At a Glance - Nail psoriasis vs eczema nail

Dr Jean Watkins, a sessional GP in Hampshire

Psoriasis

Features

  • Aetiology is uncertain - possible combination of environmental, genetic and immune factors.
  • Nail changes are commonly found in patients with other signs of psoriasis and/or psoriatic arthritis and occasionally in those with no other skin manifestations of psoriasis.
  • Incidence increases with age.
  • Salmon patch: translucent yellow-red discoloration in the nail bed.
  • Pitting of the nails, onycholysis, leukonychia.
  • Dystrophic nail changes.
  • Occasionally nail biopsy from the nail bed is needed to confirm the diagnosis.

Management

  • Potent steroid solution under occlusion may help.
  • PUVA sometimes helps the nails as well as the skin.
  • Intralesional triamcinolone every 4-6 weeks may help reduce pitting, leukonychia and ridging.
  • Systemic methotrexate, retinoids or ciclosporin, but recurs after stopping treatment.
  • Avulsion of the nail.
  • Antifungal therapy if associated with fungal infection.

ECZEMA

Features

  • Nail changes may develop with pompholyx or chronic eczema of hands and/or feet.
  • Patients may have a genetic tendency to atopic eczema and/or pompholyx eczema.
  • May result from outside factors such as stress, handling irritant substances, frequent immersion in water or contact allergies.
  • May occur at any age. Usually patients have a history of long-standing eczema.
  • Irregular transverse ridging.
  • Pitting, thickening and discolouration.
  • Other signs of eczema of the hands or feet affected.
  • Usually a clinical diagnosis. Investigations not usually necessary except allergy testing and nail clippings to exclude fungal infection.

Management

  • Advise patients to avoid further use of any possible aggravating factors.
  • Protect hands with cotton-lined rubber gloves when in water.
  • Advise frequent use of emollients.
  • Topical steroids - a potent one may be necessary for the hands and feet.
  • Tacrolimus or pimecrolimus, azathioprine, methotrexate or ciclosporin.
  • Phototherapy.
  • If the eczema improves, nails will usually return to normal.

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