Focal, painless discoloration of the
left thumbnail (A) developed several
years earlier in this 46-year-old man.
Oral antifungal therapy had no effect
on the lesion.
Examination reveals yellowish
brown spots under the nail. No signs
of onychomycosis are seen on other
fingers or toes. The presence of
plaques with silvery white scale on
both elbows corroborates the diagnosis
of nail psoriasis.
(Case and photographs courtesy of Joe Monroe, PA-C.)
Would you prescribe a different
antifungal-or consider another
A REVIEW OF THE OPTIONS
Psoriasis of the nails may be either
an isolated finding or one of several
manifestations of the disease.
The clinical changes in affected nails
include pitting, which occurs most
commonly; oil spots; onycholysis; and/or thickened nail plates with subungual
very severe disease may cause the
nails to crumble (B).
Pitting can affect several or all
nails; it is characterized by depressions
in the nail that are usually
smaller than 1 mm in diameter. Oil
spots resemble a drop of oil on the
surface of the nail plate. Onycholysis
presents as a separation of the nail
plate from the nail bed. The thickened
dystrophic nails with subungual hyperkeratosis that are seen in psoriasis
are similar to nails with onychomycosis,
a fungal infection.
Management of psoriatic nails is
extremely difficult and rarely results
in complete improvement. Injection
of intralesional corticosteroids into the
proximal and lateral nail folds is effective;
however, this treatment is quite
painful and should be considered
only for highly motivated patients. Although
less effective, a high-potency
topical corticosteroid applied to the
proximal nail fold may be tried. Psoralen-
UV-A (PUVA) therapy or systemic
agents, such as methotrexate or
cyclosporine, can be beneficial for psoriatic
nails; reserve these modalities
for patients with extensive disease that
requires more aggressive treatment.
(Photograph B courtesy of Drs Sonia Arunabh and
APPROACH AND OUTCOME
Reassured and relieved that he
did not have a fungal infection, the patient