Here is a photo of my horrid nails. They were all tidied last week and are back like this again. They don't look like a typical pitted psoriatic nail though even though they just won't grow nice

I think it’s worth showing that to a dermatologist for an opinion. It’s not an emergency, but an opinion could influence your diagnosis from the rheumatologist.

I’ve seen worse nails (like mine) but what I notice is ragged free edges and the darker areas of the nail bed. Also the scaliness of the cuticle. Google “psoriasis nails” and click on images. What do you think?

PS I don’t think that’s simply bad grooming.

Breaking off or crumbling … splitting hairs! I had nails and cuticles similar to yours before I went on Enbrel. The ragged, overgrown cuticles turned normal with the aggressive therapy. My toenail “fungus” disappeared as well.

No, you are right. Not everyone has psoriatic nails. And a small percentage of people have psoriasis which emerges only after the arthritis. If your nails are a symptom of psoriasis, it’s very mild. But here’s the thing: severity of skin manifestations doesn’t correlate with severity of arthritis. You can be severe in one and mild in the other. That is why, even if it seems vain and trivial to you, it’s important to have a derm look at those nails. If a dermatologist says, yes, that’s psoriasis, your rheumatologist then has another piece of information.

Good luck with this.

You saw a derm and were treated for what? (If you don’t mind my asking.)

There’s no harm in getting a referral, and everything to gain!

Well then, you have psoriasis. Maybe it hasn’t been very active, but it’s there. Almost makes asking about the nails unnecessary

Put your psoriasis history on top of your list of “stuff” and make sure your rheum knows it. I think I’ve changed my mind … no need to bother a dermatologist for your nails! Your history (a hospital admission for Ps)and your patches here and there will be quite enough information for the rheumatologist. But if you decide to go to a derm about the nails anyway, I’ll put my money on those being psoriatic.

I know, Nana. I’d want to know too. I had a long history of being dismissed by unhelpful doctors, and it really put the fear into me. They made me feel really stupid, and it delayed my diagnosis significantly, at the expense of my joints.

Take good care

My nails are not typical psoriatic nails either. In fact even a derm (two actually) failed to diagnose any of my skin problems as psoriasis because alot of that wasn't "typical" either. So from that point of view, NanaL, you're streets ahead with a psoriasis diagnosis already 'in the bag'.

I had a rheumy appointment in April and she spent a few minutes checking each nail and moving it in the light until she found one tiny pit on one nail ..... we laughed! But interesting what Seenie says about cuticles so I just gave mine some thought and have to concur with improvement since being on treatment. But what leaps out at me NanaL is the dry skin around the edges of your nails and finger tips (do they split?) .... that is very much how my psoriasis toes are at the moment. And my chiropodist picked up on toe nail changes ... thickening, brittle, flaking .... long before anything else.

Here is my right thumb in all it's current skin and nail psoriasis glory:

Nana L,

I had no psoriasis for 23 years or so before diagnosis. Slight exaggeration - I did have a pale patch of it on my elbow just before my first rheumy appointment. Of course it had gone by big day. I knew nothing about psoriatic arthritis, I was convinced I had Rheumatoid Arthritis. So I did wonder why the very nice rheumatologist was wasting so much time looking at one very slightly manky toenail which I'd assumed had a mild fungal infection.

It was that toenail that clinched the diagnosis.

Unfortunately psoriasis does not go away. I really thought and hoped mine had but it's back with a vengeance. Things are looking up quite a lot actually .... but the dermatologist I saw yesterday felt the need to emphasise to me that psoriasis is a long-term condition even when it is in remission.

My rheumatologist thought the rash I have now might possibly be discoid lupus. I was worried as he's so often right. But the dermatologists are now 100% sure it's psoriasis. Reason for the confusion? It's 'atypical' psoriasis. It is not text book stuff at all, it's my own little version. Same goes for the nails - skin psoriasis and nail psoriasis can vary considerably from one individual to another.

Nobody asked about your history … OK, good thing that’s on top of your list then.

And the rheumie was mystified? I’d be fairly sure that he didn’t win the prize at graduation. LOL

Oh my gosh! I'm so glad I'm not the only one! My nails look *exactly* like this. Let us know if you find anything out from your dermatologist. I was going to bring mine up with the rheumatologist, but I think I may need to make another appointment with my derm. Good luck!

I have bad heel pain (and MTP pain) so all my shoes have thick cushioned soles and those that don't take my orthotics .... although they don't do much cushioning. Skechers shoes are generally pretty good and do a range of trainer type shoes, FitFlops are also great with slightly smarter sneaker styles but still perfectly good for exercise, my biomechanical podiatrist has also recently told me about the Vionic make and my physio swears by ASICS(sp?).

Add that heel pain to your list of things to raise with the rheumy ..... PsA can cause problems with the plantar and achilles tendons both of which attach at the heel (bottom and top respectively) and can also cause the development of heel spurs at the insertion points due to the inflammation. Definitely do not overlook to mention this.

Try icing them NanaL .... I find either cold water (a paddle in the sea is heavenly) or resting with my heels in a tied bag of ice-cubes (or on the freezer block from my cool box) is great. I always have a thin teatowel between my foot and the frozen object to make sure I don't get ice burn or damage the skin. It's the ONLY thing which gives me any relief.

Have you tried rubbing in ibuprofen or diclofenac gel on your heel? This can work as well ..... my heel psoriasis is currently too bad to be able to apply a topical pain relief (apart from steroid gels and moisturisers) so I'm stuck with cool therapy only.

I shall spare everyone a picture of the soles of my feet and the wide, deep fissures on my heels and beneath the MTP's. It makes my joint pain pale into insignificance! The flare has been going on a year now. It is misery and every time I feel that I'm making progress it will slip back again. The only way I can stop all the plaques from splitting is to keep my treated and moisturised feet wrapped up in clingfilm or plastic bags 24 hours a day. My new middle name is Russelle on account of my constant rustling!

Before the psoriasis flared I used to keep my minimal hard skin under control with a gently file and CCS Heel Balm (the balm not the cream). It is well worth spending £20 to have a chiropodist tackle it the first time and then it's easier to stay on top of it yourself with a file and a balm. If it's really thick and hard then a great product is Calmurid (10% urea and 5% lactic acid) .... although it is pharmacy only my pharmacist would only sell it to me OTC when he knew I'd had it previously on prescription so you may need to ask your GP. It's £16-17 a tube OTC and you need to soak your feet first (Oilatum Bath is great for this).

I am so glad you found us NanaL ... the diagnosis would be good but in the meantime you can tap us all for practical help.

Nana L, if you go to a dermatologist and have proof of PsA, I think the dermatologist can get you a double dose of Enbrel for starters. But, that's just how they do it here in America. Your nails look like there's psoriasis around them, but you don't seem to have the pitting and rippling and the nails don't look like they're pulling away from the nail beds. I wish I had pics of mine from when they were bad. They still have some pitting and ridges, but they're 100x better than before I went on Enbrel. With all of your other symptoms, you should certainly qualify for a biologic.

I think you need a rheumatologist for a PsA diagnosis. As much as anything there's the professional reluctance to tread on a colleague's toes. You might get a very helpful opinion about PsA from a dermatologist but I suspect they'd tell you to see a rheumatologist.

It's definitely worth asking your GP for a dermatology referral. But I suspect you'd have to wait a while. I got to see a dermatologist under the 2 week rule for potential skin cancer, turned out I did not have cancer but they did commence treating my psoriasis. That was a stroke of luck as GP said I could expect a 3 month wait ordinarily.

What I'd do is ask for a dermatology referral anyway. Then, if your rheumy hums and hahs about your nails and history of psoriasis, you'd have a dermatology appointment lined up to shed some light on the subject.

My impression is that rheumatologists are getting better at diagnosing PsA. Hopefully your rheumatologist will be on the ball.

Nana L said:

I'm going to see my doctor Tuesday so I could ask him about a dermatologist. Can they diagnose PaA too or just a Rheumy ? I haven't been to see one for over thirty years. Thanks Grandma J

I had to wait until I was on my phone, but here’s a pic I just snapped of my own nails. It’s a little eerie how similar they are.
59-20150812_111225.jpg (2.43 MB)

Dermies a back door to getting the good meds more quickly. As the treatment is very similar for P and PsA, It doesn't matter. In the US, there are far fewer hoops to jump through to get the biologics for Psoriasis than PsA. You best bet is to have the two speak to each other. Believe it or not most rheumies LIKE havin the Derms manage the biologics. saves them lots of letter writing....................

I got the idea from somewhere that your rheumy appointment was quite soon Nana L. Was I wrong in that?