What Is Nail Pitting?

Nail pitting refers to the presence of small depressions or dents on the surface of the nails. These pits can vary in size and depth and are often associated with psoriasis, an autoimmune condition that accelerates skin cell turnover. While nail pitting can occur independently, it frequently manifests alongside other psoriasis symptoms, such as skin plaques and joint inflammation.

Prevalence and Risk Factors

Approximately 50% of individuals with psoriasis experience nail changes, with nail pitting being one of the most common manifestations. The condition is more prevalent in those with psoriatic arthritis, affecting up to 80% of patients. Genetic predisposition, immune system dysfunction, and environmental triggers like trauma or infections can increase the risk of developing nail pitting.

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Symptoms Associated with Nail Pitting

Beyond the characteristic dents, nail pitting may be accompanied by:

• Discoloration: Yellowish or brownish spots beneath the nail plate, known as "oil drop" or "salmon patch" signs.

• Thickening: Nails may become thickened or brittle, leading to crumbling.

• Onycholysis: Separation of the nail from the nail bed, potentially causing pain and discomfort.

• Beau’s Lines: Horizontal grooves that can appear across the nails.

These symptoms can vary in severity and may affect one or more nails.

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Diagnosing Nail Pitting in Psoriasis

Diagnosis primarily involves a clinical examination by a dermatologist. The presence of nail pitting, along with other psoriasis symptoms, can lead to a diagnosis of nail psoriasis. In cases where the diagnosis is uncertain, additional tests such as potassium hydroxide (KOH) preparation or fungal cultures may be conducted to rule out fungal infections. A biopsy of the nail matrix might be considered in atypical cases.

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Treatment Options for Nail Pitting

Managing nail pitting involves addressing the underlying psoriasis and alleviating nail-specific symptoms. Treatment strategies include:

1. Topical Treatments

• Corticosteroids: Topical steroids can reduce inflammation and are commonly applied to the affected nails.

• Vitamin D Analogues: Calcipotriol and calcitriol help normalize skin cell production.

• Retinoids: Tazarotene, a vitamin A derivative, can improve nail appearance.

2. Intralesional Steroid Injections

For localized and severe cases, corticosteroid injections directly into the nail matrix can provide relief. This method targets inflammation at the source but may be painful.

3. Systemic Therapies

In cases resistant to topical treatments, systemic medications may be prescribed:

• Methotrexate: Suppresses immune system activity.

• Cyclosporine: Inhibits T-cell activation.

• Apremilast (Otezla): Oral medication that reduces inflammation.

• Biologics: Drugs like adalimumab (Humira) and secukinumab (Cosentyx) target specific immune pathways.

4. Phototherapy

Ultraviolet light therapy, particularly PUVA (psoralen plus UVA), can be effective in treating nail psoriasis by slowing skin cell turnover.

5. Laser Therapy

Pulsed dye laser (PDL) therapy targets blood vessels under the nail, reducing inflammation and promoting healing.

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Home Care and Lifestyle Recommendations

While medical treatments are essential, home care practices can support nail health:

• Moisturization: Regularly apply emollients to keep nails hydrated.

• Nail Protection: Wear gloves during activities that may cause trauma to the nails.

• Avoid Trauma: Prevent nail injury, as it can exacerbate psoriasis symptoms.

• Dietary Considerations: Incorporate anti-inflammatory foods and consider supplements like omega-3 fatty acids.

• Avoid Smoking and Excessive Alcohol: These can trigger or worsen psoriasis flare-ups.

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Prognosis and Outlook

Nail pitting associated with psoriasis is a chronic condition that may fluctuate in severity. While treatments can manage symptoms, complete resolution is rare. Early intervention and consistent management are crucial in preventing complications and maintaining nail function.

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When to Consult a Dermatologist

Seek professional advice if you experience:

• New or worsening nail changes.

• Pain or discomfort in the nails.

• Signs of infection, such as redness or pus.

• Difficulty performing daily tasks due to nail involvement.

A dermatologist can provide a tailored treatment plan to address your specific needs.