Nail psoriasis is a common yet frequently misdiagnosed manifestation of psoriasis due to its variable clinical presentation and close resemblance to other nail disorders such as onychomycosis, nail lichen planus, and traumatic nail dystrophy. It affects approximately 40–50% of patients with cutaneous psoriasis and up to 80–90% of those with psoriatic arthritis (PsA), emphasizing its important clinical and prognostic implications.

Materials and Methods:
This observational study included 22 patients with isolated nail psoriasis without concomitant cutaneous involvement. Nail disease severity was assessed using the Nail Psoriasis Severity Index (NAPSI). Dermoscopic examination of all fingernails and toenails was performed to identify characteristic nail changes. Psoriatic arthritis was evaluated and diagnosed using the CASPAR criteria. Collected data were analyzed descriptively.

Results:
The most frequently observed dermoscopic features were nail pitting (90.9%), distal onycholysis (81.8%), and subungual hyperkeratosis (77.2%). Other findings included splinter hemorrhages, salmon patches, and leukonychia. Psoriatic arthritis was diagnosed in 32% of patients (n = 8), highlighting a substantial association between nail involvement and joint disease.

Conclusion:
Early and accurate diagnosis of nail psoriasis is essential, given its strong association with psoriatic arthritis and its potential role as an early clinical marker of systemic disease. Dermatologists frequently encounter patients with nail psoriasis before the onset of joint symptoms, placing them in a pivotal position to identify PsA at an early stage, even before clinical or radiological changes become apparent. Early recognition and timely intervention may reduce inflammation, prevent irreversible joint damage, and limit disease progression. This study underscores the importance of heightened clinical awareness, routine use of dermoscopy, and standardized diagnostic approaches to minimize misdiagnosis and improve long-term patient outcomes.

Dr. Divjot Kaur Arora has completed her M.D. residency in Dermatology from Dayanand Medical College & Hospital, Ludhiana and currently working as a Senior Resident at Sri Guru Ramdas Hospital, Amritsar. She has more than 10 presentations, 2 publications and 1 chapter.