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Managing Difficult Nail Psoriasis and Onychomycosis


Boni E. Elewski, MD, shares her management pearls of how to treat difficult nail psoriasis and onychomycosis at the 2023 Winter Clinical Hawaii Dermatology Conference.

In her session, “Difficult to Treat Nail Psoriasis and Onychomycosis: Management Pearls,” Boni E. Elewski, MD, a James Elder Professor and chair of dermatology at the University of Alabama in Tuscaloosa, Alabama, shares her recommended treatment pearls for even the most difficult nail cases.

Elewski stressed the objectives of her session are for dermatologists to be able to recognize nail psoriasis, know when topical or intralesional therapy for nail psoriasis is preferred and when to use systemic options, recognize and understand the treatment of dermatophytomas, and recognize and treat antifungal resistant onychomycosis.

One pearl that Elewski discussed was the clinical cues of nail psoriasis. Nail psoriasis will usually appear on both hands, but not on all nails. She mentions that if only one hand is affected, make sure to rule out “one hand, two foot syndrome.” Patients with nail psoriasis may have arthritis, scalp or genital psoriasis, and may be overweight. Regarding toenails, clinical presentations of psoriasis in toenails may be non-specific and therefore difficult to rule out concomitant onychomycosis.

Clinical features of nail psoriasis that are most indicative of a diagnosis include:

  • Irregular pitting of the nail plate
  • Salmon-colored patches or oil spots on the nail bed
  • Onycholysis with erythematous borders

Other less specific clinical features of nail psoriasis include:

  • Nail bed (subungual) hyperkeratosis
  • Onychorrhexis of fingernails
  • Splinter hemorrhages

Another one of Elewski’s treatment pearls reviewed challenges of topical medications used to treat nail psoriasis. Elewski’s main message was to be wary of topical corticosteroids related to distal phalangeal atrophy. In a patient example, a 62-year-old female who applied .05% fluocinonide ointment 4 times a day for one month eventually developed distal phalangeal atrophy and had a fingertip that “resembled a sharpened pencil.”

Elewski concluded her session by reviewing her key takeaways:

  • Consider topical treatment or ILK for three or less nail psoriasis involvement more than 3 nails may require systemic therapy
  • When using topical treatment for nail psoriasis, determine if the disease is in the nail bed or nail matrix
  • Biologics and systemic agents that are used for psoriatic arthritis may be most effective in nail psoriasis
  • Dermatophytomas do not respond to oral antifungals and are best treated with topical efinaconazole


  1. Elewski B. Difficult to treat nail psoriasis and onychomycosis: Management pearls. Presented at the 2023 Winter Clinical Hawaii Dermatology Conference; January 13-18, 2023; Kohala Coast, Hawaii.
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