Nail Psoriasis: Pitting, Lifting and How It Differs from a Fungal Nail
The signs of nail psoriasis, how it differs from a fungal infection, and the treatments that help.
Part of our psoriasis guide.
Get urgent help first. Call 999 or go to A&E if your skin suddenly becomes red and inflamed over most of your body, or you have widespread pus-filled spots, especially with a fever, chills or feeling very unwell. These can be signs of erythrodermic or generalised pustular psoriasis, which are emergencies. See a GP soon if you have painful, swollen joints. Online treatment isn't suitable in these situations.
Key fact: nail psoriasis affects around half of people with psoriasis. It causes pitting, lifting and discolouration, can look like a fungal infection, and takes months to improve because nails grow slowly.
Adults only online, and not in pregnancy or breastfeeding. Access Doctor's online psoriasis service is for adults aged 18 and over, and can't supply treatment if you're pregnant or breastfeeding: your GP or midwife can help. Children with psoriasis should see their GP.
Signs of nail psoriasis
- Pitting: tiny dents on the nail surface, like the surface of a thimble.
- Onycholysis: the nail lifts away from the nail bed, starting at the tip, leaving a white or yellow area.
- "Oil drop" or "salmon patch": a yellow-red mark under the nail.
- Thickening and crumbling of the nail, with build-up of skin under it.
- Discolouration and ridges; small lines of bleeding under the nail.
Nail psoriasis affects around half of people with psoriasis, and most people with psoriatic arthritis. Nail changes can be a sign that the joints may be affected, so tell your GP if you also have joint pain or swelling. See psoriatic arthritis.
Nail psoriasis or a fungal nail infection?
| Nail psoriasis | Fungal nail infection | |
|---|---|---|
| Pitting | Common | Rare |
| Number of nails | Often several fingernails and toenails | Often starts in one or two toenails |
| Skin elsewhere | Usually psoriasis elsewhere on the skin or scalp | Often athlete's foot |
| Treatment | Steroid or vitamin D treatments, or specialist treatment | Antifungal paint or tablets |
The two can look alike and can happen together. A GP may send nail clippings to the lab to check for fungus before starting treatment, because antifungals won't help psoriasis and steroids won't help a fungal infection.
How nail psoriasis is treated
Nails grow slowly, so any treatment takes months: fingernails take about 6 months to grow out and toenails about 12 to 18 months. Creams struggle to get through the nail, so they're applied to the nail fold and the skin around and under the nail.
1
Look after the nails
Keep nails short, wear gloves for wet work and avoid damaging the nails or cuticles.
2
Topical treatment
A potent steroid or a vitamin D treatment such as calcipotriol, applied to the nail folds and under lifted nails, on a prescriber's advice. Results are modest.
3
Specialist treatment
For severe or painful nail psoriasis, a dermatologist may offer steroid injections into the nail fold, or tablets and biologic injections, which often work well on nails. See tablets, injections and light therapy.
Day-to-day nail care
- Keep nails short and filed smooth so they don't catch.
- Don't push back cuticles or clean under lifted nails with sharp objects.
- Nail varnish can hide pitting and is fine to use; remove it with an acetone-free remover.
- Avoid false nails, which can lift the nail further.
UK safety and reporting side effects
Prescription psoriasis treatments are only supplied after a GPhC-registered pharmacist independent prescriber reviews your consultation, including where your psoriasis is, how much skin it covers and what you have used before. Always read the patient information leaflet. Since 2024, UK steroid packs show their strength on the front (mild, moderate, strong or very strong). The MHRA advises using topical steroids for the shortest time needed, and to tell a healthcare professional if your skin flares badly after you stop a steroid you have used for a long time, which can be a topical steroid withdrawal reaction.
If you think you've had a side effect, tell your pharmacist or doctor. You can also report it to the MHRA through the Yellow Card scheme.
Getting help with nail psoriasis
Nail psoriasis usually needs a GP or dermatologist, especially if it's painful or affects many nails. If you have plaque psoriasis on your body, arms or legs, our pharmacist prescribers can assess that online: see our psoriasis treatment page.
Frequently Asked Questions
What does nail psoriasis look like?
Tiny dents (pitting), the nail lifting from the nail bed, yellow-red "oil drop" patches, thickening, crumbling and discolouration. It often affects several nails.
How can I tell nail psoriasis from a fungal infection?
Pitting and several affected fingernails point to psoriasis, while a fungal infection often starts in one or two toenails with athlete's foot. They can look alike, so a GP may test nail clippings.
What is the best cream for nail psoriasis?
A potent steroid or a vitamin D treatment such as calcipotriol, applied to the nail folds and under lifted nails, can help, but results are modest. Severe nail psoriasis usually needs specialist treatment.
How long does nail psoriasis take to improve?
Months. Fingernails take about 6 months to grow out and toenails 12 to 18 months, so you won't see the full effect of any treatment until the new nail has grown.
Is nail psoriasis linked to arthritis?
Yes. Nail changes are much more common in people with psoriatic arthritis. Tell your GP if you have nail psoriasis and painful, stiff or swollen joints.
References
- NICE Clinical Knowledge Summaries. Psoriasis. cks.nice.org.uk
- NICE. Psoriasis: assessment and management (CG153). nice.org.uk
- British Association of Dermatologists. Psoriasis: an overview (patient information leaflet), August 2023. skinhealthinfo.org.uk
- NHS. Psoriatic arthritis. nhs.uk
Medical disclaimer: This article is for information only and isn’t medical advice. Prescription psoriasis treatments need a clinical consultation before they can be supplied. If your skin is red all over, you have widespread pus spots, a fever or you feel unwell, seek medical advice the same day. In a medical emergency, call 999.