Nail psoriasis is a special form of psoriasis that affects the nails on the hands and/or feet. Doctors call this disease psoriatic thyroid muscular dystrophy (from Greek.y-Nails,dys-Violation,Trophy-Food).
From this article, you will learn about the reasons for the development of nail psoriasis, its symptoms (which do not always clearly indicate the correct diagnosis) and dangerous misunderstandings about this form of the disease.
notes.There are many photos in the article that may frighten an unprepared reader.
Where do the nails come from?
To understand the problem of nail psoriasis, it is important to understand how the so-called nail appliances work.
Nails have two functions: processing and beauty. First, the nail protects the fingertips from harm, improves the accuracy and sensitivity when handling small objects, and can be used as a weapon of attack or defense. Finally, with the help of nails, we can itch. Secondly, the aesthetic or cosmetic function of nails is also very important, especially for women.
Nails are formed from the epidermis, the outer layer of the skin. Nail devices include:
- Nail board-directly nail itself,
- Matrix-it produces nail plates,
- The nail hole or menstrual zone is the only visible part of the matrix. This is the white moon-shaped area at the bottom of the nail plate.
- ep bone-nail roller, can protect the matrix from damage,
- Nail bed-located under the nail plate, responsible for fixing it on the phalanx of the finger,
- Hypothalamus-the transitional area between the nail bed and the fingertip skin.
The etiology and pathogenesis of nail psoriasis
In its process-regular aggravation and relief-psoriasis on the nails resembles the vulgar form of this disease.
It is believed that the development of nail psoriasis has the same cause and occurs in the same pattern as a typical psoriasis outbreak. Among these reasons, there is a difference between external and internal factors.
The main inherent factor is genetic susceptibility. There are many external causes, such as injuries, poor diet, poisoning (alcohol and tobacco), infections and certain drugs.
Under the influence of these reasons, the standard mechanism for the development of nail psoriasis can be briefly described as follows:
- Stimulating factors, such as trauma, activate immune cells.
- The activated immune cells migrate to the area of the nail matrix or nail bed.
- Immune inflammation occurs in these areas.
- The division of skin cells accelerates sharply, and their maturation is destroyed.
- There are typical symptoms of psoriasis on the nails.
Similarly, the cause of nail psoriasis can also be considered to be the result of the human body’s inability to adapt to adverse environmental conditions. According to this view, the main cause of psoriasis is evolutionary alien habitat.
As a result, this evolutionary approach regards unhealthy diet, lack of sunlight and clean water, excessive toxins, lack of normal physical activity, sleep disturbances and chronic stress as the direct causes of the disease.
Nail psoriasis is linked to psoriatic arthritis
The link between nail damage and psoriatic arthritis has long been known.
Based on observations, scientists found that nine out of ten cases of psoriatic arthritis were accompanied by nail damage.
However, the mechanism of this connection has not been fully studied. But, for example, the authors of several studies from the Institute of Molecular Medicine in Leeds (UK) tried to explain this connection with the concept of immune inflammation.
They believe that the fact is that the knuckles are located beside the nails and are anatomically related to the nails.
Therefore, the small trauma that causes primary joint inflammation and Kebner's phenomenon-psoriatic arthritis-can also cause secondary pathological changes on the nearest nail.
This is why psoriatic arthritis is often associated with nail damage.
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Therefore, the symptoms of nail psoriasis usually indicate psoriatic arthritis.
Now, let us look at the main myths that accompany this disease and their dangers.
Myth 1: Nail psoriasis is rare.
Not really. Obviously, psoriasis nails are very susceptible to suffering.
According to various sources, the incidence of nail psoriasis ranges from 6% to 82% of cases of psoriasis vulgaris. Assessing the prevalence of this disease is so widespread because of its accounting problems. Medical statistics first consulted doctors in a vulgar form, followed by nails. In scientific research, in addition to the main object of interest (psoriasis with skin lesions), cases of nail psoriasis are usually studied.
However, many publications say
Up to 80-90% of patients with psoriasis vulgaris report recurrent nail damage.
Moreover, 90% of patients with psoriatic arthritis and scalp psoriasis develop psoriasis of the nails.
It should be noted that usually adults suffer from this disease.
According to various sources, in children, about 7-37% of psoriasis cases are affected by nails. Unfortunately, the performance of psoriasis on the nails of children is often not given the attention it deserves. Parents or doctors believe that this is the result of a standard variant or trauma, or that it did not attract attention due to the mildness of the symptoms.
Misunderstanding 2: It is easy to identify nail psoriasis by symptoms
In fact, this is not always the case. the fact is
Nails can only respond to various diseases with limited symptoms. Therefore, the manifestations of various diseases on the nails may look the same.
Of course, if the patient has severe symptoms of psoriasis vulgaris, nail psoriasis can be suspected. However, compared with skin lesions, nail lesions may be smaller, and doctors can easily ignore them.
Generally, the more active psoriasis is on the skin, the more severe the damage to the nails.
First, the nails are affected.
It is also important to know that in 5% of cases, nails may be the only initial manifestation of psoriasis. In other words, the typical manifestations of psoriasis on the skin may disappear completely.
The appearance of nail psoriasis depends on the origin of the pathological changes-in the nail matrix or nail bed.
When choosing a treatment, the source of the symptoms (matrix or bed) must be considered. Therefore, it is necessary to define it correctly.
Symptoms originating from nail matrix are:
- Symptoms of thimble
- White spots and small spots (leukocytosis),
- The red dot on the hole,
- Broken nails.
Although the cause of these symptoms is at the stromal level, pathological changes will appear on the nail plate as the nail grows.
The symptom that causes it is the nail bed:
- Nail loss (cracked oracle)
- Longitudinal bleeding,
- Sublingual hyperkeratosis,
- Symptoms of oil stains.
Next, we will discuss each symptom separately. Let's start with the performance that originated from the matrix.
Symptoms of thimble
Symptoms of thimble appear on the surface of the nail plate with holes or pits that look like depressions in the thimble.
This defect mainly occurs on the nails, but rarely on the feet. As the nail grows, the pit moves from the crease of the nail to the edge of the nail board.
The depressions of nail psoriasis are usually deep, large and chaotic. They are produced due to the shedding of loose cell clusters on the nail surface, which weakens cell division and keratinization.
The more severe the psoriasis, the more frequent the thimble symptoms.
However, it should be remembered that in addition to psoriasis, pits on the nails are also characteristic of alopecia areata, hair loss, eczema, and dermatitis, and may also occur during fungal infections, for example.
Counting the total number of pits on all nails will help make a correct diagnosis.
- Less than 20-psoriasis is not common,
- From 20 to 60-suspected psoriasis,
- More than 60-confirm the diagnosis of psoriasis.
White spots (white spots)
Leukocytosis is a symptom that manifests as white spots or spots on the nails.
Vitiligo (from Greek.Lecos-White andy-Nails), in contrast to the shallow pits in thimble symptoms, cells that are damaged by division and keratinization are located in the thickness of the nail plate. At the same time, the surface of the nail remains smooth. The whiteness of the spots is caused by light reflections from loosely located clusters of cells.
However, some studies have shown that cataracts are very common in healthy people and are therefore not a hallmark of psoriasis. For example, injuries to manicure can cause cataracts.
Broken nails
When the superficial pits (thimble symptoms) and the deep diphtheria area (white spots) merge, the nails begin to collapse.
Usually, nail chipping is accompanied by long-term nail psoriasis.
The stronger the inflammation of the nail matrix, the greater the damage to the nail plate. In severe cases, the nail will collapse completely and fall out.
Red dot on nail slot
Obviously, due to the increased blood flow to the blood vessels under the nails, red spots and their general redness appeared in the hole area.
Similarly, due to the violation of the structure of the nail plate itself, a red dot is formed on the hole: it becomes more transparent and thinner. Therefore, firstly, the blood vessels become more clearly visible; secondly, the thin nail plate exerts less pressure on the blood vessels below it, and they are filled with blood.
Thinning of the nail plate can also cause the entire nail bed to become red.
Separation of nails (hyperlysis)
Now, let us consider the symptoms, the source of which is the nail bed.
Toonycholysis refers to the separation of the nail plate from the bed. This is due to the accumulation of cells under the nail that causes the division and keratinization to be damaged.
A solution itself (from Greek.y-Nails andλύσις-Separation) is not necessarily a sign of psoriasis, for example, it may develop due to nail injury.
Initially, the loss of contact force between the nail and the bed occurred in the lower airway area along the outer edge of the orbital plate. Then, the strong force spreads to the nail folds in the form of a semi-circular line. Due to the accumulation of air under the nail, the peeling area turns white.
The edge of psoriasis is usually visible on the finger with a reddish border (scientifically known as erythema), which is a characteristic of psoriasis and helps to make a correct diagnosis.
With prolonged force release, the nail bed loses its performance, and the growing new nails are likely to fail to attach to the nails properly. Therefore, even if the nail plate is completely renewed, the forceful release will continue.
Since formolysis promotes the penetration of bacteria and fungi, infections may occur. Sometimes it can cause discoloration of nails. For example, it will appear green when bacteria attachPseudomonas aeruginosa(Pseudomonas aeruginosa) and so on.
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Longitudinal submandibular bleeding
Longitudinal subnail hemorrhage occurs on the nail bed, and there are dark red lines 1-3 mm long.
Increased blood flow and edema in the inflamed area of the nail bed cause capillary rupture, which manifests itself in the form of bleeding.
Due to the particularity of the blood supply, most bleeding occurs near the free edge of the nail-the lower respiratory tract area.
Sublingual hyperkeratosis
Submandibular hyperkeratosis refers to the accumulation of dead cells below the outside of the plate.
Suffering from psoriasis, submandibular hyperkeratosis (from Greek.ultra-Excessive andKailas-Horn) is usually silvery white, but it can also be yellow. When the infection merges, it may become green or brown, for example.
The more times the nail is lifted above the nail bed, the higher the activity of the pathological process.
On the fingers, subnail hyperkeratosis usually manifests as a loose layer under the nail plate. On the legs, these blocks are tightly welded with thickened nails.
In addition, the toenail pathology of psoriasis is characterized by a combination of subtoe hyperkeratosis and small osteolysis (nail separation).
Oily symptoms
The symptoms of oil stains appear as yellow-red (salmon) spots under the nail plate.
They appear on the nail bed near the nail fold and move toward the edge of the nail as the nail grows.
The reason for this symptom is inflammation of the nail bed, capillary expansion and accumulation of cells involved in inflammation, as well as cells that are damaged in division and keratinization.
Oil stains come in various shapes and sizes. They can be found in the center and edge of the nail near the thyroid osteoporosis area.
Misunderstanding 3: Nail psoriasis is just a cosmetic problem.
Actually this is incorrect. Although more than 90% of patients do report unsightly psoriatic nails, this is not only a cosmetic problem.
According to various studies, nail psoriasis can greatly reduce the quality of life of patients:
- 52% of patients also complained of pain,
- 59%-For problems in daily activities,
- 56%-Difficulties at home and other areas
- 48%-due to work difficulties.
Therefore, it is very important to make the correct diagnosis and start treatment as soon as possible, because improving the condition of the nails will greatly improve the quality of life of patients with psoriasis.
Myth 4: Nail psoriasis is not dangerous
In fact, this is not the case. When talking about the cause of this disease above, we have already written
Nail psoriasis is an important symptom of psoriatic arthritis.
It is important to remember that there may be no external manifestations of arthritis at all. In this case, we can not only talk about the fact that the joints of the fingers and toes are affected, but also the joints of the spine and pelvic bones.
You can check the joints for arthritis by ultrasound (ultrasound) or magnetic resonance imaging (MRI).
Even if there are no obvious symptoms of arthritis, but there are manifestations of nail psoriasis, it is important to ensure that all joints are neat.
Then regularly monitor the condition of the joints. Otherwise, it is easy to miss psoriatic arthritis! Late diagnosis will lead to late treatment and therefore irreversible joint damage and disability.
Therefore, if the doctor does not order an insurance study because there are no obvious signs of arthritis, you must contact the clinic yourself and perform a fee-based ultrasound scan.
How to diagnose nail psoriasis
It is important to be able to recognize many of the symptoms of nail psoriasis that we described above, because they help establish the correct diagnosis. However, since the nail change characteristics of psoriasis may also occur in other diseases, it may be difficult to make a correct diagnosis immediately.
In this case, the simultaneous appearance of several symptoms on different nails can help the diagnosis.
The important signs of psoriasis on nails are:
- Symptoms of thimble: There are more than 20 pits on all the nails of the hands indicating the possibility of psoriasis, and more than 60 pits confirm the diagnosis of psoriasis.
- Loose nails (cracked oracle), with red borders around the edges,
- Oil stains (salmon) on the nail bed.
Difficulty in diagnosing nail psoriasis with a single symptom
If only one symptom appears, it is difficult to diagnose nail psoriasis.
For example, if it only manifests as a tonic fracture of the arm and/or leg, or only subtoe hyperkeratosis of the arm and/or leg.
The only way to make a reliable diagnosis in isolated onychomycosis (nail separation) may be to study the lower respiratory tract with a special microscope-dermoscope.
For this, a high-magnification video dermoscope is used. Please note that the handheld dermoscope does not provide the required magnification. What is needed is a video dermoscope with at least 40x magnification. Then, you can see the characteristic of the expanded capillaries of psoriasis.
For isolated submandibular hyperkeratosis, if the accumulation of scales under the nails is whitish silver, and all the nails on the hands or feet are infected, the possibility of psoriasis is high.
Psoriasis or nail fungus?
Approximately 30% of nail psoriasis patients also have fungal infections-scientifically onychomycosis.
From the outside, hyperkeratosis of psoriasis and onychomycosis (separation of nails) may resemble fungal infections. Therefore, it may be difficult to make a differential diagnosis, that is, to determine the true cause of the nail plate change.
Moreover, both psoriasis and fungus can affect the same nail at the same time. It is most commonly found on the toes and is the main characteristic of elderly patients.
Similarly, in fungal infections, one or both nails on the big toe are often affected. Usually, in psoriasis, several nails are affected at the same time.
The following symptoms indicate psoriasis:
- Symptoms of oil stains and/or thimble on nails,
- Signs of psoriasis on the scalp and/or large folds of the skin,
- Regularly relieve and aggravate nail damage.
They say in favor of onychomycosis:
- There are longitudinal stripes on the nail of the affected area,
- Fungus detection when inspecting a scraper (KOH test) scratched with potassium hydroxide on the affected nail under a microscope,
- Positive culture of fungus.
In general, it is impossible to completely exclude nail fungal infections in patients with psoriasis based on external manifestations.
It should also be remembered that fungal infections can cause the Kebner phenomenon on the nails and surrounding skin, leading to symptoms of psoriasis. So anyway
Go to a mycologist to check for fungus and find that antifungal treatment (if found) is useful.
Important findings and treatment methods
Let us summarize important information about nail psoriasis and its symptoms.
Diagnosis function:
- Nail psoriasis is very common, but it is often missed.
- The manifestation of nail psoriasis may be small, so even experts often do not pay attention to it.
- In 5% of cases, nail damage may be the only symptom of early psoriasis.
- The presentation of different diseases on the nails may look the same, which complicates the diagnosis.
The main manifestations of nail psoriasis are:
- Symptoms of thimble-pits on the nails,
- White dot
- Broken nails
- The red dot in the hole area,
- Nail loss
- Longitudinal bleeding under the toes,
- Submandibular hyperkeratosis-loose clusters under the nail
- Symptoms of oil stains.
Psoriasis and fungus:
- Usually, nail psoriasis is accompanied by fungal infections.
- To exclude it clearly, it is necessary to contact a mycologist and conduct other research.
Nail psoriasis and psoriatic arthritis:
- Nail psoriasis is a common partner of psoriatic arthritis.
- It is important to find the pathological changes of the joints as early as possible so that treatment can be started on time and irreversible complications and disability can be avoided.
- Even if there are no external symptoms of arthritis, but nail psoriasis can be detected, the joints must be examined using ultrasound or MRI.