What is the management and treatment of nail pitting?

Management and Treatment of Nail Pitting

For nail pitting associated with psoriasis, treatment should be stratified based on the number of nails involved and disease severity, starting with intralesional triamcinolone acetonide (5-10 mg/cc) for limited disease (<3 nails) and escalating to systemic therapies for extensive involvement. 1

Initial Assessment and Diagnosis

Nail pitting is most commonly associated with psoriasis, occurring in approximately 37% of psoriatic patients, with incidence increasing with disease duration and severity. 2 The finding is present in up to 90% of patients with psoriatic arthritis. 1

Key diagnostic considerations:

• Pitting can occur in all psoriasis subtypes and may be the sole or first presentation of disease 3
• Dermoscopy enhances detection of subtle nail changes that may be missed clinically, with pitting being the most common finding (60.5% in fingernails, 84% overall) 4, 3
• Rule out other causes including alopecia areata, eczema, and connective tissue disorders 5

Treatment Algorithm Based on Disease Extent

Limited Nail Involvement (<3 Nails)

For nail matrix disease (where pitting originates):

• Intralesional triamcinolone acetonide 5-10 mg/cc is first-line treatment 1
• This targets the source of pitting in the nail matrix directly

For combined nail matrix and bed involvement:

• Intralesional triamcinolone acetonide PLUS topical steroids with or without topical vitamin D analogs 1
• This combination addresses both the pitting (matrix) and other nail plate changes (bed)

Extensive Nail Involvement (>3 Nails)

Systemic therapy is indicated:

• Acitretin 0.2-0.4 mg/kg daily is the primary systemic option 1
• Second-line option: Apremilast for patients who cannot tolerate or fail acitretin 1

Severe Disease or Dose-Limiting Toxicity

When nail disease significantly impacts quality of life or limits other treatments:

• IL-12/23 inhibitors (ustekinumab) or IL-17 inhibitors (secukinumab, ixekizumab) are preferred biologics 1
• Second-line biologics include TNF inhibitors (infliximab, etanercept, adalimumab, golimumab) 1
• Alternative systemic options: methotrexate 15 mg/week, cyclosporine A 3-5 mg/kg, or tofacitinib 1

Adjunctive Local Care

Supportive measures to optimize treatment response:

• Daily dilute vinegar soaks (50:50 dilution) twice daily to reduce inflammation 1, 6, 7
• Mid to high-potency topical steroid ointment applied to nail folds twice daily 1, 6, 7
• Regular nail trimming to prevent secondary trauma 6

Important Clinical Caveats

Treatment considerations:

• Nail psoriasis is acknowledged as "a significant therapeutic challenge" by the American Academy of Dermatology, requiring patience and realistic expectations 1
• The incidence of pitting increases with both duration and severity of cutaneous psoriasis (32% in <1 year duration vs 40.5% in >1 year; 34.2% in mild disease vs 47.6% in severe disease) 2
• Fingernails are involved in approximately 50% of psoriatic patients and toenails in 35% 1

When considering systemic immunomodulators:

• Consultation with relevant specialists is essential if the patient has comorbidities or is on other immunosuppressive therapies 1
• The choice between biologics may be guided by the presence of psoriatic arthritis or extent of cutaneous disease 1

Monitoring and follow-up:

• Reassess treatment response after appropriate intervals (typically 1-3 months depending on therapy) 1
• Watch for signs of infection, particularly with intralesional injections 6
• Dermoscopy can detect improvement in nail changes before clinical signs are apparent 4, 3

Treatment Failure Considerations

If inadequate response occurs:

• Verify treatment compliance and proper application technique 6
• Consider switching to alternative systemic agents within the same class or different mechanism of action 1
• Reassess for comorbid conditions that may impair treatment response 1