Psoriatic arthritis nails: signs, causes & treatment

If you've noticed tiny pits, sudden thickening, or a nail that seems to be pulling away from the skin, you're probably staring at a classic warning sign of psoriatic arthritis nails. Those changes can feel frustrating, even a bit scary, but the good news is that you don't have to live with them in silence. Spotting the problem early gives you a head start on the right psoriatic arthritis nail treatment and can keep your nails looking healthier sooner rather than later.

Understanding why your nails act the way they doand what you can do about ithelps you stay in control, reduces the risk of infection, and eases the emotional weight of having something that looks "different." Let's dive in together, step by step, as if we were having coffee and chatting about a friend's experience.

Why Nails Matter

The hidden alarm

Think of your nails as the canary in the coal mine. When the airway of the nail matrix (the part that builds the nail) gets inflamed, the changes you see on the surface are often the first clue that your immune system is firing up. In fact, studies from the National Psoriasis Foundation show that up to 90% of people with psoriatic arthritis (PsA) develop some form of nail involvement.

When nail changes precede joint pain

It's not uncommon to spot nail pitting or onycholysis (the nail lifting off the bed) months before you feel any joint stiffness. That early warning can be a lifesaver because the sooner you get help, the easier it is to keep the disease from spreading deeper into your joints.

Why you should care now

Besides the aesthetic concerns, nail problems can cause pain, catching on clothing, and even bacterial infections if the skin underneath cracks. Recognising the signs means you can talk to a dermatologist or rheumatologist with confidence and get the right plan in place.

Nail Change Checklist

Nail pitting

Small, pinprick depressions scattered across the nail surface are called pitting. They happen when inflammation disrupts the nail matrix's ability to lay down smooth keratin. If you're seeing a "Swiss cheese" pattern, that's a classic sign of nail pitting in PsA.

Onycholysis

This is the upward lifting of the nail from the nail bed. It often starts at the tip and can create a dark space where debris (and sometimes bacteria) love to hide. If your nail looks like it's floating, you're probably dealing with onycholysis.

Subungual hyperkeratosis

Thick, crumbly material builds up under the nail. It can feel gritty when you tap the nail and may cause the nail to become rigid. The term sounds clinical, but to you it just feels like a stubborn, hard patch you can't scrape off.

Thickening and crumbling

Many describe this as "thick nails psoriatic arthritis" because the nails become noticeably bulkier and may start to split or crumble at the edges. It's not just a cosmetic issuethick nails are more prone to breaks and pain.

Colour changes & splinter hemorrhages

Watch for a yellowish tint, brown streaks, or tiny red dots under the nail surface. These tiny splinter hemorrhages signal tiny blood vessels that have broken, another hallmark of inflammation.

Feature	PsA Nail Change	Fungal Infection	Eczema Nail
Pitting	Common, multiple small depressions	Rare	Occasional
Onycholysis	Often starts at the tip, may be bilateral	Often distal, may be painful	Less common
Hyperkeratosis	Subungual buildup, gritty feel	May appear as thickened nail plate	Usually mild
Colour	Yellow, brown spots, splinter hemorrhages	Yellowwhite, diffuse	Redness, scaling around nail

What Happens Inside

The inflamed nail matrix

The nail matrix is the growth centre at the base of the nail. When PsA's immune cells target this area, they release cytokines like TNF and IL17, which disrupt keratin production. The result? Those uneven pits and thick plates you've been noticing.

Koebner phenomenon

Ever notice that a small scratch on your toe suddenly turns into a pitted nail? That's the Koebner effecttrauma or pressure can trigger a flare in the same spot. It's why tight shoes or aggressive manicures sometimes make things worse.

Link to joint flareups

When the nail matrix is inflamed, the nearby tendons and joints often feel the heat too. Many patients report that a sudden change in their nails coincides with a burst of joint pain in the fingers or toes. Keeping an eye on the nails can give you a headsup before a fullblown flare.

Expert insight

Rheumatologist Dr. Wilson Liao from UCSF notes, "Nail involvement is not just a skin problem; it's a marker of disease activity. Regular nail checks are a simple yet powerful tool for monitoring PsA."

Diagnosing Nail PsA

Who to see first?

If you're unsure whether the changes are psoriasisrelated or something else, start with a dermatologist for a skinfocused exam. If they suspect joint involvement, they'll refer you to a rheumatologist who can take the whole pictureskin, nails, and jointsinto account.

Clinical exam & dermoscopy

During a visit, doctors often use a dermatoscopea tiny magnifying deviceto zoom in on the nail matrix. This helps them differentiate between true pitting and, say, a fungal infection that can mimic similar patterns.

Lab work and imaging

Blood tests for Creactive protein (CRP) and erythrocyte sedimentation rate (ESR) can flag systemic inflammation. Ultrasound of the nail unit or an Xray of the adjacent joints may also show subtle changes that support a PsA diagnosis.

Differential diagnosis checklist

• Fungal nail infection (onychomycosis)
• Psoriasisonly nail changes (without arthritis)
• Eczemarelated nail dystrophy
• Traumainduced nail damage

Helpful resources

For a deeper dive, the Arthritis Foundation offers clear explanations of nail involvement in PsA, and the National Psoriasis Foundation provides patientfocused guides on getting the right diagnosis.

Treatment Options Overview

Topical therapies

Firstline treatment often starts with potent corticosteroid ointments applied directly to the nail fold and matrix. Calcipotriene (a vitaminD analogue) can also help normalise keratin production. Consistency is keyapply twice daily for several weeks, and you'll start to see improvement.

Systemic medications

For moderatetosevere nail disease, especially when joint pain is present, doctors turn to biologics that target the exact cytokines driving the inflammation. TNF inhibitors (like etanercept), IL17 blockers (such as secukinumab), and newer IL23 inhibitors have all shown good results in clearing nail psoriasis.

Intralesional steroid injections

If a particular nail is especially stubborn, a specialist can inject a small dose of corticosteroid directly into the nail matrix. It's a quick office procedure, and many patients feel relief within weeks. The downside? A tiny risk of nail thinning, so it's usually reserved for isolated problem nails.

Light and laser therapies

Excimer laser and UVA1 phototherapy can target the nail matrix without affecting surrounding skin. These options are great for people who can't tolerate strong steroids or systemic drugs, though they often require multiple sessions.

Adjunct care

• Keep nails trimmed short to reduce trauma.
• Moisturise daily with a fragrancefree emollient.
• Avoid artificial nails and harsh chemicals that can worsen inflammation.
• Wear protective gloves when doing chores that involve water or detergents.

Balancing benefits & risks

Every treatment has pros and cons. Topicals are lowrisk but may be less effective for thick nail disease. Biologics can dramatically improve both skin and nails, but they require monitoring for infections. Discuss your lifestyle, preferences, and any past medication experiences with your doctor so you can pick the best path.

Living with Nail PsA

Emily's 6month journey

Emily, a 34yearold graphic designer, first saw tiny pits on her thumbnails while working on a client project. She thought it was stressrelated, but the pitting worsened, and a locking sensation appeared around her finger joints. After a referral to a rheumatologist, she started a biologic therapy combined with a topical steroid. Six months later, her nails were noticeably smoother, and she could finally wear short sleeves without feeling selfconscious.

Practical lifestyle hacks

• File nails in one directionbackandforth motions can cause splitting.
• Use a softbristle nail brush instead of metal tools.
• Swap harsh soaps for mild, pHbalanced cleansers.
• Apply a thin layer of petroleum jelly before bed to lock in moisture.

Mentalhealth matters

It's normal to feel frustrated or even embarrassed when your nails look different. Talking to a therapist, joining a PsA support group, or simply sharing your experience with friends can lift that emotional weight. Remember, you're not alonemany people face the same challenges and find strength in community.

Where to find support

The Psoriasis and Psoriatic Arthritis Association runs online forums where members exchange tips on nail care, medication experiences, and coping strategies. The National Psoriasis Foundation also offers a helpline for personalized advice.

Key Takeaways Summary

Nail changes like pitting, thickening, or onycholysis are often early signals of psoriatic arthritis nails. Spotting these signs early lets you get the right psoriatic arthritis nail treatment before joint pain escalates. Diagnosis involves a dermatologist, rheumatologist, dermoscopy, and sometimes lab tests or imaging. Treatment ranges from topical steroids and moisturisers to systemic biologics and laser therapyeach with its own riskbenefit profile. Daily nailcare habits, protective gear, and emotional support are essential for longterm wellbeing.

Now that you've got the rundown, why not take the next step? Check your nails for any of the clues we discussed, jot down what you notice, and bring it to your next doctor's visit. If you've already started treatment, share your progress in the commentsyour story could help someone else feel less alone.

Disclaimer: This article is for informational purposes only and does not constitute medical advice. Always consult with a healthcare professional before starting any new treatment regimen.