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Impact of Psoriatic Arthritis on Nails
Psoriatic arthritis is a chronic autoimmune disease. It triggers joint pain and swelling and can also wreak havoc on your nails. It can lead to unsightly and painful changes in your nail appearance. From pitting to discoloration, nail damage often goes unnoticed until it's too late. But fear not! In this blog post, we'll explore the root cause and provide you with practical tips and remedies. Using these tips, you can keep them healthy and beautiful despite the condition's challenges. So, let's dive in!
Psoriatic arthritis- A brief introduction
Psoriatic arthritis is a chronic inflammatory disorder commonly found in people with psoriasis. This skin disease manifests as itchy and scaly rashes on the trunk, scalp, elbows and knees. The WHO regards psoriasis as a serious non-communicable disease that is more prevalent in higher-income countries and regions with older populations. Psoriatic arthritis has a less common incidence impacting 5-10% of people with psoriasis but profoundly impacting the individual's social and psychological lives.
Plaque psoriasis, the most common form of the disease is characterized by thin, discoloured nails that tend to lift from the fingers. Psoriatic arthritis, in comparison, impacts nails in the form of pitting that, in addition to looking unsightly, affects their tactile efficiency.
Nail involvement in Psoriatic Arthritis
The cause of psoriasis, the chief factor behind psoriatic arthritis, is still undergoing evaluation. Studies have, however, suggested it to be an immune system problem where the infection-fighting cells mistakenly attack the healthy cells resulting in inflammatory reactions throughout the body. Psoriatic patients with more severe skin problems develop psoriatic arthritis because of immune activation and proinflammatory cytokine expression throughout the dermis.
That, added by an increased expression of TNF-alpha and interleukin-17 cytokines produced by T cells and other cell types, potently activate keratinocytes, the dysregulation and abnormal expression of which cause several chronic inflammatory conditions like psoriasis, atopic dermatitis and allergic contact dermatitis. Keratinocytes are also present in the nails, and along with skin problems, keratin activation leads to nail damage in conditions of psoriatic arthritis.
It is essential to understand the pathophysiology of the skin and nails to understand the effect of psoriatic arthritis on the nails and decide the correct treatment to deal with it.
Pathophysiology of Nails
The fingernails and toenails of a person are composed of skin cells and keratin and play an essential role in grasping and holding movements along with protecting the finger and toe tips. The nail unit in general consists of the
Nail plate or visible hard part of the nail
The nail bed or the skin beneath the nail plate
The nail folds or the skin that holds the nails on three sides
All three of these are impacted by conditions of psoriatic arthritis.
Signs of Nail Damage in Psoriatic Arthritis
Colour changes in the nails
Oil drop appearance or salmon patches characterized by translucent yellow-red discolouration in the nail bed are hallmark signs of psoriasis. In addition, whitish, brownish, and sometimes reddish marks are noticed on the nail plate because of parakeratosis ( incomplete maturation of keratocytes) or damage to capillaries under the nail bed.
Beau's lines are indentations caused on the nail bed occurring because of inflammation of the matrix ( the area where your fingernails and toenails start to grow) and the proximal nail folds. Beau's lines can occur on all the fingers and toenails but are most prominently observed on the thumb and great toenails.
Nail Ridges look like vertical lines on the nail surface and occur as a result of psoriatic lesions on the nail matrix. Studies have also hypothesized that injury or weakness of the nail bed or matrix because of inflammatory conditions can result in these ridges.
Nail pitting is the most common symptom of psoriatic arthritis that occurs in the form of superficial depressions within the nail plate and is associated with inflammation of the proximal nail matrix. Studies have shown that nail pitting occurs in almost 68% of psoriatic conditions and, in severe conditions, can cause pain and discomfort.
Onycholysis is the term used to describe the nail plate separating from the nail bed that begins at the tip of the nail and spreads towards the cuticle. Usually, onycholysis results in bacterial/fungus accumulation under the nails, which can increase the infection risk considerably.
Subungual Hyperkeratosis is a painful nail condition characterized by the excessive production of skin cells accumulating between the nail and the nail bed and imparting a chalky appearance. The intensity of subungual Hyperkeratosis depends on the thickness of the accumulated skin cells. A thickness below 2 mm is considered slight, between 2-3 mm is moderate, and above 3mm is considered serious.
Topical steroids and Vitamin-D-based solutions like Calcipotriene are some of the primary treatment options that, when combined, epidermal differentiation and proliferation and regulation of production and release of proinflammatory cytokines. Calcineurin inhibitors, Cyclosporine A and Tazarotene, are other systemic medications that help improve the nail morphology in Psoriatic Arthritis.
Systemic treatments like Methotrexate are considered an overall treatment option in conditions where topical treatments prove ineffective or unsatisfactory in working on nail damage. Methotrexate improves the symptoms of psoriatic arthritis and prevents it from getting worse, thus lowering the chance of long-term joint damage. Apremilast and Acitretin are other medications that work as antiinflammatories to provide symptomatic relief to the patient.
Lasers are some of the best treatment options that have shown positive results for conditions of nail psoriasis. The PDL or pulsed dye laser is especially useful in targeting the dilated capillaries in the nail bed and matrix of the nails. Studies and clinical trials have proved its effectiveness and deemed it a painless method of reducing nail inflammations compared to the Yag laser with a shorter pulse length.
Photodynamic therapy (PDT) is another effective method in addition to PDL that uses light and a photoactive substance to generate reactive oxygen species able to kill the accumulated cells in the nail beds and matrix.
Corticosteroid injections treat nail psoriasis by treating the buildup under the nails and ridges. In addition, they work on separating nails and cases of thickening cells.
Other ways of managing nail damage due to psoriatic arthritis
Some of the other ways in which you can manage nail damage due to psoriatic arthritis are
Avoid picking or biting nails, as it can exacerbate inflammation.
Cut your nails at regular intervals.
Wear gloves when doing manual work to prevent pathogen buildup under the nailbed.
Moisturize your hands regularly.
Psoriatic arthritis can cause severe damage to the nails and their surrounding skin. That can further lead to pain and even infection. Thankfully, there are ways you can treat these symptoms. It involves managing your psoriatic arthritis through lifestyle changes as well as medications. With proactive measures, you’ll be able to recover better from flare-ups. Plus, you can nullify damages caused by psoriasis on your nails with ease.
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