Nail Psoriasis or Onychomycosis? Pearls on Diagnosis and Management of Psoriatic Nail Disease

The discussion revolves around the differentiation and management of nail psoriasis versus onychomycosis. An essential part of diagnosis includes examining both fingernails and toenails, as abnormalities in more than one nail could indicate psoriasis. Key features of nail psoriasis include pitting, onycholysis with a red border, and oil spots, while onychomycosis typically presents with a history of athlete's foot. Nail psoriasis may sometimes be the only sign of psoriatic disease. A thorough inquiry into joint pain and symptoms is vital, as half of the patients with nail involvement may later develop psoriatic arthritis. The presentation of nail disease often varies between fingernails and toenails due to their differing growth rates. Treatment modalities differ based on the severity and extent of involvement; systemic therapies are recommended for extensive nail disease (four or more nails affected) due to better efficacy, with biologics like acitretin and specific IL-17 inhibitors showing significant effectiveness. For milder cases with fewer nails affected, topical treatments or intralesional steroid injections can be effective. A multi-faceted approach, depending on whether the disease is in the nail matrix or nail bed, is crucial for managing symptoms effectively. In summary, understanding nail pathology and using appropriate therapeutic strategies are key elements in treating patients displaying signs of nail psoriasis.