inhibit excessive proliferation, resulting in normal nail growth and morphology. Vitamin D analogues are sometimes used in combination with corticosteroids for enhanced efficacy. This combination can minimise the risk of side effects and decrease the frequency of corticosteroid use.

• Salicylic Acid: Topical salicylic acid preparations can soften and exfoliate thickened nail plates in psoriatic nails, allowing other medications to penetrate the nail. Salicylic acid is usually applied topically to the affected nails after soaking them in warm water. It aids in the removal of excess scale and debris, thereby improving the absorption of other topical medications.

• Moisturizers and Emollients: Regular application of moisturisers and emollients can help hydrate the nails and surrounding skin, reducing dryness and preventing nail brittleness. Moisturise your nails and cuticles every day, especially after bathing or handwashing, to keep them hydrated and protect the nail barrier.

• Nail Lacquers: Nail psoriasis can be treated with medicated nail lacquers like ciclopirox (Penlac), amorolfine, or tazarotene. These formulations are applied directly to the nails and allowed to dry, resulting in a protective film on the nail surface. Nail lacquers contain antifungal or anti-inflammatory ingredients that penetrate the nail plate and target the underlying pathology. They are generally well tolerated and can be used as an adjunctive treatment.

Advanced Therapies: How Biologics Can Improve Nail Health

Biologic therapies have transformed the treatment of psoriatic arthritis (PsA) and its associated nail psoriasis by targeting specific pathways involved in inflammation and immune dysfunction. Biologics provide significant benefits for improving nail health in PsA patients who have not responded well to conventional therapies. Biologics can improve nail health in PsA by targeting cytokines, reducing inflammation, normalising keratinocyte proliferation, resolving nail psoriasis signs, maintaining long-term response, providing systemic benefits, a variety of treatment options, and having a safe profile. By addressing underlying inflammatory mechanisms and modulating immune responses, biologics provide significant benefits for achieving and maintaining remission of nail psoriasis symptoms, ultimately improving affected individuals' overall well-being.

Home Care Tips: Protecting Your Nails from Further Damage

One of the most important aspects of managing nail psoriasis and psoriatic arthritis (PsA) is keeping your nails safe from further harm. The following home care advice can help preserve the health of your nails and reduce exacerbations:

1. Gentle Nail Care: Keep your nails short to reduce the risk of trauma and snagging. To smooth rough edges, use a gentle nail file and avoid aggressive filing or shaping. Avoid biting or picking at your nails because it can aggravate nail damage and increase the risk of infection. Be cautious when engaging in activities that may strain or injure your nails, such as gardening or household chores.

2. Moisturize Regularly: To keep your nails and cuticles hydrated and free of dryness, apply a moisturising cream or ointment regularly. Choose products with ingredients like shea butter, glycerin, or ceramides to help restore and maintain the skin's natural moisture barrier.

3. Protective Measures: Wear gloves when doing tasks that will expose your nails to water, chemicals, or harsh detergents, such as dishwashing or cleaning. Wear protective gloves when working with your hands outside, especially in cold or dry weather, to avoid exposure to environmental irritants.

4. Avoid Harsh Nail Products: Choose nail care products that are gentle and do not contain harsh chemicals, fragrances, or allergens. Limit the use of acetone-based nail polish removers, which can strip the nails of natural oils and contribute to dryness and brittleness.

5. Maintain Good Hygiene: Keep your nails clean and dry to avoid bacterial and fungal infections. Wash your hands regularly with mild soap and warm water, making sure to clean under the nails and around the cuticles. After washing, thoroughly dry your hands and nails to prevent fungal growth.

6. Healthy Lifestyle Choices: Maintain a healthy diet high in vitamins, minerals, and antioxidants to promote nail health and overall well-being. Maintain hydration by drinking plenty of water throughout the day, as dehydration can lead to dry and brittle nails. Avoid smoking and binge drinking, as these habits can impair nail growth and weaken the nails.

7. Stress Management: Meditation, yoga, deep breathing exercises, and relaxing hobbies can all help you reduce stress. High levels of stress can exacerbate PsA and nail psoriasis symptoms, so self-care and stress management techniques should be prioritised.

Beyond Treatment: Living Well with Psoriatic Nail Arthritis

Living well with psoriatic nail arthritis necessitates a comprehensive approach that includes self-care, healthy lifestyle choices, and strategies for managing the physical and emotional aspects of the disease. Here are some tips for thriving with psoriatic nail arthritis:

• Education and Self-awareness: Learn about psoriatic arthritis and nail psoriasis to better understand your condition and treatment options. Stay current on treatment options, lifestyle changes, and self-care practices that can improve nail health and overall well-being. Be aware of any triggers that may exacerbate your symptoms, such as stress, specific foods, or environmental factors.

• Adherence to Treatment: Follow your healthcare provider's treatment plan exactly, including medications, topical therapies, and lifestyle suggestions. Keep track of your symptoms and treatment responses, and communicate with your healthcare team regularly to make adjustments to your treatment plan. Attend scheduled appointments and screenings to stay on top of your health and address any issues as soon as possible.

• Healthy Lifestyle Choices: Maintain a well-balanced diet high in fruits, vegetables, lean proteins, and whole grains to improve overall health and immune function. Regular exercise can help improve joint mobility, strengthen muscles, and reduce inflammation. To protect your joints, stick to low-impact activities such as swimming, walking, or yoga. Get enough sleep every night to improve immune function, mood regulation, and overall well-being.

• Stress Management: Meditation, deep breathing exercises, mindfulness, and relaxing hobbies are all effective stress-reduction techniques. Set realistic expectations and priorities, and practice delegating tasks or asking for assistance when necessary.  Seek help from friends, family, or support groups to deal with the emotional challenges of living with a chronic condition.

• Nail Care and Protection: Use gentle nail care to reduce trauma and prevent further damage to your nails. Keep your nails short and do not pick or bite them. Use moisturisers and protective gloves to keep your nails and hands hydrated and free of harsh chemicals, detergents, and environmental irritants. Avoid wearing tight or restrictive footwear, which can aggravate nail psoriasis or joint symptoms in the feet.

• Emotional Well-being: Stay in touch with loved ones, friends, and support groups for emotional support and encouragement. Practice self-compassion and acceptance, recognising the difficulties of living with psoriatic nail arthritis while emphasising your strengths and resilience. Consider seeking professional counselling or therapy to alleviate any emotional distress, anxiety, or depression caused by your condition.

• Regular Monitoring and Self-care: Stay aware of changes in your nail health and joint symptoms, and seek medical attention if you notice any new or worsening symptoms. Maintaining good hygiene, staying hydrated, and managing stress are all examples of routine self-care practices that can help improve your overall health and wellbeing.

Daily Nail Care Practices for Psoriatic Arthritis Patients

Daily nail care practices are critical for managing psoriatic arthritis (PsA) and nail psoriasis because they help prevent damage, maintain nail health, and reduce the risk of exacerbations. Gentle cleaning, moisturising regularly, trimming and shaping, avoiding harsh chemicals, nail strengthening products, hydrating soaks, protective measures, and regular monitoring are some daily nail care practices designed specifically for PsA patients. By incorporating these daily nail care practices into your routine, you can help maintain nail health, reduce nail psoriasis symptoms, and lower your risk of complications from psoriatic arthritis. If you have any concerns or questions about nail care, speak with your healthcare provider or a dermatologist for personalised advice and suggestions.

When to Seek Professional Help: Consulting Your Dermatologist

Individuals with psoriatic arthritis (PsA) who suffer from nail psoriasis should consult a dermatologist, as dermatologists specialise in diagnosing and treating skin and nail conditions. Persistent or worsening symptoms, severe nail involvement, suspected secondary infections, joint symptoms, treatment concerns, diagnostic confirmation, an individualized treatment plan, and regular monitoring and follow-up are all indicators that it is time to see a dermatologist.

The Psychological Impact of Nail Psoriasis and Coping Strategies

Nail psoriasis can have a significant psychological impact on a person's life, affecting factors such as self-esteem, body image, social interactions, and emotional well-being. Coping with nail psoriasis entails developing strategies to manage the emotional challenges that come with the condition while also improving overall quality of life. Some common psychological effects of nail psoriasis and coping strategies include low self-esteem and body image, social withdrawal and isolation, anxiety and depression, negative self-perception, relationship problems, loss of enjoyment in activities, and seeking professional help. Despite the challenges presented by nail psoriasis, you can improve your resilience and quality of life by implementing coping strategies, developing a strong support network, and prioritising self-care.

Tailoring Your Treatment Plan: A Collaborative Approach

Tailoring a treatment plan for nail psoriasis necessitates a collaborative effort between healthcare providers and patients to address individual needs, preferences, and treatment objectives. Here's how to use a collaborative approach to effectively tailor treatment for nail psoriasis, including comprehensive assessment, shared decision-making, patient preferences, regular monitoring and feedback, individualised treatment goals, a multimodal approach, patient education and empowerment, and ongoing communication and support. By taking a collaborative approach to tailoring treatment for nail psoriasis, healthcare providers and patients can improve treatment outcomes, patient satisfaction, and overall quality of life for those living with this chronic condition.