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Nail Psoriasis affects fingernails and toenails. The nails are affected in many people with psoriasis. Nail Psoriasis may not be accompanied by any lesions on the skin.
Nail Psoriasis manifests with any number of the following changes: nails thicken, lose luster, raise, changes in color, and become friable - the so-called psoriatic nail dystrophy.
Nail Psoriasis is encountered frequently together with the psoriatic lesions on the skin, but sometimes it may be the only manifestation of psoriasis on the body.
Common changes with Nail psoriasis are:
Onycholysis - the nail partly detaches from the nail bed and a gap develops underneath the nail; if recent, there is a dull area underneath the nail with a salmon pink or red rim; the gap between the nail and the nail bed can become colonized by bacteria and fungus.
Pitting - small inconsistently arranged pits, making the nail look like the surface of a thimble.
Subungual hyperkeratosis - an accumulation of chalky material underneath the nail, makes the nail raise up. This may create considerable discomfort and pain, i.e. when the toe nails are being pressed by shoes.
Discoloration - abnormal coloration of the nail, like yellow-brown.
Onychomycosis - a fungal infection that can induce thickening of the nails. 30% of patients with Nail psoriasis may also have a fungal infection that may worsen their psoriasis. Treating the infection can help the nails to improve, or may not have any influence on the clearance of Nail psoriasis. Fungal infection can be treated with a systemic anti-fungal medicine.
Longitudinal ridging of the nails.
Splinter hemorrhages - red marks under the nails due to tiny popped blood vessels underneath the nails.
The changes of the nails with psoriasis can be separated into two forms: point damage and diffuse damage.
With point damage of the nails there is formed pits of a different depth. The nails in this case may look pricked similarly to a dressmaker's thimble.
A diffuse damage of the nails can have a wide variety of the manifestations. The minimum changes are the light haze on the surface plate, the grayish color of the nail and hardly noticeable longitudinal striation.
With the significant diffuse damage of the nails they separate the Atrophic Onychodistrophia, Hypertrophic Onychodistrophia and Psoriatic Onychia in the form of subungual hemorrhages.
Atrophic Onychodistrophia
Atrophic Onychodistrophia, or Psoriatic Onchylosis, is characterized by the thinning of the nail without the previous inflammatory changes. The nail, gradually becoming thinner, is separated from the matrix unguis or, being gradually lysed, disappears, up to the remainders of the grayish color in the nail lune. The thinning nail and its lyzing more frequently begins on the free edge of the nail, but it can also occur on the lateral sections of the nail.
Hypertrophic Onychodistrophia
Hypertrophic Onychodistrophia is manifested by the diverse changes in both the form, color and in the consistency of the nail. Most frequently there appears a thickening of the nail with deformation and change in the color from the grayish-yellowish to a dull gray. The nail loses luster, becomes dim and uneven. The deformation of the nail plate begins with the fissures in the nail lune. The infiltration strengthens in the process of the involvement of the subungual bed; the nail thickens and gets deformed even more. The nail becomes dense, and starts resembling the claw of a bird. This process is more frequently developed in the region of the toenails. In other cases the nail gets completely destroyed. The nail becomes friable, fragile and gradually gets torn away, leaving only a small friable corneal stratification in the nail lune.
Psoriatic Onychia
Psoriatic Onychia of the type of subungual hemorrhages has 2 types of hemorrhages.
The hemorrhagic spots of the first type, which are translucent through the nail, can be located in the region of the nail lune. They are formed due to the extended capillaries of the matrix unguis and disappear with pressure.
The second type of subungual hemorrhages is characterized by the striata hemorrhages, becoming yellowish-brown or black in color. Sometimes the thin arrow-shaped strips in the distal part of the nail produce the impression of splinters.
All the damages of the nails are accompanied by the redness, infiltration, damage of near-ungual roller (Psoriatic Paronychia). Rear ungual skin is infiltrated, with the abundant peeling, which is absent with Onychomycoses and Candidiasis.
Psoriatic Paronychia
Psoriatic Paronychia is frequently accompanied by serous, sometimes even purulent discharge from under the rear ungual roller, which is one of the most important diagnostic signs, making it possible to distinguish Psoriatic Paronychia of Candidiasis etc.
Diagnosis
In the classic version the diagnosis is simple, but sometimes Nail Psoriasis may be confused with Onychomycosis (fungus damage of the nails). The inflammatory border on the periphery of the affected section of the nail, on the edge of the papule in the matrix unguis, translucent through the nail plate, serves as the distinguishing feature, which makes it possible in these cases to differentiate from psoriasis and Onychomycosis.
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