Nail pitting

Pits are superficial depressions within the nail plate that vary in morphology and distribution. A pit indicates a defect in the uppermost layer of the nail plate, which arises from the proximal nail matrix.
Or for more simple, Nail pitting Superficial depressions in the nail plate.

 When a series of transverse grooves parallels the proximal nail fold the cause is likely to be repeated trauma from overzealous manicuring. ‘Rhythmic’ parallel transverse grooves may be an isolated sign of psoriasis, equivalent to patterned pitting.

Nail pitting may also be present in alopecia areata and lichen planus.5 However, the most characteristic features in lichen planus are longitudinal grooves and fissures, and dorsal pterygium, and nail pitting may not be present.3 In alopecia areata, nail pitting is usually fine and stippled, and other features such as areas without body hair should be present.

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Nail pitting due to psoriasis. Pits are large, deep and irregularly scattered, in contrast with alopecia areata, where they are small, superficial and geometrically distributed.
Diseases that produce nail pitting include psoriasis, alopecia areata and eczema.

Nail matrix damage produces irregular pitting and Beau’s lines; onychomadesis can occur in severe cases. Chronic eczema frequently localizes to the hyponychium, resulting in subungual hyperkeratosis, onycholysis and fissuring of the hyponychium. Chronic eczema of the proximal nail fold can lead to chronic paronychia. In atopic dermatitis, the nail plate frequently shows mild superficial abnormalities such as irregular pits and Beau’s lines. Controlling the skin disease results in gradual improvement of the nails.

For example, pitting must be treated at the level of the nail matrix. It is useless to treat the nail plate for pitting because the pathology that causes pitting is in the matrix. The nail plate is the end-product of the nail matrix and, in its normal state, is a smooth translucent hard structure that is tightly adherent to the nail bed. Nail plate abnormalities can be traced to the nail matrix, as in pitting, or to the nail bed or nail fold, as in a space-occupying lesion.


The configuration of nail pitting depends on the area of the matrix involved, and the duration of the pathological process in the nail matrix. The longitudinal dimension of the pits is determined by the length of time that the psoriasis is active in that portion of the nail matrix.

Treatment of pitting due to any of the dermatological disorders must be directed to the matrix of the nail. Topical corticosteroids under occlusion and intralesional triamcinolone acetonide 2–3 mg/ml into the proximal nail fold are the most effective treatment for nail pitting.

The combination of the nail pitting and onycholysis with the silvery-white, scaly patches in the external ear canal and scalp (classical signs of skin psoriasis) makes nail psoriasis the most likely diagnosis in this case.

Nail pitting

 In alopecia areata, nail pitting is usually fine and stippled, and other features such as areas without body hair should be present.

Pitting was the most common finding in psoriasis, accounting for 70% cases. Next most common nail changes were onycholysis in 52% and subungual hyperkeratosis in 40%cases. Discoloration was found in 25% cases followed by paronychia in10% cases. Splinter hemorrhages were seen in 12% and Beau’s lines were observed in 14% cases.

Pitting is most common nail abnormality seen in psoriasis and affects finger nail more commonly than toe nails. Pitting is due to focal parakeratosis of abnormally keratinizing cells of the proximal nail matrix. As the nail plate grows out, parakeratotic cells are lost and leave behind a punctate surface depression.

Pitting in psoriasis is deep, irregularly and randomly placed. In psoriasis, onycholysis commonly starts at the free distal edge of the nail plate but may commence in the centre of the nail plate also. When onychodermal band is disrupted, the condition is progressive.

It has been shown that regular pitting may convert to rippling or ridging, and these two conditions appear, at times, to be variants of uniform pitting . Nails showing diffuse pitting grow faster than the apparently normal nails in psoriasis. Occasional pits occur on normal nails. Deep pits can be attributed to psoriasis, and profuse pitting is most often due to this condition. In alopecia areata shallow pits are usually seen and they are often numerous, leading to trachyonychia  and twenty-nail dystrophy; however, curiously, one nail often remains unaffected for a long time, Pits may also occur in eczema or occupational trauma. In some cases a genetic basis is thought likely. In secondary syphilis and pityriasis rosea pitting occurs rarely. One case of the latter has been observed with the pits distributed on all the finger nails at corresponding levels, analogous to Beau’s lines.

Since treatment of nail psoriasis is always disappointing, before treatment is started the individual problems of every patient should be carefully considered, and in particular the degree of discomfort that results from the nail lesions. Reassuring the patient is probably the best approach for isolated nail pitting, oily patches, mild onycholysis and splinter haemorrhages. However, diffuse onycholysis, subungual hyperkeratosis and severe nail plate surface abnormalities may require a positive therapeutic approach.

See the video with nail pitting


Resources of study:

Journal of Pakistan Association of Dermatologists 2011
Nail changes in psoriasis – A profile Neerja Puri, B B Mahajan

The Royal Australian College of General Practitioners 2016 Nail pitting and onycholysis Joana Tendais-Almeida, Fátima Aguiar, Tiago Torres

An Atlas of DISEASES OF THE NAIL
Rich Phoebe, Richard K.Scher

Nail Disorders
Antonella Tosti and Bianca Maria Piraccini