Sophia Delgado
Pitted fingernails are characterised by small indents or depressions on the nail surface. While nail pitting is not always a cause for concern, it may indicate an underlying condition such as psoriasis, dermatitis, alopecia areata, or other autoimmune conditions. Psoriasis is a common skin condition that causes inflammation and patches of red, scaly skin, and it affects the nails of up to 50% of sufferers. If you notice pits on your nails, it is advisable to consult a doctor or dermatologist, who can diagnose any underlying causes and recommend appropriate treatment options.
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Psoriasis
Nail pitting is often a symptom of nail psoriasis, an autoimmune condition that affects the nails on your fingers and toes. It causes discoloration, pitting and changes in the shape of the nails. While nail pitting is not always something to worry about, it may be a sign of underlying conditions like psoriasis, dermatitis and autoimmune conditions.
Nail psoriasis is a chronic condition that tends to flare up at different times in a person's life, due to reasons such as stress or illness. It is caused by the immune system overreacting, leading to new skin cells growing too fast. Typically, new skin cells grow every 28 to 30 days, but in people with psoriasis, new cells grow and move to the skin surface every three to four days, creating a skin rash.
Nail psoriasis is common, affecting over 50% of people with psoriasis and around 86% of people with psoriatic arthritis. It is not contagious and cannot be spread through skin-to-skin contact. It can occur in people with no signs of psoriasis on their skin, and it may be more likely to develop in people over 40 years old.
The symptoms of nail psoriasis include discoloration, pitting, thickening, and changes in the shape of the nails. Nails may turn white, yellow, or brown, and may have small red or white spots underneath. They may also develop ridges or grooves, and pinprick holes on the nail surface. Chalky white material can gather under the nail, causing it to lift away from the skin, which can be painful.
There is no cure for nail psoriasis, but there are treatments to alleviate symptoms. Treatment options include topical medications such as corticosteroids, vitamin D, and retinoid creams, as well as phototherapy and systemic medications. Good nail care is also important in managing the condition.
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Alopecia areata
Nail changes in people with alopecia areata can occur before, during, or after hair loss, or as an isolated finding. The most common nail problems include pitting, ridging, leukonychia (white nails), trachyonychia (rough, sandpaper-like nails), and in rare cases, a red-mottled lunula. Nails often show improvement as hair growth improves, but some people experience nail cosmetic disfigurement, pain, and functional limitations. Nail pitting is the most common nail manifestation of AA, caused by punctate erosion in the nail plate surface, sometimes called nail psoriasis. The depth and width of nail pits are related to the extent of the matrix involved, while the length can be determined by the duration of the matrix damage. Trachyonychia is another common nail manifestation caused by AA, making the nails look sandpapered. This is not a distinctive disorder that will allow clinicians to diagnose AA, but it is a presenting sign of several disorders.
People with nail symptoms tend to have more severe alopecia areata that is harder to treat. It is necessary to consider factors like age and disease severity when determining the optimal treatment approach for AA of the nails. The emergence of JAK inhibitors shows promise as an avenue due to their success in hair regrowth. Additionally, the development of new topical formulations holds the possibility of improved safety, particularly for vulnerable populations like pediatric patients, older adults, and individuals with comorbidities that precluded the use of systemic JAK inhibitors.
To protect your nails from damage, it is important to get alopecia under control. A dermatologist can help you find the right treatment to manage hair loss and nail problems. Some people with alopecia take nutrients like vitamin B complex, vitamins D and E, and biotin to strengthen their nails. You can also get these nutrients from a well-balanced diet.
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Atopic dermatitis
Nail pitting refers to small depressions or dimples that develop in finger and toenails. While it is not always indicative of a serious issue, nail pitting may be a symptom of an underlying condition, such as psoriasis, dermatitis, or autoimmune conditions.
Dermatitis, specifically, is an inflammatory condition that can affect the fingers, hands, and wrists. Atopic dermatitis, also known as atopic hand eczema, is a form of dermatitis that arises from a combination of inherited and environmental factors, leading to skin barrier dysfunction and immune system dysregulation. It is the most significant risk factor for chronic hand dermatitis, with a prevalence that increases with age.
The presence of nail pitting in individuals with atopic dermatitis has been observed in studies. In one study of 235 patients with atopic dermatitis, 10.2% exhibited nail abnormalities, with transverse groove (Beau's line) being the most common, followed by nail pitting at 16.7%. Another study examined the relationship between nail abnormalities and the severity of atopic dermatitis, finding that patients with total nail abnormalities had higher EASI (eczema area and severity index) scores than those without abnormalities.
The treatment for nail pitting associated with atopic dermatitis may involve a combination of medications, topical treatments, and lifestyle changes. It is important to consult a doctor for guidance and to determine the underlying cause of the nail pitting.
In addition to dermatitis, nail pitting is commonly associated with psoriasis, an autoimmune condition that affects the nails and skin. Psoriasis causes skin cells to reproduce rapidly, leading to nail changes such as discoloration, pitting, and alterations in nail structure. Treatment options for nail psoriasis include corticosteroid creams, ointments, or nail polish, as well as oral medications and medicine injections in more severe cases.
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Underlying health conditions
Fingernail pits, or small dents in your nails, can be a sign of an underlying health condition. While nail problems are usually not caused by anything serious, they can sometimes indicate an underlying health issue that requires medical attention.
One of the most common causes of nail pitting is psoriasis, a chronic skin condition that causes red and silver itchy, scaly skin. Nail changes are present in 25-50% of all cases of psoriasis, with pitting being the most frequent change observed. The presence of more than 20 nail pits suggests a psoriatic cause, and more than 60 pits per person are very likely to be caused by psoriasis. Psoriasis can also cause nails to thicken or separate from the underlying nail bed, known as onycholysis.
Other causes of nail pitting include atopic dermatitis (eczema), alopecia areata (hair loss), and arthritis. In rare cases, nail pitting can be caused by more serious underlying conditions, such as endocarditis or nail melanoma.
Nail pitting can also be associated with nutritional deficiencies. For example, white marks or discolouration on the nail could suggest heavy metal poisoning with lead or arsenic. Additionally, spoon nails, or nails that curve inwards and look thin and brittle, can be a sign of anaemia or iron deficiency. In some cases, spoon nails may also indicate coeliac disease or other inflammatory skin diseases like psoriasis.
While nail findings are often insignificant, it is important to see a healthcare provider if you notice any nail changes or other unexplained symptoms. They can administer tests to rule out and diagnose underlying conditions, and most causes of nail issues are easy to treat once identified.
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Treatments
Fingernail pitting is characterised by small indents or depressions on the nail surface. It is often linked to psoriasis but can indicate several other conditions, including alopecia areata, atopic dermatitis, arthritis, and sarcoidosis. If you notice nail pitting, it is important to see a healthcare provider, who can administer tests to rule out and diagnose underlying conditions.
Nail pitting can be challenging to treat, and treatment is often a long-term process that does not always yield the best results. However, some modern methods have been shown to be effective. Here are some treatment options for nail pitting:
- Medicines: Prescription and over-the-counter medications can help reduce symptoms of nail pitting. These include apremilast, biologics, cyclosporines, deucravacitinib, methotrexate, retinoids, upadacitinib, and tazarotene.
- Corticosteroids: Topical or injected corticosteroids are commonly used to treat moderate cases of nail pitting. Corticosteroids can help reduce inflammation and must reach the nail bed and the area where the nail starts to grow (nail matrix) to be effective. Corticosteroid treatments may take up to four to six months to show noticeable improvement.
- Medicine injections: In more severe cases, healthcare providers may inject medicine directly into the skin around the nails. These medicines include etanercept, adalimumab, and ustekinumab.
- Biologics therapy: In more severe cases of nail pitting, biologics therapy is the first-line option.
- Vitamin D3: Synthetic forms of vitamin D, or vitamin D analogs, are often used to help clear up the condition.
- Calcineurin inhibitors: Medications that affect how the immune system functions, such as calcineurin inhibitors, can be used to treat nail pitting.
- Antifungal treatment: If a fungal infection is causing nail pitting, antifungal treatment may be necessary.
- Steroid injections: Steroid injections directly into the nail can be painful but may be effective in treating nail pitting.
- Nail removal: In severe cases, nails can be removed using an ointment that takes about seven days to work, or through surgery with a local anaesthetic.
- Sarcoidosis treatment: For nail pitting caused by sarcoidosis, treatment includes oral corticosteroids, topical steroids, and steroid injections directly into the nail bed. The antimalarial medication hydroxychloroquine sulfate has also been used to treat nail changes caused by sarcoidosis.
- Alopecia areata treatment: Research has shown that immunosuppressants such as Xeljanz (tofacitinib) and Olumiant (baricitinib) are potential treatments for nail pitting caused by alopecia areata.
- Self-management: People with nail pitting should consider self-management steps such as wearing gloves during manual labour, avoiding cleaning nails with sharp objects or brushes, and soaking nails in warm water to remove debris. If the condition is mild and not causing discomfort, individuals can lead a normal life and may choose to cover the pits with nail varnish that does not contain acetone.
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Frequently asked questions
Fingernail pits are small indents or depressions on the nail surface.
Fingernail pits are often linked to psoriasis, a common skin condition that causes inflammation of the skin. However, they can also be caused by other conditions such as alopecia areata, atopic dermatitis, and eczema.
Fingernail pits are more common than toenail pits. In one study, fingernail pitting was present in 37% of patients with psoriasis, while it was present in only 9.7% of the control group.
Fingernail pits are usually not something to worry about, but they may be a sign of an underlying condition. If you notice pits on your fingernails, it is a good idea to see a doctor or dermatologist, who can examine your nails and perform tests to rule out any health concerns.
