Case study A 52-year-old medical secretary presented with 3 months history of painful fingers. She was concerned about repetitive strain injury. Nail involvement in psoriasis is common and present in up to 50 of patients with psoriasis. It can be the first presenting symptom in 5-10 of individuals. While finger and toenails can be affected, changes are seen more commonly i-n finger nails. Nail changes are associated with severe disease and significant morbidity. Psoriatic nail disease can affect nail matrix, nail bed or both. Changes in the nail matrix lead to pitting (most common), transverse ridging, leuconychia, spotting of lunula and crumbling; while nail bed disease leads to onvcholysis (very common, splinter haemorrhages, subungual hyperkeratosis and oil drop discolouration. The nail psoriasis severity index (NAPSI) is used to assess disease severity and response to nail-specific treatment. Differential diagnoses of nail pitting include alopecia areata, eczema and lichen planus. Concomitant onychomycosis can be found in a quarter of patients with nail psoriasis. If diagnosis is in doubt, a biopsy from the proximal nail matrix can be useful.
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