Clinical Challenge: Disfiguration of Finger and Toe Nails - MPR

Clinical Challenge: Disfiguration of Finger and Toe Nails

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A 50-year-old, moderately obese man presents with a complaint of disfigurement of his toe and finger nails. The patient has a history of diabetes for which he takes metformin and insulin. He also has a history of asthma that is being treated with a levalbuterol inhaler. The patient reports that although the nail changes are asymptomatic, he does experience wrist joint discomfort. Physical examination reveals nail changes and several erythematous patches on his knees and elbows.

Psoriasis is a common skin condition that may negatively affect a patient’s quality of life.1 The disorder is associated with multiple comorbidities such as cardiovascular disease and diabetes mellitus.2 A significant percentage of patients with psoriatic nail changes will develop psoriatic arthritis,3 and...

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Psoriasis is a common skin condition that may negatively affect a patient’s quality of life.1 The disorder is associated with multiple comorbidities such as cardiovascular disease and diabetes mellitus.2 A significant percentage of patients with psoriatic nail changes will develop psoriatic arthritis,3 and nail psoriasis frequently accompanies cutaneous disease in up to 50% of patients.4 Less common is the patient with psoriasis who presents with only nail disease.

Clinical characteristics of nail psoriasis include nail pitting, discoloration or oil spots, lines, onycholysis, and nail crumbling. Unlike in patients with onychomycosis, nail changes in patients with psoriasis are more prominent in fingernails than toenails.

Topical therapies are hampered by poor penetration into the nail.5 Intralesional injection of triamcinolone, although effective, is painful and must be repeated at variable intervals.6 Acceptable clearance with systemic therapies (methotrexate, cyclosporine, and acitretin) has been inconsistent.7 Superior results have been achieved with a number of biologic agents including tumor necrosis factor inhibitors, a combination of interleukin (IL)-12 and IL-23 inhibitors, and IL-17 inhibitors.8

Stephen Schleicher, MD, is director of the DermDox Center for Dermatology, associate professor of medicine at Commonwealth Medical College, and clinical instructor of dermatology at Arcadia University and Kings College.

References

1. Duvetorp A, Østergaard M, Skov L, et al. Quality of life and contact with healthcare systems among patients with psoriasis and psoriatic arthritis: results from the NORdic PAtient survey of Psoriasis and Psoriatic arthritis (NORPAPP)Arch Dermatol Res. 2019;311(5):351-360.

2. Gisondi P, Bellinato F Birolomoni G, Albanesi C. Pathogenesis of chronic plaque psoriasis and its intersection with cardio-metabolic comorbiditiesFront Pharmacol. 2020;11:117.  

3. Ogdie A, Coates LC, Gladman DD. Treatment guidelines in psoriatic arthritis. Rheumatology (Oxford). 2020;59(Suppl 1):i37-i46.  

4. Baran R. The burden of nail psoriasis: an introductionDermatology. 2010;221(Suppl 1):1-5.

5. Thatai P, Khan AB. Management of nail psoriasis by topical drug delivery: a pharmaceutical perspectiveInt J Dermatol. doi:10.1111/ijd.14840

6. Pasch MC. Nail psoriasis: a review of treatment optionsDrugs. 2016;76(6):675-705.

7. Schons KR, Knob CF, Murussi N, Beber AA, Neumaier W, Monticielo OA. Nail psoriasis: a review of the literatureAn Bras Dermatol. 2014;89(2):312-317.

8. Elewski BE, Baker CS, Crowley JJ, et al. Adalimumab for nail psoriasis: efficacy and safety over 52 weeks from a phase-3, randomized, placebo-controlled trialJ Eur Acad Dermatol Venereol. 2019;33(11):2168-2178.