A 50-year-old woman comes to the office due to nail discoloration for the past several months. The patient is a realtor and says she feels embarrassed to shake hands with clients due to nail disfiguration. She has used several over-the-counter antifungal creams but with no relief. The patient reports no fever, chills, joint pain, or skin rash. She has no prior medical problems and takes only a daily multivitamin supplement. The patient has smoked half a pack of cigarettes daily for 30 years and drinks alcohol occasionally.
Vital signs are within normal limits. Most of her fingernails have the findings shown in the image below.

Which of the following is the most appropriate next step in management of this patient's condition?

Question

A 50-year-old woman comes to the office due to nail discoloration for the past several months.  The patient is a realtor and says she feels embarrassed to shake hands with clients due to nail disfiguration.  She has used several over-the-counter antifungal creams but with no relief.  The patient reports no fever, chills, joint pain, or skin rash.  She has no prior medical problems and takes only a daily multivitamin supplement.  The patient has smoked half a pack of cigarettes daily for 30 years and drinks alcohol occasionally.
Vital signs are within normal limits.  Most of her fingernails have the findings shown in the image below.

Which of the following is the most appropriate next step in management of this patient's condition?

Quizplus · Accepted Answer

This patient has nail pitting (small depressions on nail plate) and distal onycholysis (nail separation from nail bed), which are typical manifestations of psoriasis. Psoriasis is a common inflammatory skin disorder characterized by erythematous, well-defined plaques covered by thick silvery scales. The lesions are typically seen over the scalp, knees, elbows, back and gluteal cleft, and nail plates, and may be associated with mild itching. Psoriatic arthritis is a common extradermal manifestation, and the risk is increased in those with nail involvement. The diagnosis of psoriasis is typically based on clinical findings. For this patient, a careful skin examination may identify classic plaques and clarify the diagnosis. Skin lesions are usually treated with high-potency topical corticosteroids. Mild nail psoriasis involving 1 or 2 digits can be treated with topical corticosteroids and/or vitamin D analogs (eg, calcipotriol). Widespread nail involvement, as in this patient, generally warrants systemic therapy (eg, tumor necrosis factor-alpha inhibitors, methotrexate). plaques (Choice A) Bronchiectasis and tuberculosis are associated with yellowing of nails. Clubbing of the distal digits and nails is associated with intrathoracic neoplasms, intrathoracic suppurative diseases (eg, lung abscess, bronchiectasis), fibrotic lung disease, and cyanotic congenital heart disease. Pitting and onycholysis are more consistent with nail involvement of psoriasis. (Choice B) Fracturing and crumbling of the nails in psoriasis may resemble onychomycosis; potassium hydroxide microscopy or fungal culture can be helpful to clarify the distinction. However, pitting is more typical of psoriasis. (Choice C) Hypothyroidism is associated with brittle nails and onycholysis, but pitting is not a typical feature. (Choice D) Chronic viral hepatitis is associated with brittle, dystrophic nails, leukonychia, longitudinal striations, and an increased risk of onychomycosis. Educational objective: Pitting and onycholysis of the nail are typical manifestations of psoriasis. Nail involvement in psoriasis increases the risk of psoriatic arthritis. Mild nail psoriasis involving 1 or 2 digits can be treated with topical corticosteroids and/or vitamin D analogs, but widespread nail involvement generally warrants systemic therapy. __________ References: Nail psoriasis: a review of the literature. (http://www.ncbi.nlm.nih.gov/pubmed/24770509)

A 50-Year-Old Woman Comes to the Office Due to Nail