Psoriatic, or pitting nails, are not a very common condition of toenails but are worthy to mention as many are affected by psoriasis. Pitting of the nails may be concerning at first to see, but they generally do not cause any major problems. As the name suggests, it is associated with the skin condition psoriasis. As the nails are made of the same component as skin (keratin), this is unsurprising that they would be affected by a dermatological condition. Psoriasis results in dry, scaly skin that may show up in patches, and this can appear at the nail as well, but underneath.
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Symptoms
Psoriatic toenails can look dfferent depending on where on the nail it is occurring. If it occurs at the end of the nail, near the white distal edge, it will appear as if the nail is lifting and uneven, with the “white” spreading in to create an uneven “splotch.” The nail can even become loose as it lifts more. However, the psoriasis can start within the nail, forming in the central nail. This will usually look like a much more round circle or circles, and at times they may appear white, or resemble a complete indentation to look like a pit within the nail.
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Causes
Psoriasis causes psoriatic or pitting toenails and itself is complex and not yet fully understood. It is believed to be a result of the autoimmune system attacking the skin cells to create the hallmark scaly plaques on the skin and subsequently under the nail. The causes are purported to be both genetic and environmental. People with a family history, and specifically the PSORS1 gene, are more likely to be afflicted by psoriasis in general. Some environmental factors include fungal elements that can cause the skin to be inflamed along with other irritants.
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Treatment
To treat the pitting nail, we must treat the underlying cause. However, we cannot directly treat the psoriatic skin with the nail on top. If already loose and lifted, it is best to remove as much of that nail as possible and apply creams to the affected area underneath. Steroid creams may be used, but very sparingly, and only short term due to their side effects. There are oral medications to reduce flare ups, but they often have side effects as well and are usually stronger.
Often, fungal nails and psoriatic nails can be mistaken for one another. If treatment for psoriatic nails are failing, it may be best to biopsy the toenail to determine if fungus is present.
Lifestyle changes can have positive outcomes on the skin condition, likely due to increased circulation and other factors such as hormone production when making such changes. This might include diet, exercise, or getting more sunlight. The autoimmune nature of psoriasis makes it difficult to treat and the subsequent pitting nails can be a challenge to remedy, aside from maintenance.
