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How Psoriatic Arthritis Affects Nails

Managing PsA

July 06, 2023

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Photography by Jyoti Sangya/Getty Images

Photography by Jyoti Sangya/Getty Images

by Stephanie Orford


Medically Reviewed by:

Margaret R. Li, MD, FACR


by Stephanie Orford


Medically Reviewed by:

Margaret R. Li, MD, FACR


Nail changes in PsA aren’t just cosmetic — they can be painful, affect your ability to function on a daily basis, and impact your quality of life. But there are treatments to help.

People living with PsA often develop issues with their nails. It can affect just one nail up to all your fingernails and toenails and can look a few different ways.

Psoriatic arthritis affects the nails in as many as 90% of people with PsA.

If you have any psoriasis-related nail changes but haven’t been diagnosed with PsA, it’s a strong sign that you may have it or have a higher chance of getting it.

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Symptoms of psoriatic arthritis in nails

PsA nail changes can appear differently depending on what part of the nail is affected.

Some symptoms happen when psoriasis affects the nail matrix. This is the tissue at the base of the nail where the nail grows out of.

Other symptoms can happen if psoriasis affects the nail bed, which is the flat tissue underneath your nails.

Here are the different ways PsA can appear in nails:

Nail conditionAppearanceNotes
Nail pittingsmall dents in the nail surfaceThe most common type of nail change in psoriasis. It’s caused by psoriasis in the nail matrix.
Beau’s lineshorizontal grooves in the nailThis is caused by psoriasis in the nail matrix.
Trachyonychiarough nail edges and nail crumbling; nails may have a shiny or rough “sandpaper” surfaceIt’s caused by psoriasis in the nail matrix over a longer period of time.
Leukonychiawhite spots on the nailThis is also caused by psoriasis in the nail matrix.
Onycholysisnail separates from the nail bed; the nail may fall off completely, which is called onychomadesisThis happens gradually but is not painful. It’s caused by a combination of psoriasis in the nail matrix and nail bed.
Oil drops, also called salmon patchestranslucent yellow or orange patches in the nailThey’re a pathognomonic sign of psoriasis, meaning they’re not a symptom of any other condition.
Subungual hyperkeratosisthickened nailsThis is caused by psoriasis in the nail bed. Skin cells build up under the nail leaving a white, chalky debris.
Splinter hemorrhagestiny, splinter-shaped, dark brown blood spots in the nailThis happens when delicate capillaries under the nail between the nail and nail bed are damaged, mainly due to trauma.
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Early signs of nail psoriasis

Any nail symptoms in the list above may be an early sign of nail psoriasis.

That said, you’re more likely to get some symptoms than others. Pitting, loosening of the nail plate, and nail thickening are more common than discoloration, such as oil patches, white spots, and splinter hemorrhages.

It’s worth noting that nail pitting is the most common symptom in PsA and that nail issues in PsA are often the first sign that you have the condition.

Sometimes nail psoriasis can happen years before you feel any joint issues.

The differences between nail psoriasis and nail fungus

Nail psoriasis has a few overlapping symptoms with fungal nail infections, so sometimes they can be hard to tell apart.

Symptoms that tend to be caused by nail psoriasis — but not by nail fungal infections — are nail pitting, splinter hemorrhages, and oil drops.

But nail fungal infections can look similar to nail changes in psoriasis, including nail fragility, cracking, darkening, and thickening. And both PsA and nail fungal infections can have nail separation from the nail bed.

One unique thing about nail fungal infections is that they can be accompanied by athlete’s foot — which is not a symptom of psoriasis.

But sometimes it’s not as simple as knowing whether you have one condition or the other. You can have both.

If your nail plate separates due to PsA, it becomes more prone to nail fungal infections. It’s common for one to lead to the other.

According to The Psoriasis and Psoriatic Arthritis Alliance, about 35% of people with psoriasis nail changes also have a nail fungal infection. Your doctor can help you determine if you have nail fungus by taking a sample of your nail for analysis.

That’s why, even if you know PsA is causing your nail changes, it’s important to have your doctor assess whether you also have a nail fungal infection.

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How to care for psoriatic arthritis nails

Preventing trauma to your nails — that is any bumps, scrapes, or other injuries — is key. That’s because trauma can cause the Koebner phenomenon, a reaction in which an injury leads to a flare.

Keeping your digits and nails free of infection is important, too, since that can cause nail trauma and complicate your treatment.

Here are some do’s and don’ts if you’re caring for nail issues in PsA:

  • Do wear gloves while working in the kitchen, garden, or any workshop.
  • Don’t put a latex glove directly on your hand. Use a cotton glove against your skin instead, then put the latex glove over that.
  • Do keep your nails short since longer nails have a greater risk of trauma, which can trigger a psoriasis flare.
  • Don’t wear artificial nails, like acrylic or gel nails, since they can cause nail damage during application and removal.
  • Don’t bite your nails or push back your cuticles.
  • Do apply a protective nail polish or nail hardener under the supervision of your doctor.
  • Don’t scrape under your nails since this may leave them prone to infection.

Treatment options for psoriatic arthritis nails

Since nail fungal infections can sometimes look like nail psoriasis changes, it’s important to see your doctor to diagnose and treat the issues appropriately.

Treating nail issues in psoriatic arthritis can be difficult. Biologic drugs seem to be the most effective therapy.

According to research in 2017, these are the top biologics for nail issues, from most effective to least effective:

  1. adalimumab (Humira)
  2. etanercept (Enbrel)
  3. ustekinumab (Stelara)
  4. infliximab (Remicade)
  5. apremilast (Otezla)
  6. golimumab (Simponi)

Although biologics are the most effective therapy for nail psoriasis so far, they could also increase your chances of getting a nail fungal infection.

The drugs methotrexate and cyclosporine have also been shown to be effective in treating nail changes in psoriasis.

Many doctors also prescribe topical therapy, particularly corticosteroids and vitamin D3 analogs.

But keep in mind: Even if you’ve found the right treatment plan for your PsA and it’s under control, you may still experience nail changes.

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If you have PsA, there’s a strong chance you also have nail changes related to psoriasis. They can be tough to treat, but certain medications may help.

Nail changes in PsA can also look a lot like nail fungal infections, and people with PsA-related nail issues can have nail fungal infections at the same time.

That’s why it’s important to see a doctor as soon as you observe any changes in your nails.

Paying attention to nail changes may help you get an early PsA diagnosis so you can start treatment ASAP and help prevent joint damage.

Medically reviewed on July 06, 2023

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