Psoriatic Arthritis – Nail Involvement and Treatment

Psoriatic Arthritis – Nail Involvement and Treatment

Psoriatic arthritis (PA) is an autoimmune arthritis associated with the skin condition psoriasis. Joint pain, swelling, and stiffness often affecting the fingers, toes and lower spine (other joints may be also be impacted) are the key signs and symptoms. These can range from mild to severe and the disease may enter periods of remission. Although it is more common to develop psoriasis first, joint problems from PA can appear first and skin contribution to the disease can remain minimal. One extraordinarily common symptom (up to 90%) in PA patients is nail involvement. Chances are that if you are a patient with PA, you have noticed changes to your nails. These changes can affect a single nail or up to all twenty nails. This symptom is not usually painful, but it does have emotional ramifications for many patients.

Putting a Finger on the Problem

Changes to your nails can take on a number of different forms. Nail pitting is common, occurring in two out of three patients, and appears as shallow or deep and small or large holes within the nail. Separation of the nail from the underlying nail bed (a painless process) can occur. A secondary problem that can result from this is an opportunistic bacteria or fungal infection in the now exposed nail bed. Around one third of patients with nail involvement from PA will develop a fungal infection. Subungual hyperkeratosis is the build-up and accumulation of a flaky or chalk like substance under the nail, resulting from the rapid build up of skin cells. This occurs more frequently in toenails due to the pressure from wearing shoes. New nail growth occurs from the base of the nail. In PA patients, due to inflammation in this area, it can leave nails with grooves and ridges running length wise (also called Beau’s lines). Usually this will affect every nail. Long term inflammation can cause the nails to appear crumbly. As nails and skin consist of the same protein, the excessive growth of the skin cells seen in psoriasis can also affect the nails. This can lead to overly rapid growth of the nails as well as thickening of the nails. Discoloration of the nails is also a symptom frequently experienced by PA patients. Nails can turn white, yellow, brown or develop areas that appear red (often caused by splinter haemorrhages resulting from tiny blood vessels bursting under the nail.

Hit the Nail on the Head

This list can seem discouraging, but don’t lose heart. The list of treatments is just as long as the list of symptoms. Nail involvement can be a stubborn symptom and it may be necessary to try multiple treatments or combinations thereof. Usually, nail growth is slow so even if a treatment is successful it can take quite some time before you will see the full benefit. In the interim period while you wait for the treatments to take full effect there are a number of things you can do to help speed the process along and avoid doing any further damage.

Damage to the nail or any form of trauma can cause flare in nail psoriasis. To limit the chance of this occurring try keeping your nails short so that the risk of harm from everyday tasks is lessened. Short nails will also limit nail lifting and discourage build up from forming under the nail. It is also helpful wear gloves whilst working with your hands. This offers an additional level of physical protection and prevents your nails from getting wet which can increase the risk of infection.

It can be tempting to try to disguise your nail problems but avoid treatments such as acrylic, gel or artificial nails as the application and removal can be physically and chemically damaging which will in the long term make the problems worse. Certain products such as a simple nail polish or hardener may be safe to use, but you should discuss the potential use of any products with your doctor first. Pushing your cuticles back or cutting them can cause trauma, increasing the risk of exposure to infection. The same is true for biting or picking at your nails, so it may be necessary to try and avoid this habit. Although it can be very tempting, do not constantly remove the build-up from under your nails as this too increases the risk of infection. With treatment this build-up will slowly start to clear. Instead of physically forcing the debris out, soak the affected nail in warm soapy water. This can help to gently remove the debris without damage.

Healing Hands

PA nail symptoms can be treated and may respond well to general PA treatments that reduce overall inflammation. Common treatments for PA include nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen and naproxen, disease-modifying antirheumatic drugs (DMARDs) such as methotrexate and biologics, which are a new generation of arthritis drugs resulting from genetic engineering, all of which should positively impact PA nail involvement.

Other treatments exist that are designed to directly target the nail. Cortisone injections, usually used to treat specific joints, can be used to directly target nail bed inflammation. Alternatively, in less aggressive cases a steroid cream may be given which can be applied directly to affected nails. Light or phototherapy may be prescribed for more persistent cases. Ultraviolet light can be used to target nail psoriasis by slowing skin and nail growth. Your doctor can perform the treatment in room or alternatively special equipment can be bought so that the treatment may be performed at home. Antifungal medication or antibiotics either oral or topical may be needed to control secondary fungal or bacterial infections.

If you are struggling with nail psoriasis, remember that these physical manifestations of PA can be remedied. Keep trying, be patient, and you certainly can improve the appearance and health of your affected nails.

ANRF
Article Author
Arthritis National Research Foundation
arthritisresearch@curearthritis.org

The Arthritis National Research Foundation's mission is to provide initial research funding to brilliant, investigative scientists with new ideas to cure arthritis and related autoimmune diseases. Writing articles about the patients affected and the science being done to find a cure shows why we need to come together to #CureArthritis!

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