Nail pitting: small dents in the nails, causes and when to see a GP

Nail pitting refers to small depressions in the surface of the nail plate, The PCDS describes pits as punctate surface depressions and notes that they affect the fingernails more often than the toenails.

Because pits are small and can be few, many people only notice them when they look closely, or when the pattern becomes extensive. The NHS includes pitting in its pictures of nail changes, describing small dents or pits in nails as possibly a sign of nail psoriasis, eczema or alopecia.

The PCDS gives a useful rule of thumb: the type of pit can hint at the cause. A clinician looks at the pattern, as well as at the skin and scalp, to decide what is going on.

The NHS says psoriasis can affect the fingernails and that the surface of the nails can have dents and pits. In its image description of nail psoriasis, it notes small pits and dents, and thicker, whiter areas near the tip. The PCDS lists the findings in nail psoriasis as pits, distal and lateral onycholysis, oil drops, subungual hyperkeratosis, an uneven nail surface, paronychia, transverse midline depressions in the thumbnails and occasionally splinter haemorrhages.

The NHS says some people with psoriasis can develop psoriatic arthritis, an inflammatory condition affecting the joints, as they get older. Nail changes and psoriatic arthritis are related, so if you have pitting and also have joint pain, stiffness or swelling that keeps coming back, tell your GP. The PCDS notes that most nail conditions, including psoriasis, provide a major therapeutic challenge, so expectations should be realistic.

The NHS says to see a GP if a nail has changed shape, changed colour or fallen off and you do not know why. Pitting merits a GP appointment if you have not had a diagnosis, if you have patchy hair loss, a scaly rash or joint symptoms, or if the nails are becoming thickened, lifted or painful. The NHS also says to see a GP if you have psoriasis and your treatment is not working or is giving you side effects.

A GP can examine the nails and skin, scalp and joints, may take a nail clipping or sample if a fungal infection is suspected, and may refer you to dermatology. The PCDS notes that to avoid false negative results in suspected fungal infection, the nail should be cut back and debris removed for mycology rather than simply asking for a clipping.

There is no quick fix for pitted nails, and treatment depends on the underlying cause. For nail psoriasis, treatment is usually part of the overall psoriasis plan, which the NHS says may include vitamin D creams, emollients, steroid creams, and, if psoriasis is more severe, light therapy and medicines. A GP or dermatologist can advise on whether any of these are likely to help the nails specifically.

The PCDS general nail measures are sensible whatever the cause: protect hands from solvents and other chemicals by using gloves, use plenty of emollients and avoid soap, and avoid manicures. The NHS suggests rubber gloves for wet work, regular hand cream, trimming nails straight across, and not picking or biting nails.

• Wear gloves for cleaning and wet work.

• Moisturise hands and nails regularly, and avoid harsh soap.

• Avoid nail biting, picking and aggressive manicures or artificial nails.

• Keep nails short and trimmed straight across to reduce catching.

• Keep a record of any new skin, scalp or joint symptoms to show your GP.

On the NHS the route is the GP, and then a referral to dermatology if the diagnosis is unclear or nail psoriasis is associated with more extensive skin disease or joint symptoms. The NHS also says some areas allow self-referral to a podiatrist for nail problems. Some people see a private dermatologist for a quicker diagnosis. Whichever route, the diagnosis is usually reached by examination, and the same treatment options apply.