Introduction:
Depression in fingernails or toenails is called nail pitting. Nail pitting is most commonly associated with psoriasis. It may also be associated with eczema and joint inflammation. It also has the possibility of being inherited. It presents tiny dents in fingernails and toenails. Pitting is considered diagnostic when more than 20 pits are present in all the nails, and more than 60 pits are suggestive of nail psoriasis. Nail pitting does not always have to be counted as a problem; it is normal to observe a few nail pits in a person.
If nail pitting is associated with nail psoriasis, it may show the following changes:
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Deformation - Change in normal shape.
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Discoloration - Change in nail color.
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Thickening - Abnormal nail thickness.
Patients may also experience loose nails (nails may separate from nail beds called onycholysis); in severe cases, nails may even crumble.
What Are the Signs and Symptoms of Nail Psoriasis?
Nail psoriasis does not have any sex predilection, but patients over the age of forty are twice as affected as those under the age of 20. Nail changes may be the first clue in detecting psoriasis, as it is mainly associated with the disease. Discoloration, onycholysis (a nail disorder where the nail separates from its nail bed), and hyperkeratosis (a condition characterized by thickening of the outer layer of the skin) are also seen.
If nail pitting is associated with psoriasis, other symptoms expressed are:
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Dry, cracked, bleeding skin.
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Red patches on the skin.
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Burning skin or itching skin.
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Swollen or stiff joints.
What Are the Causes of Nail Pitting?
Nail pitting is most commonly associated with psoriasis. However, there are a few other causes of nail pitting that are unrelated to psoriasis. These include the following disorders:
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Reactive Arthritis: Reiter's syndrome or reactive arthritis is also a condition in which nail pitting is found. It occurs after an infection in the intestine, genitals, or urinary tract.
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Incontinentia Pigmenti: It is a rare genetic condition, also known as Bloch-Sulzberger syndrome. Some symptoms include short, smaller teeth and eyes that are smaller than average, other than nail pitting. In addition, it has female predominance, while the male affected die before birth.
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Pemphigus Vulgaris: It is a rare autoimmune disorder marked by blistering skin and mucous membranes.
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Alopecia Areata: It is an autoimmune disease causing hair loss on the head and body. In addition, the dents in the condition are finer than those from other conditions, and the nail may break easily.
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Lichen Planus: Lichen planus is a condition where the exact cause is not found. It is characterized by swelling and irritation of the skin, nails, hair, and mucous membranes.
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Psoriatic Arthritis: It is also a persistent disease; it causes stiffness, pain, and swelling in joints, where ligaments and tendons attach to the bones. Nail pitting is the most common symptom associated with this disease; the continual growth of the nail causes it. The inflammation in the nail matrix causes the nails to grow continuously, which causes pitting.
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Eczema: If eczema is present on the hands and feet, nail pitting may also be found. It may be uneven and rough in contrast to other conditions where it is uniform.
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Sarcoidosis: It is a disease characterized by clumps of inflammatory cells in different body parts. In rare cases of sarcoidosis, nail pitting is seen.
How to Diagnose Nail Pitting?
The first step after noticing nail pitting is to consult a doctor. One must also share other symptoms they face, as this will help the doctor diagnose the underlying condition and determine if it is associated with psoriasis or any other disorder.
A skin biopsy may be ordered to confirm the diagnosis. This is done by taking a small sample of the skin or nails and examining it under a microscope. It is a painless procedure as it is done under local anesthesia.
How to Treat Nail Pitting?
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The pits are formed as the nails form, and because of this, treating nail pitting is difficult. As it has to be prevented before the formation of nails, topical medications will not be effective.
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In addition, topical medications will not be able to reach the nail bed, and because of this, topical steroid injections may be used. However, the results of these injections may vary.
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Phototherapy or light therapy may be a good option. Ingesting vitamin D3 supplements may also be recommended.
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Immunosuppressants such as Cyclosporine and Methotrexate are also suggested; however, these medications have severe side effects, so taking them for treating nail pitting is not recommended unless these medications treat the underlying cause.
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Since the treatment of nail pitting takes time, patients may have to do cosmetic procedures such as filing, polishing, or scraping for short-term results.
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In rare cases, surgical removal of the nail may be necessary to facilitate regrowth.
Is Nail Pitting Curable?
The treatment for nail pitting is often a time-consuming slow process. And the treatment might show results infrequently. Preventing or avoiding the cause of nail deformity is the best alternative. Care has to be taken to avoid trauma to the hands and feet. The treatment option differs from the underlying cause of nail pitting. If a person is diagnosed with nail psoriasis, the treatment involves multiple levels of interprofessional approach. As most patients with psoriasis would feel discouraged about their condition, they would be stressed and upset. Hence they would need counseling. If the nail is observed to be separating from the nail bed, it might be due to a fungal infection, and appropriate treatment is warranted.
How to Limit Nail Pitting?
One may not be able to avoid nail pitting altogether, as it might be one of the earliest signs, but it can be prevented from getting worse by:
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Proper hydration.
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Intake of vitamin B and zinc.
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Proper diet.
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Clipping the nails so that any friction-related damage can be avoided.
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Manicures are better avoided, as they may be sensed as trauma and aggravate the pitting.
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Wearing gloves will prevent chemical or physical damage. For example, cotton or nitrile gloves can be used while cooking or washing dishes.
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Moisturizing hands and feet will keep the nail bed and the skin around the nail hydrated and protected.
Conclusion:
Nail pitting is a condition where an individual's nails have pits or depressions. This usually occurs due to other disorders, such as psoriasis, lichen planus, reactive arthritis, etc. Treating the underlying condition resolves the nail changes. Symptomatic treatment, such as moisturizing and preventing any cause of aggravation, can also keep the disease in check.
