Nail pitting psoriasis

Nail pitting psoriasis, common causes of nail pitting include psoriasis, alopecia areata, and eczema. A few pits can also be seen in normal nails. Uncommon causes include parakeratosis pustulosa, pemphigus vulgaris, sarcoidosis, dermatomyositis, drug-induced erythrodenna, secondary syphilis, Reiter’s disease, chronic renal failure / hemodialysis, and chronic paronyehia 

Certain characteristics of nail pitting can help to identify its etiology. Psoriatic pits are typically deep, indicating involvement of the intermediate and ventral nail plate. Moreover, presence of more than 20 pits is suggestive of psoriatic nail disease. 

Over 60 pits has been said to be diagnostic of psoriasis. In contrast, pits in alopecia areata are small, superficial and usually arranged in a regularly distributed geometric pattern. 

They may demonstrate a “rippled” effect and run along longitudinal or transverse lines. Other nail signs of alopecia areata include mottled erythema of the lunula, onychomadesis, and trachyonychia. 

Pits in eczema are coarse, very irregular and associated with cross ridging. The term elkonyxis describes a very large irregular depression, which can be seen in syphilis, Reiter’s disease, following a traumatic event, or after isonetinoin therapy. 

Small pitted craters on the middle and ring fingers, known as Rosenaus depressions, are characteristically seen in patients with diabetes mellitus. It is important to remember that an isolated pit is not diagnostic and may be idiopathic in nature. 

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