The Bottom Line

Nail pitting — small dents or depressions in the nail surface — looks like the nail was poked with a pin. It happens when psoriasis, alopecia areata, or another inflammatory condition disrupts the cells in the nail's growth zone (matrix), causing small defects in the nail plate. Nail pitting is present in up to 50% of people with psoriasis and in about 30–66% of people with alopecia areata. Treating the underlying condition is the primary goal; the nail pitting itself often improves when the disease is controlled, though this takes months because nails grow slowly.

What Is Nail Pitting?

Nail pitting refers to small, shallow depressions or pits in the surface of the nail plate — like tiny pinpricks or ice-pick indentations. The pits can range from very shallow and fine to deep and coarse (clearly visible and felt when you run a finger across the nail surface).

Nail pitting is not a standalone diagnosis — it is a physical sign that reflects an underlying condition affecting the nail matrix, the growth center of the nail. The matrix sits under the skin at the base of the nail. When inflammation disturbs the matrix cells, small clusters of abnormal cells form and are incorporated into the nail plate. As the nail grows out, these abnormal clusters fall out, leaving behind small pits.

Who Gets Nail Pitting?

Nail pitting is most commonly associated with two conditions:

  • Psoriasis — up to 50% of people with psoriasis have some nail involvement, and pitting is the most common nail sign. In psoriatic arthritis, nail pitting is present in up to 80% of patients and is a hallmark finding that helps dermatologists and rheumatologists make the diagnosis.
  • Alopecia areata — the autoimmune hair loss condition. Nail pitting occurs in 30–66% of patients. Fine, geometric pitting arranged in rows is particularly characteristic of alopecia areata.

Other conditions that can cause nail pitting include eczema (atopic dermatitis), reactive arthritis, lichen planus affecting the nails, and sarcoidosis.

How Psoriasis Causes Nail Pitting

In nail psoriasis, the immune system attacks the nail matrix cells, causing them to proliferate abnormally and form parakeratotic clusters — clumps of immature, abnormal cells. When these clusters are shed as the nail plate grows out, they leave pits behind. Psoriasis also causes other nail changes beyond pitting, including:

  • Onycholysis — nail separation from the bed, often with a yellow-brown oil-drop discoloration at the margin
  • Subungual hyperkeratosis — thickening of the tissue under the nail
  • Splinter hemorrhages — thin dark red lines under the nail
  • Nail crumbling in severe cases

Nail Pitting in Alopecia Areata

In alopecia areata, the characteristic pitting tends to be fine, regular, and arranged in geometric rows — this geometric pitting is quite specific for alopecia areata. The pits tend to be smaller and more uniform than those seen in psoriasis. Nail findings can actually help confirm the alopecia areata diagnosis.

Diagnosis

A dermatologist can usually identify nail pitting on clinical examination. Key questions and observations include how many nails are affected, what the pits look like, whether there are other nail changes, whether skin psoriasis or hair loss is present, and whether there are joint symptoms. Dermoscopy (a magnifying device used to examine the nail) improves visualization. A nail biopsy is rarely needed but can confirm psoriasis or lichen planus in unclear cases.

Treatment Options

For Nail Psoriasis

  • Topical potent corticosteroids (clobetasol, betamethasone) applied to the nail fold and under the free edge — first-line for mild-to-moderate nail psoriasis
  • Intralesional corticosteroid injections (triamcinolone 2.5–5 mg/mL) into the nail matrix area — effective but can be briefly uncomfortable; typically repeated every 4–6 weeks
  • Topical vitamin D analogs (calcipotriol) or combination products
  • Biologic medications (TNF inhibitors like adalimumab/etanercept, IL-17 inhibitors like secukinumab, IL-23 inhibitors like guselkumab) are highly effective for nail psoriasis. Response rates of 60–80% improvement in nail scores have been reported with biologics.
  • Methotrexate, cyclosporine — older systemic options for moderate-to-severe disease

For Alopecia Areata

Treating the alopecia areata (with corticosteroids, minoxidil, or newer JAK inhibitors like baricitinib or ruxolitinib) typically improves nail pitting as well. Nail pitting associated with alopecia areata is generally not treated separately.

What to Expect

Because nail pitting represents a defect formed at the nail base, you need to wait for the nail to grow out before you can see improvement. Fingernails grow about 3–4 mm per month, so even with effective treatment, the pitted nail surface can take 4–6 months to be replaced by smooth, new nail. Be patient — nail improvement lags behind disease control, but it does come.

When to See a Dermatologist

  • You notice small dents or pits in your nails, especially if several nails are affected
  • You have psoriasis and your nails look pitted, discolored, or separated from the bed
  • You have alopecia areata and your nails have changed
  • Nail pitting is accompanied by joint pain or swelling (possible psoriatic arthritis — early rheumatology referral is important)
  • Your nail changes are affecting quality of life or making you self-conscious

Frequently Asked Questions

Does nail pitting hurt?

The pits themselves are usually not painful. However, when psoriasis causes significant nail lifting or thickening under the nail, pressure or contact with debris can cause discomfort. Intralesional corticosteroid injections used for treatment can be briefly uncomfortable but are well-tolerated by most patients.

Can I prevent nail pitting?

Nail pitting cannot be directly prevented — it is driven by the underlying condition. However, controlling your psoriasis or alopecia areata effectively will minimize nail involvement. Avoiding nail trauma is also helpful, as trauma can trigger or worsen nail psoriasis in a process similar to the Koebner phenomenon.

Do I have psoriasis if I have pitted nails?

Not necessarily — but psoriasis is the most common cause. Nail pitting should prompt a visit to a dermatologist to check for psoriasis, alopecia areata, or other conditions. If you have family members with psoriasis or you notice scaly red patches on your skin or scalp, that makes psoriasis more likely.

Can nail pitting go away completely?

Yes — with good disease control, nail pitting can resolve significantly or completely. Biologics in particular have shown impressive nail clearing in psoriasis patients. Even with non-biologic treatments, many patients see meaningful improvement within 6–12 months of consistent therapy.

  1. Jiaravuthisan MM, et al. Psoriasis of the nail: anatomy, pathology, clinical presentation, and a review of the literature. J Am Acad Dermatol. 2007;57(1):1-27.
  2. Tosti A, et al. Nail lichen planus. J Am Acad Dermatol. 1993;28(5):724-730.
  3. Alkhalifah A. Nail changes in alopecia areata. Dermatol Clin. 2013;31(2):141-154.
  4. Rich P, et al. Treatment of nail psoriasis with a biologic agent: a review. J Am Acad Dermatol. 2015;73(2):307-313.
  5. Scheinfeld NS, Tutrone WD. Psoriasis with nail and scalp involvement. Dermatol Ther. 2000;13(1):52-63.
  6. Baran R. A nail psoriasis severity index. Br J Dermatol. 2004;150(3):568-569.
  7. Tan ES, et al. Nail pitting in psoriasis: a clinical review. J Am Acad Dermatol. 2012;66(6):1008-1014.

Trusted Resources

Always consult a board-certified dermatologist for diagnosis and personalized treatment recommendations. This article is for educational purposes only.