Isolated Nail Psoriasis: A Case Report with Ten-Month Photographic Follow-Up 孤立性甲银屑病：一例随附十个月影像随访的病例报告

Nail psoriasis affects up to 50% of patients with cutaneous psoriasis and 80% of those with psoriatic arthritis [1], yet it may also occur in isolation without skin or joint involvement. Isolated nail psoriasis is diagnostically challenging and frequently confused with onychomycosis, traumatic dystrophy, or systemic conditions such as thyroid disease. Treatment of nail psoriasis is often difficult, with slow nail growth delaying visible recovery. Furthermore, therapeutic options are limited in patients who are breastfeeding, as many systemic or topical pharmacological agents carry risks of transfer into breast milk or potential harm to the infant.

We present the case of a 30-year-old postpartum woman with hyperthyroidism and a family history of psoriasis who developed isolated nail psoriasis. Due to her preference to avoid chemical-based medications during breastfeeding, she opted for oral herbal medicine therapy. Serial photographic documentation over ten months demonstrated progressive and near-complete remission.

Case Presentation

A 30-year-old female presented with a five-year history of progressive fingernail dystrophy. Her nails had become increasingly dull, brittle, and irregular, without any treatment during this period. She denied pain, joint stiffness, swelling, or cutaneous lesions. Toenails were unaffected.

Medical history was significant for hyperthyroidism. She was recently postpartum, actively breastfeeding, and expressed a strong preference to avoid chemical-based products during this period. Family history was notable for psoriasis in a first-degree relative. She worked in an office setting with no chemical or occupational exposures.

On examination, ten fingernails showed:

  1. Diffuse surface roughness and longitudinal ridging
  2. Pitting and dull opacity of the nail plates
  3. Distal onycholysis with yellow-brown discoloration
  4. Subungual hyperkeratosis

Skin and musculoskeletal examination were normal. KOH preparation and fungal culture were negative, excluding onychomycosis.

 

 

Treatment and Clinical Course

Given her postpartum status, breastfeeding, and avoidance of chemical or pharmacological products, and based on a TCM diagnosis of Qi Deficiency and Blood Stagnation leading to nail malnourishment, the patient was prescribed a customized daily oral herbal compound aimed at regulating systemic inflammation, improving peripheral circulation, and restoring nail matrix health, with close clinical monitoring. The formula was based on the classical Tangs Clinical Centre TCM prescription. All herbs were selected for their established safety profile during lactation. No topical or systemic conventional pharmaceuticals were used.

Photographic Documentation

  • Baseline: Multiple dystrophic nails with rough, brittle surfaces, ridging, pitting, subungual hyperkeratosis, and yellow-brown discoloration. Thumbnails were severely affected.
  • Month 2: Minimal change; dystrophy persisted though early reduction in subungual debris was noted.
  • Month 4: Improvement in nail surface smoothness and reduction of discoloration; edges less irregular.
  • Month 6: Significant improvement with clearer nail plates, decreased hyperkeratosis, and reduced onycholysis.
  • Month 8: Dramatic recovery; nails showed near-complete reattachment, smooth surface texture, and restored translucency. Thumbnails demonstrated substantial improvement.
  • Month 10: Near-complete remission; nails appeared smooth, structurally intact, and clinically indistinguishable from healthy nails.

The patient tolerated the herbal medicine well, with no adverse effects reported during treatment or breastfeeding.

Discussion

This case illustrates several important points:

  1. Diagnostic challenges:
    Nail psoriasis without cutaneous or articular involvement can mimic other conditions. Key diagnostic features in this case included pitting, ridging, subungual hyperkeratosis, and “oil-drop” discoloration, which distinguish it from hyperthyroidism-related onycholysis (Plummer’s nails) or fungal infection (ruled out by negative KOH).
  2. Postpartum therapeutic considerations:
    Management of nail psoriasis in postpartum and breastfeeding women is challenging, as systemic agents (methotrexate, acitretin, biologics) and even some topical therapies steroid may pose risks. This patient sought a non-chemical approach to avoid potential transfer through breast milk.
  3. Oral herbal medicine as an option:
    The patient achieved progressive and near-complete remission over ten months using only oral herbal therapy. While the precise mechanisms may include modulation of systemic inflammation, improvement in microcirculation, and support of nail matrix regeneration, further controlled studies are needed to validate efficacy and safety.
  4. Natural disease course vs therapeutic effect:
    Nail psoriasis is typically persistent and rarely resolves spontaneously, particularly when longstanding and familial. The temporal sequence of recovery documented in this case — with progressive improvement corresponding to continuous treatment — supports a therapeutic benefit rather than spontaneous remission.
  5. Long-term monitoring:
    Isolated nail psoriasis may precede psoriatic arthritis. This patient will require continued follow-up for early detection of articular involvement, especially given her family history.

Conclusion

We report a case of isolated nail psoriasis in a postpartum woman with hyperthyroidism and a family history of psoriasis, who achieved near-complete clinical remission over ten months with oral herbal medicine therapy alone.

This case underscores the importance of considering nail psoriasis in patients with unexplained nail dystrophy, even without cutaneous or joint disease. It highlights the unique therapeutic challenges in postpartum, breastfeeding women, where standard pharmacological options may not be acceptable. Serial photographic documentation provides strong objective evidence of therapeutic response, supporting the potential role of oral herbal medicine as a safe and effective management option in carefully selected patients.

Privacy

In situations where the disease information had already been made publicly available (as evidenced by prior articles), genuine names of individuals have been utilized. Conversely, in instances where there was no pre-existing public disclosure or at the explicit request of patients for privacy, pseudonyms have been employed. Furthermore, identities have been deliberately obscured, and certain contextual details and diagnoses have been modified to hinder any attempts at identification. It is essential to emphasize that the patients and encounters described in this work are authentic, and their consent for publication was duly obtained. As responsible authors, we earnestly implore all our readers to honor the privacy and confidentiality of these individuals. Additionally, certain scenarios, assessments, and clinical interventions have been altered to safeguard the anonymity of both patients and healthcare providers.

Reference

  1. Schons KR, Beber AA, Beck Mde O, Monticielo OA. Nail involvement in adult patients with plaque-type psoriasis: prevalence and clinical features. An Bras Dermatol. 2015 May-Jun;90(3):314-9. doi: 10.1590/abd1806-4841.20153736. Epub 2015 Jun 1. PMID: 26131859; PMCID: PMC4516108.