When should I consider referring a patient with nail changes for derma

Guideline-aligned answer with reasoning, red flags and references. Clinically reviewed by Dr Kola Tytler MBBS CertHE MBA MRCGP.

Consider referring a patient with nail changes for dermatological assessment if:

There is diagnostic uncertainty about the cause of the nail changes.
The nail disease has a major functional or cosmetic impact on the patient.
The nail changes are part of psoriasis that is severe, extensive, or not controlled with topical treatment.
Any type of psoriasis, including nail involvement, is having a major impact on the person's physical, psychological, or social wellbeing.
In specialist settings, use the Nail Psoriasis Severity Index to assess nail disease when it has significant impact or before and after treatment specifically for nail disease.

Immediate referral is also indicated if the patient has generalised pustular psoriasis or erythroderma, which may include severe nail involvement.

Children and young people with any type of psoriasis, including nail changes, should be referred to a specialist at presentation.

These recommendations are based on NICE guidelines for psoriasis assessment and management.

When should I consider referring a patient with nail changes for dermatological assessment?