What is nail psoriasis. How does it affect the nails. What are the main symptoms of nail psoriasis. Who is most likely to develop nail psoriasis. How is nail psoriasis diagnosed. What are the best treatment options for nail psoriasis. Can nail psoriasis be cured completely.

Understanding Nail Psoriasis: A Comprehensive Overview

Nail psoriasis, also known as psoriatic nail dystrophy, is a condition that affects the nails as part of the broader spectrum of psoriasis. It occurs when psoriasis involves the nail matrix or nail bed, leading to specific and non-specific changes in the nail structure and appearance. This condition can significantly impact a person’s quality of life, affecting both fingernails and toenails.

Is nail psoriasis common? Nail psoriasis is surprisingly prevalent, affecting up to 90% of patients with chronic plaque psoriasis at some point in their lives. It is more common in adults, with a prevalence of up to 80%, compared to children, where it has been reported in 7-13% of cases. Interestingly, nail psoriasis can occur in 5-10% of adults even without the presence of skin or joint psoriasis.

The Underlying Causes of Nail Psoriasis

Understanding the causes of nail psoriasis is crucial for effective management. This condition is part of the multifactorial systemic disease of psoriasis, which involves inflammation and epidermal hyperproliferation. Several theories attempt to explain the specific mechanisms behind nail psoriasis:

• Activation of the antimicrobial peptide LL-37 by Candida and the cytokine overflow theory
• Increased expression of interleukin(IL)-10 in the affected nail bed, contrasting with its downregulation in psoriatic skin lesions
• Koebnerisation of psoriasis triggered by onychomycosis or nail trauma

Can nail psoriasis be triggered by external factors? Yes, nail trauma or fungal infections (onychomycosis) can potentially trigger or exacerbate nail psoriasis in susceptible individuals. This phenomenon, known as the Koebner effect, highlights the importance of protecting the nails from injury and promptly treating any fungal infections.

Clinical Features and Symptoms of Nail Psoriasis

Nail psoriasis can manifest in various ways, affecting both the nail matrix and the nail bed. The clinical features can be categorized based on the area of the nail involved:

Signs of Nail Matrix Involvement:

• Pitting
• Leukonychia (white spots on nails)
• Red spots in the lunula
• Onychorrhexis (longitudinal nail ridges, splits, or fissures)
• Beau lines (transverse lines and ridges)
• Nail crumbling

Signs of Nail Bed Involvement:

• Oil-drop sign and salmon patch
• Onycholysis (separation of the nail from the nail bed), typically with a pink zone proximally
• Subungual hyperkeratosis (thickening of the skin under the nail)
• Splinter hemorrhages under the distal third of the nail plate

Do these symptoms cause discomfort? Indeed, psoriatic nail dystrophy can cause tenderness and pain, alter the sense of fine touch, and make it difficult to perform tasks requiring manual dexterity, such as picking up small objects or manipulating buttons and shoelaces.

Diagnosing Nail Psoriasis: Methods and Challenges

Diagnosing nail psoriasis accurately is essential for proper treatment. The process typically involves:

1. Clinical examination: Nail psoriasis is usually diagnosed based on the characteristic nail changes in patients with psoriatic arthritis and/or cutaneous psoriasis.
2. Severity assessment: The Nail Psoriasis Severity Index (NAPSI) is used to estimate the severity of nail psoriasis. Each nail is divided into quadrants and scored for clinical signs to generate a numerical score.
3. Fungal testing: Nail clippings are taken for fungal microscopy and culture to rule out or confirm concurrent onychomycosis.
4. Biopsy: In rare cases, a proximal nail matrix biopsy may be necessary to confirm the diagnosis, especially when only a single nail is affected or when a tumor needs to be excluded.

Are there any risks associated with nail biopsy? While a nail biopsy can provide definitive diagnosis in challenging cases, it’s important to note that it can lead to permanent nail deformity. Therefore, it’s typically reserved for cases where the diagnosis remains unclear after other non-invasive methods have been exhausted.

Treatment Approaches for Nail Psoriasis

Managing nail psoriasis often requires a multifaceted approach. Treatment options can be categorized into general measures, topical treatments, systemic treatments, and non-pharmacological interventions:

General Measures:

• Minimizing nail trauma
• Keeping affected nails short
• Treating associated onychomycosis for at least three months before addressing psoriasis

Topical Treatments:

• Corticosteroids
• Vitamin D3 analogues
• Tazarotene
• Tacrolimus
• 5-Fluorouracil

Systemic Treatments:

• Methotrexate
• Cyclosporine
• Acitretin
• Apremilast
• Biologic agents (e.g., TNF-α inhibitors, IL-12/23 inhibitors, IL-17 inhibitors)

Non-pharmacological Treatments:

• Phototherapy
• Pulsed dye laser
• Intralesional injections

Which treatment is most effective for nail psoriasis? The effectiveness of treatments can vary from person to person. Systemic treatments, particularly biologic agents, have shown promising results in severe cases. However, for milder cases, a combination of topical treatments and general measures may be sufficient. It’s crucial to work closely with a dermatologist to determine the most appropriate treatment plan based on the severity of the condition and individual factors.

Complications and Associated Conditions

Nail psoriasis can lead to various complications and is associated with other health concerns:

• Secondary onychomycosis: The damaged nail plate becomes more susceptible to fungal infections.
• Psychosocial effects: Nail psoriasis can impact social relationships and work-related activities due to the visible nature of the condition.
• Association with psoriatic arthritis: Nail psoriasis is considered a risk factor for the development of psoriatic arthritis.
• Metabolic syndrome: There is a potential association between nail psoriasis and metabolic syndrome, highlighting the systemic nature of psoriasis.

Does nail psoriasis increase the risk of other health problems? While nail psoriasis itself may not directly cause other health issues, its association with psoriatic arthritis and metabolic syndrome suggests that patients with nail psoriasis should be monitored for these conditions. Early detection and management of these associated conditions can lead to better overall health outcomes.

Prognosis and Long-term Outlook

The prognosis for nail psoriasis can vary significantly from person to person. Key points to consider include:

• Variable response to treatment: Some individuals may see significant improvement with treatment, while others may have more resistant cases.
• Slow visible response: Due to the slow growth rate of nails, visible improvements may take weeks or months to become apparent.
• Fluctuating severity: The severity of nail psoriasis can fluctuate over time, with periods of improvement and exacerbation.
• Possibility of spontaneous resolution: In some cases, psoriatic nail disease may resolve on its own without treatment.
• Risk of recurrence: Even with successful treatment, relapses are common, necessitating ongoing management and care.

Can nail psoriasis be cured permanently? While there is no permanent cure for nail psoriasis, many patients can achieve significant improvement or even temporary remission with appropriate treatment. The key to managing nail psoriasis effectively is early diagnosis, consistent treatment, and regular follow-ups with a dermatologist to adjust the treatment plan as needed.

Living with Nail Psoriasis: Practical Tips and Lifestyle Adjustments

For individuals living with nail psoriasis, certain lifestyle adjustments and practical tips can help manage the condition and improve quality of life:

• Nail care: Keep nails short and clean to minimize trauma and reduce the risk of infection.
• Protective measures: Wear gloves when doing manual work or household chores to protect the nails from trauma.
• Moisturizing: Regular use of moisturizers can help keep the nails and surrounding skin hydrated.
• Stress management: Since stress can exacerbate psoriasis, adopting stress-reduction techniques like meditation or yoga may be beneficial.
• Dietary considerations: While there’s no specific diet for nail psoriasis, maintaining a balanced diet rich in anti-inflammatory foods may support overall health.
• Avoid nail cosmetics: Limiting the use of nail polish and artificial nails can reduce chemical exposure and potential irritation.

How can patients cope with the psychological impact of nail psoriasis? The visible nature of nail psoriasis can significantly affect a person’s self-esteem and social interactions. Joining support groups, seeking counseling, and openly communicating with friends and family about the condition can help manage the psychological aspects. Additionally, working closely with a healthcare provider to achieve the best possible treatment outcomes can boost confidence and improve overall well-being.

Emerging Research and Future Directions in Nail Psoriasis Treatment

The field of nail psoriasis treatment is continually evolving, with ongoing research aimed at developing more effective and targeted therapies. Some promising areas of research include:

• Novel biologic agents: Researchers are exploring new biologic therapies that target specific pathways involved in psoriasis pathogenesis.
• Nanotechnology-based treatments: Nanocarriers are being investigated for their potential to enhance drug delivery to the nail unit.
• Combination therapies: Studies are examining the efficacy of combining different treatment modalities to achieve better outcomes.
• Personalized medicine approaches: Research is focusing on identifying biomarkers that could predict treatment response, allowing for more tailored treatment plans.
• Improved topical formulations: Development of new vehicle technologies aims to enhance the penetration and efficacy of topical treatments.

What advancements can patients expect in the near future? While it’s difficult to predict specific breakthroughs, the ongoing research suggests that patients may have access to more targeted and effective treatments in the coming years. These advancements could potentially lead to better management of nail psoriasis, with fewer side effects and improved quality of life for those affected by the condition.

In conclusion, nail psoriasis is a challenging condition that requires a comprehensive approach to diagnosis and treatment. While it can significantly impact a person’s quality of life, advances in understanding and treating the condition offer hope for better management and outcomes. By working closely with healthcare providers, staying informed about new developments, and adopting appropriate lifestyle measures, individuals with nail psoriasis can effectively manage their condition and maintain healthy nails.

Nail psoriasis | DermNet NZ

Authors: Vanessa Ngan, Staff Writer, 2003; A/Prof Amanda Oakley, Dermatologist, Hamilton, New Zealand, February 2016; DermNet NZ Update August 2021. Copy edited by Gus Mitchell

What is nail psoriasis?

Nail psoriasis, also known as psoriatic nail dystrophy, is due to psoriasis involving the nail matrix or nail bed, resulting in specific and non-specific clinical changes in the nail.

Nail psoriasis

Who gets nail psoriasis?

Nail psoriasis affects 90% of patients with chronic plaque psoriasis at some time in their life. It is more common in adults with a prevalence of up to 80%, compared to children in whom it has been reported in 7–13%. In the absence of skin or joint disease, psoriatic nail disease has been described in 5–10% of adults.

Psoriatic nail disease may be a risk factor the development of psoriatic arthritis and is often associated with prolonged severe cutaneous psoriasis.

Nail psoriasis can affect all races and age groups, and both sexes, although a male predominance has been reported in one large case series.

What causes nail psoriasis?

Psoriasis is a multifactorial systemic disease including inflammation and epidermal hyperproliferation.

Nail psoriasis can involve the nail bed, nail matrix, hyponychium, and nail folds.

Theories include:

• Activation of the antimicrobial peptide LL-37 by Candida and the cytokine overflow theory
• Increased expression of interleukin(IL)-10 in the affected nail bed compared to downregulation of IL-10 in psoriatic skin lesions
• Koebnerisation of psoriasis in onychomycosis or nail trauma.

What are the clinical features of nail psoriasis? 

Fingernails and toenails can be affected by nail psoriasis.

Psoriatic nail dystrophy can cause tenderness and pain, altered sense of fine touch, and difficulty picking up or manipulating objects such as shoelaces or buttons.

Clinical signs of nail matrix involvement

• Pitting
• Leukonychia
• Red spots in lunule
• Onychorrhexis (longitudinal nail ridge, split, or fissure)
• Beau lines (transverse lines and ridges)
• Nail crumbling

Signs of psoriatic nail matrix involvement

Clinical signs of nail bed involvement

• Oil-drop sign and salmon patch
• Onycholysis — typically with a pink zone proximally
• Subungual hyperkeratosis
• Splinter haemorrhages under the distal third of the nail plate

Signs of psoriatic nail bed involvement

Other clinical signs of psoriatic nails

Psoriatic nail dystrophy

[see also Nail psoriasis images]

What are the complications of nail psoriasis?

• Secondary onychomycosis in the damaged nail plate
• Psychosocial effects impacting social relationships and work-related activities
• Association with psoriatic arthritis and metabolic syndrome

How is nail psoriasis diagnosed?

Nail psoriasis is usually diagnosed clinically in a patient with psoriatic arthritis and/or cutaneous psoriasis.

The severity of nail psoriasis can be estimated using the Nail Psoriasis Severity Index (NAPSI) in which each nail is divided into quadrants and scored for clinical signs to come up with a numerical score.

Nail clippings for fungal microscopy and culture should be taken as onychomycosis may precede or complicate psoriatic nail dystrophy, and immunosuppressive medications may be used in treatment.

A proximal nail matrix biopsy is occasionally needed to confirm the diagnosis of nail psoriasis, particularly in the absence of signs of psoriasis elsewhere or where only a single nail is affected and a tumour cannot be excluded by other means. Biopsy can lead to permanent nail deformity.

What is the differential diagnosis for nail psoriasis?

What is the treatment for nail psoriasis?

General measures

• Minimise nail trauma, keep affected nails short
• Treat associated onychomycosis first for at least three months

Specific measures

• Topical treatments
• Systemic treatments
• Nonpharmacological treatments

What is the outcome for nail psoriasis?

Nail psoriasis has a variable response to treatment. The visible response may take weeks or months due to slow growth of the nail plate, and relapses are common.

Psoriatic nail disease can fluctuate in severity over time and can resolve spontaneously.

Bibliography

• Alves NCPOP, Moreira TA, Malvino LDS, et al. Onychomycosis in psoriatic patients with nail disorders: aetiological agents and immunosuppressive therapy. Dermatol Res Pract. 2020;2020:7209518.  doi:10.1155/2020/7209518. Journal
• Manhart R, Rich P. Nail psoriasis. Clin Exp Rheumatol. 2015;33(5 Suppl 93):S7–13. Journal
• Pasch MC. Nail psoriasis: a review of treatment options. Drugs. 2016;76(6):675–705. doi:10.1007/s40265-016-0564-5. Journal
• Schons KR, Knob CF, Murussi N, Beber AA, Neumaier W, Monticielo OA. Nail psoriasis: a review of the literature. An Bras Dermatol. 2014;89(2):312–17. doi:10.1590/abd1806-4841.20142633. PubMed Central
• Ventura A, Mazzeo M, Gaziano R, Galluzzo M, Bianchi L, Campione E. New insight into the pathogenesis of nail psoriasis and overview of treatment strategies. Drug Des Devel Ther. 2017;11:2527–35. doi:10.2147/DDDT.S136986. Journal

On DermNet NZ

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The Impact of Nail Psoriasis and Treatment on Quality of Life: A Systematic Review – FullText – Skin Appendage Disorders 2021, Vol. 7, No. 2

Abstract

At least 80% of patients with psoriasis will have nail involvement during their lifetimes. Understanding quality of life (QoL) impact of this condition and associated treatments is of utmost importance. Study objectives were to review the available literature describing patient-reported QoL outcomes in nail psoriasis and relationship with disease severity and treatment. A literature search was performed for English-language articles published prior to August 1, 2020. Articles were included in the review if primary data and validated patient-reported outcome measures assessing QoL were presented, and nail involvement was specifically examined. Fifteen studies were included in the final analysis. Patients with nail psoriasis had higher Psoriasis Area Severity Index and Dermatology Life Quality Index scores than those with psoriasis without nail involvement. The largest percent improvement in QoL score was associated with adalimumab. Studies investigating topicals, intralesionals, and systemic treatments were excluded since only biologic studies utilized validated patient-reported outcome measures. This review affirms that nail psoriasis is physically and emotionally distressing, warranting prompt treatment. Increased efforts are needed to address the impact of treatment on patient QoL using validated outcome measures that assess cosmetic, physical, and social problems.

© 2021 The Author(s). Published by S. Karger AG, Basel

Introduction

Psoriasis is a chronic skin disorder affecting about 2% of the US population [1]. At least 80% of psoriasis patients will have nail involvement in their lifetimes, while an estimated 10% have isolated nail psoriasis [1]. Clinical findings include nail plate pitting, onycholysis, splinter hemorrhages, “oil spots,” and subungual hyperkeratosis. Yet the impact of nail psoriasis extends beyond aesthetics, as this condition causes pain, functional impairment, and embarrassment.

While there is an expanding number of treatments for nail psoriasis, patient comorbidities, medication interactions, potential adverse effects, and costs must be considered [2]. Therefore, it is crucial to understand the impact of nail psoriasis on quality of life (QoL) to recommend treatment. Patient-reported outcome measures (PROMs) are useful tools to help patients vocalize their concerns. This review sought to evaluate the available literature describing the relationship of psoriasis severity and treatment with QoL outcomes as assessed by PROMs in nail psoriasis.

Materials and Methods

A search of the English-language literature published prior to August 1, 2020, for studies reporting QoL in patients with nail psoriasis was performed. MEDLINE and Embase databases were examined with the search terms “nail” and “QoL” (C.F.L). Abstracts were screened by 2 researchers (R.K. and L.A.) using the exclusion criteria: not an original article, valid PROM not used, and outcomes not reported in patient subgroup with nail involvement. Full-text articles were reviewed by 2 researchers (R.K. and L.A.) with discrepancies resolved by a third (C.R.). References of articles were searched to identify additional articles that may have been missed, although no studies were added (C.F.L.). Data were extracted and confirmed by 2 researchers (C.S. and L.A.). Study design, population demographics, severity, and QoL scores were extracted. To measure evidence level, we used a 5-point scale with the following ratings: (1) randomized clinical trial or systematic review with meta-analysis; (2) controlled trial without randomization or prospective cohort trial; (3) case-control study or retrospective cohort study; (4) cross-sectional study or case series with more than 5 patients; and (5) case report.

Results

A total of 430 full-text articles were assessed for eligibility with 15 studies included in this analysis. The study selection process is detailed in Figure 1.

Fig. 1.

Flow diagram of the study selection process.

Patient-Reported Outcome Measures

Five PROMS were used to assess QoL, with Dermatology Life Quality Index (DLQI) most commonly used (n = 10). DLQI scores correlate as 0–1 no effect, 2–5 small effect, 6–10 moderate effect, 11–20 large effect, and 21–30 extremely large effect [3]. The minimal clinically important difference has been established as 4.0 [4]. The International Onychomycosis-Specific Questionnaire, while designed to measure QoL in patients with onychomycosis, was used in 3 studies. This PROM is scored on a 0–100 scale with 100 representing the worst QoL [5]. The Nail Psoriasis QoL measure, Nail Assessment in Psoriasis and Psoriatic Arthritis Questionnaire (NAPPA-QoL), and NPQ10 Score were used in 1 study each. In the Nail Psoriasis QoL measure, scores range from 0 to 10 with 10 as most severe impact [6]. The NAPPA-QoL is a 20-item nail-specific QoL questionnaire assessing nail status, stigma, emotional, and everyday life impact [7]. The NPQ10 score is a nail-specific scale with scores ranging from 0 to 20 with higher scores indicating poorer QoL [8].

Demographics

The demographics of study populations were varied. The mean age of subjects across studies was between 43.3 and 57.5 years [6, 9-22]. Composition of females in study samples also varied from 19.2 to 63.0% [6, 9-22]. The mean duration of psoriasis in those with nail involvement ranged from 11.5 to 34.3 years [6, 9-22]. No studies included patients with comorbid onychomycosis.

Psoriasis Severity and Quality of Life

Eight studies compared clinician-assessed severity and DLQI in patients with and without nail involvement (Table 1) [9-15]. Severity was reported by Psoriasis Area Severity Index (PASI) and Nail Psoriasis Severity Index (NAPSI). Across studies, psoriasis with nail involvement was associated with significantly higher baseline PASI scores [9-15]. Nail involvement was also associated with significantly greater QoL impairment [9-15]. In studies with subgroup analysis by gender, women had higher PASI and DLQI scores than men [10, 12, 13].

Table 1.

Review of studies reporting the impact of nail involvement in psoriasis on QoL as measured by DLQI score

Reich and Szepietowski [23] (n = 30) found that patients with nail psoriasis were most concerned with appearance and disease worsening; NailQoL scores were correlated with NAPSI in women, but not in men. Ortonne et al. [8] (n = 795) reported that female gender, shorter disease duration, and presence of both fingernail and toenail involvement were associated with worse QoL, as measured by the NPQ10 Scale; PASI and NAPSI scores were not reported. In addition, 86% of patients considered nail psoriasis to be bothersome, 87% as unsightly, and 59% as painful [8].

Treatment, Severity, and Quality of Life

Nine studies reported QoL data in combination with systemic biologic treatments (Table 2) [6, 9, 16-22]. Two randomized controlled trials received the highest Level 1 quality of evidence ranking; all other prospective, open-label studies received Level 2 [6, 22].

Table 2.

Review of studies reporting efficacy and QoL impact of various treatments in psoriasis with nail involvement

For all treatment modalities (infliximab, etanercept, adalimumab, ustekinumab, and secukinumab), authors reported statistically significant improvement in both NAPSI and QoL with treatment [6, 9, 16-22]. Ortonne et al. [8] reported that 72% of patients were dissatisfied with treatment, but specific therapies were not specified. Infliximab (5 mg/kg infusion at baseline, 2, 6, and every 8 weeks thereafter for 38 weeks) was associated with the greatest reported percentage improvement in NAPSI (94.1%) [16] which was 4.3 percentage points higher than the next highest scoring treatment, ustekinumab [21], and 48. 8 percentage points higher than the lowest scoring treatment, secukinumab [22]. The ustekinumab dose was 45 mg for patients <100 kg and 90 mg for patients over 100 kg subcutaneous at baseline, 4, 16, and every 12 weeks thereafter for 40 weeks; secukinumab was dosed 300 or 150 mg subcutaneous weekly for 5 weeks and every 4–16 weeks [21].

While different parameters were used to assess QoL impact, multiple studies identified similar themes in specific domains of QoL that improved with treatment. Commonly mentioned themes across medications included improvement in symptoms, pain, functionality, and cosmetic appearance of nails, as well as improvements in personal relationships, business interactions, and ability to perform daily activities [16-18, 22].

When comparing reported percent improvement in QoL across treatment types, adalimumab had the greatest percent improvement from baseline. In 1 study, there was a 87.7% improvement in DLQI score, and in another study, a 88.2% improvement in Nail Psoriasis QoL Score [6, 19]. Of note, in a recent study by Kokolakis et al. [20], there was a lower percent improvement than Khobzey et al. [19] (60.0 vs. 88.2%) in DLQI. This difference may be due to the longer duration of disease in the study population investigated by Kokolakis et al. [19, 20]. In the study, using the Onychomycosis-Specific Questionnaire, the authors reported a mean improvement of 74.4% from baseline, while the studies reporting Nail Psoriasis QoL found 87.7% improvement [6, 18]. The percentage of patients with concomitant joint involvement ranged from 28.6 to 66.7% in these studies [6, 18-20].

Discussion

This review affirms that nail psoriasis is associated with both worse clinician-assessed severity and larger patient-reported QoL impact compared to psoriasis patients without nail involvement. Furthermore, the reviewed studies confirm that treatment of nail psoriasis leads to improved QoL. In our review, adalimumab was associated with the greatest percentage improvement in health-related QoL.

Some clinical trials have incorporated PROMs, however, analyzing patient QoL with validated outcome measures should be standard [24]. Our study also raised concerns as to whether existing PROMs can adequately evaluate the impact of nail changes. Though all studies found that DLQI is higher in patients with nail involvement, the differences in scores ranged from 1.2 to 1.9, which is below the minimal clinically important difference [4]. These findings contrast with clinical practice, in which patients with nail disorders have aesthetic, physical, and social disabilities. The DLQI, which is designed for general skin conditions, may not have relevant content validity to measure the outcomes most important in nail psoriasis. In a review of health-related QoL in patients with nail disorders, Reich and Szepie­towski [23] pointed out that when DLQI is applied to patients with both skin and nail involvement, the instrument cannot differentiate between the influence of nail versus skin changes on QoL. Since no studies excluded patients with psoriatic arthritis, it is not clear whether improvement in QoL scores was attributable to improvement in nail or joint symptoms. Only 3 studies utilized nail psoriasis-specific PROMs, thus limiting our comparisons.

This study is subject to several limitations. The lack of literature evaluating QoL and meeting our screening criteria limits the generalizability of our findings. None of the studies included children and only the studies by Radtke et al. [11] and Shear et al. [17] included adults over the age of 75, despite nail psoriasis being a concern in both pediatric and older patients. In the Joint American Academy of Dermatology – National Psoriasis Foundation guidelines for the treatment of psoriasis in pediatric patients, Menter et al. [25] recommended for consideration of the impact of disease on the “physical, social, and psychological QoL and/or activities of daily living” when determining the severity of psoriasis in children. Additionally, they highlighted the use of the Children’s DLQI, a derivative of the DLQI designed for patients aged 4- to 11-year old – a recommendation that we support for future research in this subgroup [25, 26]. Another limitation is that topicals, intralesionals, and systemics were excluded; only studies investigating biologic therapies met inclusion criteria for our review. Additionally, only 2 studies reported whether patients had previous exposure to biologics, though others did indicate that there was a washout period [17, 22]. If patients had failed treatment with other biologics, they may have had more severe disease with poorer QoL. The strength of evidence for the treatment studies was quite high, and the risk of bias was deemed to be low.

Conclusions

This review confirms that nail psoriasis is physically and emotionally distressing, warranting prompt and adequate treatment. However, the paucity of data limited types of treatments included in our analysis highlight the necessity of further research. While future studies should include PROMs as metrics to incorporate the patient perspective of the social, emotional, and functional impact of nail psoriasis, it is crucial that these PROMs capture the aspects most important to the patient and have content validity for use in nail psoriasis.

Statement of Ethics

Ethics approval was not required for this systematic review because all data was publicly available.

Conflict of Interest Statement

The authors have no conflicts of interest to disclose.

Funding Sources

The authors did not receive any funding.

Author Contributions

Claire Stewart was responsible for data extraction, writing of the manuscript, and figure creation. Leah Algu screened abstract and full-text articles and conducted data extraction. Rakhshan Kamran screened abstract and full-text articles. Cameron Leveille conducted publication search and organized search results. Khizar Abid found and organized full-text articles. Charlene Rae oversaw coordination and created the data extraction sheet. Shari Lipner is the senior author who conceived the study and wrote the manuscript. All authors reviewed the manuscript.

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Author Contacts

Shari R. Lipner

Department of Dermatology

Weill Cornell Medicine

1305 York Avenue, 9th Floor

New York, NY 10021 (USA)

[email protected]

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Nail psoriasis: clinical features, pathogenesis, differential diagnose

¹Department of Dermatology, Inselspital, University of Bern, Bern, Switzerland; ²Dermatology Practice Dermaticum, Freiburg, Germany; ³Centro de Dermatología Epidermis, Instituto CUF, Porto, Portugal; ⁴Department of Dermatology, University Hospital, Gent, Belgium

Abstract: Psoriasis is the skin disease that most frequently affects the nails. Depending on the very nail structure involved, different clinical nail alterations can be observed. Irritation of the apical matrix results in psoriatic pits, mid-matrix involvement may cause leukonychia, whole matrix affection may lead to red lunulae or severe nail dystrophy, nail bed involvement may cause salmon spots, subungual hyperkeratosis, and splinter hemorrhages, and psoriasis of the distal nail bed and hyponychium causes onycholysis whereas that of the proximal nail fold causes psoriatic paronychia. The more extensive the involvement, the more severe is the nail destruction. Pustular psoriasis may be seen as yellow spots under the nail or, in case of acrodermatitis continua suppurativa, as an insidious progressive loss of the nail organ. Nail psoriasis has a severe impact on quality of life and may interfere with professional and other activities. Management includes patient counseling, avoidance of stress and strain to the nail apparatus, and different types of treatment. Topical therapy may be tried but is rarely sufficiently efficient. Perilesional injections with corticosteroids and methotrexate are often beneficial but may be painful and cannot be applied to many nails. All systemic treatments clearing widespread skin lesions usually also clear the nail lesions. Recently, biologicals were introduced into nail psoriasis treatment and found to be very effective. However, their use is restricted to severe cases due to high cost and potential systemic adverse effects.

Keywords: nail psoriasis, etiology, pathology, quality of life, impact, treatment

Introduction

Psoriasis is a chronic inflammatory disease with a strong genetic background but highly influenced by environmental factors. Its prevalence is ~1–2% of the world population with considerable differences among regions and individuals with different skin types. It is the skin disease that most frequently affects the nail. At the time of consultation, roughly one half of the patients suffer from nail changes. Over lifetime, up to 90% of all psoriatics will have had nail alterations. The prevalence of nail psoriasis is even higher in psoriatic arthritis.¹ Nail lesions often appear around 10 years later than skin lesions, which may in part be the reason for nail psoriasis being observed less frequently in children. In general, cutaneous psoriasis is more severe in individuals with nail involvement.

Etiology and pathogenesis

Neither gender nor race predilection appears to exist. There is no association of HLA-C0602 with nail and joint involvement, but nail psoriasis is often associated with an inflammation at the insertion points of tendons and ligaments giving rise to enthesitis. Thus, the nail lesions were believed to represent an abnormal response to tissue stressing of the integrated nail-joint apparatus, rather than being due to autoimmunity. The nail and joint disease may be linked to tissue-specific factors, including tissue biomechanical stressing and microtrauma, that lead to activation of aberrant innate immune responses.² However, a case of skin and nail psoriasis definitely disappearing after allogeneic bone marrow transplantation is more in favor of predominant immunogenetic factors.³

Clinical characteristics of nail psoriasis

Psoriasis causes a variety of both specific as well as ambiguous nail lesions. Fingernails are more frequently affected than toe nails, probably because they grow faster. Particularly, for scientific purposes, nail psoriasis is often divided into matrix and nail bed involvement or both, which is also reflected in many trials differentiating the response into general, more on matrix or nail bed psoriasis. Pits are the most characteristic and most frequent signs and are seen as small, sharply delimited depressions in the nail surface. They are of remarkably even size and depth. Their distribution may be haphazard or they may sometimes be arranged in parallel transverse or short longitudinal lines. They are the result of tiny psoriatic foci in the apical matrix producing parakeratosis, which breaks off when it grows out from under the proximal nail fold then leaving these depressions. Sometimes, the parakeratosis remains and is seen as an ivory-colored spot in the proximal half of the nail plate. Pits may be single, which is not yet psoriasis specific, or multiple. Ten pits in one nail or >50 pits on all nails are regarded as proof of psoriasis. Red spots in the lunula usually represent a very active psoriasis lesion with dilatation of the capillaries and thinning of the suprapapillary plate. Red or mottled lunulae are due to the dilatation of matrix blood vessels.⁴

Total matrix affection results in complete nail destruction with crumbling of the plate, whereas leukonychia is seen when the mid- to distal matrix is affected and parakeratotic cells are incorporated into the nail plate making it optically opaque. In most cases, psoriatic leukonychia is an ill-defined white transverse band. Splinter hemorrhages are very narrow, some millimeters long reddish-darkbrown to black streaks. They are analogous to Auspitz’s phenomenon of the skin and either due to hemorrhage from the dilated capillaries in the nail bed or due to blood clots in these longitudinally arranged small vessels. Salmon or oil spots are very frequent and represent psoriatic plaques in the most distal matrix and the nail bed. This area looks like paper on which a drop of oil has fallen: a yellowish-brownish spot with a red margin shines through the plate because the psoriatic squames compressed under the nail are imbibed with serum. When a salmon spot reaches the hyponychium, the parakeratosis breaks out and psoriatic onycholysis develops. This typically has a reddish proximal margin differentiating it from most other causes of onycholysis, such as onychomycosis. Subungual hyperparakeratosis may be thick and then no oil drop phenomenon is seen. The hyperkeratosis may be very marked and at times so extreme as to resemble pachyonychia congenita. Psoriasis affecting the dorsal as well as the ventral surface of the proximal nail fold results in swelling and rounding of its free edge. This leads to a spontaneous loss of the cuticle characterizing the pattern of chronic paronychia.

As mentioned earlier, psoriatic arthritis is very frequently associated with severe nail involvement and psoriatic paronychia, complete nail destruction, and swelling of the distal interphalangeal joint. This has a serious negative influence on the quality of life.

In contrast, psoriatic pachydermoperiostosis is closely related to psoriatic arthritis but usually without obvious nail changes. Mainly the big toe is considerably swollen and often painful.

Three different forms of pustular psoriasis are differentiated. Nail changes are seen in all of them. The nail changes in the palmar plantar pustular psoriasis of Barber–Königsbeck are similar to the common type of psoriasis, but the surface defects may be larger and are called elkonyxis. Yellow subungual spots represent large Munro’s abscesses. Subungual abscesses are frequent in the generalized pustular psoriasis of von Zumbusch. Acrodermatitis continua suppurativa of Hallopeau is the most notorious form of pustular psoriasis of the nails. It often begins with one single digit where the skin of the distal phalanx turns red and develops some pustules migrating under the nail and causing nail dystrophy. With time, the entire nail unit may disappear leaving a red smooth digit tip until the disease slowly wanes off. Less frequently, acrodermatitis continua suppurativa may initially involve several fingers and toes and run a rapid and severe course. Recently, a mutation in the interleukin 36 receptor antagonist gene leading to a defect in interleukin 36 antagonist was identified in generalized pustular psoriasis and acrodermatitis continua suppurativa supporting the view that it belongs to the autoinflammatory diseases group.^5,6 Pustulosis palmoplantaris is histopathologically and genetically different and rarely affects the periungual skin.⁷

Reiter’s disease is also known as reactive arthritis. It is a systemic condition with characteristic joint, mucosal, eye, genito-urinary, skin, and nail changes. The latter are very similar to pustular psoriasis. However, they often have a more brownish tint due to a higher content of erythrocytes in the pustules. Histopathology with extensive spongiform pustules is virtually identical to pustular psoriasis.⁸

Nail psoriasis in children

Psoriasis may occur at any age. Although rare, it was also observed in the newborn. Erythrodermic psoriasis in children usually shows ungual involvement with nail dystrophy and marked subungual hyperkeratosis similar to pityriasis rubra pilaris. Even pustular psoriasis and psoriatic arthritis were observed in children.⁶

Diagnosis of nail psoriasis

In most cases, nail psoriasis follows cutaneous psoriasis and is therefore easy to diagnose. However, ~5% of nail psoriasis occurs isolated and may pose diagnostic challenges. This is particularly the case when even the nail alterations are atypical such as a single nail in a child or of a toe, isolated nail bed psoriasis without pits and salmon spots. Histopathology is usually diagnostic, provided the biopsy is sufficient, which is, unfortunately, often not the case. It has to be remembered that matrix lesions cause changes of the nail plate and those of the nail bed are seen under the nail plate. The biopsy has to be taken slightly more proximal than anticipated and must include enough subungual soft tissue. In contrast, nail clippings are diagnostic for the most important differential diagnosis, the various onychomycosis forms, and sometimes give a strong hint at nail psoriasis. Furthermore, nail psoriasis exhibits some features not commonly seen in cutaneous lesions.¹ Dermatoscopy makes the clinical signs more obvious and helps in the diagnosis. Videodermatoscopy allows higher magnifications than the usual hand-held dermatoscopes. Capillaroscopy shows the dilated tortuous capillaries of the proximal nail fold. This is even better visible in laser confocal microscopy. The features of high-frequency ultrasound are less reliable but may be of help for the very experienced. Optical coherence microscopy uses a similar principle but has a much higher resolution.

Differential diagnosis

In most cases, nail psoriasis is diagnosed on clinical grounds.⁸ Skin lesions elsewhere with one or several psoriatic nail features suggest the correct diagnosis. With a good biopsy, histopathology is usually pathognomonic and helps to delineate nail psoriasis from other conditions, particularly onychomycosis. The clinical diagnosis of pustular psoriasis is made on the basis of red skin areas with a rim of small pustules. Reiter’s disease requires additional laboratory examinations.¹

Onychomycosis is said to be the most frequent nail disease. It has many features in common with nail psoriasis, both clinically and histopathologically (Table 1).¹

Another important differential diagnosis is the asymmetric gait nail unit syndrome seen mainly in the big toenail as an onycholysis without further criteria of nail psoriasis or onychomycosis.⁹ Furthermore, nonspecific nail dystrophy, particularly of toenails, is very common in the elderly, in subjects with peripheral arterial disease, chronic venous stasis, after trauma to the leg, in peripheral neuropathy, and in some dermatoses such as eczema, nail lichen planus, Darier’s disease, Hailey-Hailey disease, alopecia areata, and many drugs.^1,8

Grading and assessment of nail psoriasis

Reliable repeatable specific validated severity and outcome measures are necessary to evaluate a disease and its response to a specific treatment.¹¹ This was missing in nail psoriasis until the nail psoriasis severity index (NAPSI), target NAPSI, and its many variants were established.¹² NAPSI is calculated by dividing each nail into four quadrants. Each quadrant is evaluated for the presence of psoriasis manifestations of the nail matrix, such as pitting, leukonychia, red spots in the lunula, and nail plate crumbling, as well as of the nail bed, such as oil-drop phenomenon, onycholysis, subungual hyperkeratosis, and splinter hemorrhages. If any of these signs is present in all four quadrants, a score of 4 is given. A score of 0 represents no signs in any quadrant. Each nail is evaluated for a matrix and a nail bed score of 0–4. They are combined to yield a maximal score of 0–8 for each nail. All nails may be evaluated, with the total NAPSI score being the sum of the scores, up to 80 if only fingers are considered, or up to 160 if fingers plus toes are included.¹² If only the most seriously affected nail is evaluated, it is called target NAPSI; this is often done to assess the effects of a therapeutic regimen.¹¹ Many therapeutic studies use (target) NAPSI-50, NAPSI-75, and NAPSI-90 to indicate the percentage of patients that reach a (target) NAPSI improvement of 50, 75, or 90%, respectively. The NAPSI has some disadvantages, such as being too time-consuming to be used in clinical practice, and that the NAPSI scores often do not correspond with the clinical severity of nail psoriasis.¹³ A new scoring system, the N-NAIL, overcomes many of these limitations, but it has yet to prove its clinical practicability.¹³ The use of many different scoring systems, major differences in study design, inclusion criteria, and follow-up make it difficult if not impossible to compare the results of most nail psoriasis trials.¹¹ In addition, subjective and objective patient factors such as quality of life, satisfaction with treatment ease and outcome, adverse effects and not the least practicability, and cost of treatment are important factors.¹¹ Such an evaluation and assessment tool for nail psoriasis has recently been published under the term of nail assessment in psoriasis and psoriatic arthritis.¹⁴

Associations

Psoriasis is a frequent skin disease. In the last decades, a metabolic syndrome associated with psoriasis has been described; however, this is not of particular importance for ungual psoriasis except in psoriatic arthritis. Associations and co-occurrence with other skin disorders involving the nail are rather common. The most important differential diagnosis is onychomycosis. Both conditions may look very similar. A psoriatic nail may be colonized with pathogenic fungi, and a true infection of the psoriatic nail is not infrequent (Table 1).^1,15

Impact on quality of life

Nail psoriasis has a profound negative influence on all aspects of quality of life as well as on daily, sports, and professional activities.^16–20 Women try to hide their nails and cover them with nail lacquer; although common nail varnishes are not harmful, artificial nails, particularly when long, increase the mechanical stress and strain to the nail plate – nail bed attachment acting as a Köbner phenomenon and worsening nail psoriasis. Similarly, professional activities with particular use of the fingers may have a deteriorating effect on the disease. Matrix involvement scores higher than pure nail bed affection as it results in more obvious nail plate damage.¹⁹

Course

Nail psoriasis is chronic but often improves and worsens without known reasons (Figures 1–4). Trauma may play an important role in the exacerbation of nail psoriasis. There may be periods without any nail alterations.^1,8,10

Management of nail psoriasis

Management of the disease includes patient education, avoidance of trauma to the nails, and different therapeutic approaches with physical and pharmaceutical procedures and agents.

Patient counseling includes education on the nature of psoriasis, how life may be influenced by nail involvement, about the specific problems of treatment, that nail psoriasis is not due to an allergy or an “unhealthy” diet and thus is not treatable with particular foods. However, smoking increases the risk of psoriasis and obesity and alcohol use are associated with a higher risk for psoriasis. It is important to avoid trauma to the nail unit that will inevitably exacerbate the condition or induce recurrences. Manicure and nail cleaning have to be performed cautiously without further traumatizing the hyponychium and attachment of the nail to the nail bed. It is helpful to explain that genes are the most important etiological factors and that the skin and nail lesions are amenable to treatment but that the genes cannot be corrected. Many genes contribute to the psoriatic personality, which may explain the enormous variability of the clinical features including the response to treatment. Particularly, chronic repeated trauma is thought to be an aggravating factor. The development of pits may be the result of microtraumata to the enthesis of the extensor tendon and the dorsal aponeurosis of the distal interphalangeal joint.² They may be masked using nail varnish.

All nail psoriasis treatments require a long time, as the nail is a slow-growing cutaneous appendage. The effect of any treatment can usually not be evaluated before 3–6 months, and it may take a year or longer to reach the maximum improvement achievable with a given therapy. Pretreatment photographs are highly recommended and should be repeated at all follow-up visits to show the therapeutic result to the patients. Concomitant onychomycosis may prevent clinical cure, and it is a must to exclude fungal infection when starting nail psoriasis therapy; a single remaining altered nail during an otherwise efficacious therapy may be a hint at a concomitant mycotic infection.^1,21

Many different therapeutic measures are available. Their choice depends on various factors such as severity of nail involvement and its impact on quality of life, associated skin lesions, psoriatic arthritis, comorbidities, profession, age, patient preferences, potential risks, and not the least costs and their reimbursement.

Nail psoriasis is very recalcitrant to almost all topical treatments, whereas systemic therapies clearing the skin are usually effective also in nail psoriasis.²² The problem of all topical drugs is their limited penetration to the diseased tissue: through all layers of the proximal nail fold with the underlying nail in matrix lesions, through the nail plate, and subungual hyperkeratosis in nail bed psoriasis. Hence, pits, though often being rather inconspicuous, are the most resistant to treatment. Nevertheless, a 3-month trial of a potent antipsoriatic topical preparation is warranted (Figure 1). The less nail is left the easier the penetration of the drug to the very psoriatic lesion is. Clipping the onycholytic nail over the nail bed is essential to reach nail bed psoriasis. Thinning the nail by filing or grinding, or drilling holes into the nail plate with mechanical burrs²³ or with ablative lasers, is often used to enhance nail penetration.²⁴

Corticosteroids are often used in nail psoriasis. They have to be class IV (high potency) and applied once or twice a day on the proximal nail fold in case of matrix and on the nail plate in nail bed affection. Although probably still the most commonly used drugs, corticosteroids were rarely tested in controlled studies. Both clobetasol and betamethasone dipropionate were tested in clinical trials and showed comparable results¹¹ concerning pitting, salmon patches, subungual hyperkeratosis, and onycholysis.^25,26 All high-potency steroids carry the risk of skin atrophy when used on the proximal nail fold, often associated with hypopigmentation. Whether or not using them for 4–5 days a week as a “pulse” treatment is equally effective and reduces this risk remains to be proven. Clobetasol 8% was tested as a nail lacquer with good results depending of the duration of the treatment.²⁷

Perilesional injections are another type of local treatment. This increases the concentration of the drug at the site of disease while minimizing the dose for the whole organism. Perilesional injection of corticosteroids is by far the most often performed (Figure 2), either by injection with a needle or by high air-pressure devices.²⁸ Injection with a 30 G needle and using some distraction techniques such as vibration and pressure around the area to be injected make the procedure tolerable although some patients prefer the needle-less technique. Apparently, the efficacy of different high-pressure injectors varies considerably (O Correia, Inst CUF, personal communication, 2014). We inject 0.1 mL of a triamcinolone acetonide suspension (10 mg/mL) into both sides of the proximal nail fold; injection into or under the nail bed is extremely painful and requires prior anesthesia.^29,30 The injections are repeated on a monthly basis for 6 months and, then, followed by every 6 weeks and later every other months. However, not all patients tolerate the injections. Matrix and nail bed signs of psoriasis respond slightly differently with salmon spots and subungual hyperkeratosis usually showing the best effect. Adverse effects are not uncommon with subungual hematoma and temporary nail deformation being relatively frequent^29,30 and the disappearing digit, atrophy of the terminal phalanx bone, and rupture of the extensor tendon being the most serious ones.^31–34 Epidermoid inclusion cysts were observed after jet injections necessitating amputation.³⁵

The combination of the vitamin D₃ derivate calcipotriol and a potent corticosteroid, such as betamethasone dipropionate, has shown good results;^26,27 personal experience has shown that twice or even thrice daily application may be worth trying. Another vitamin D derivative, such as tacalcitol, was used alternatively with 8% clobetasol nail lacquer.³³

Vitamin D₃ (calcitriol) and its analogs calcipotriol and tacalcitol are well established in the therapy of psoriasis vulgaris due to their effects on epidermal differentiation and proliferation and regulation of production and release of proinflammatory cytokines.¹¹ Most studies were done with calcipotriol and tacalcitol.^36,37 Apparently, their effect on nail bed lesions is more marked than on matrix signs.

Calcineurin inhibitors have a profound inhibitory effect on T-cell functions that are implicated in the pathogenesis of psoriasis. Used systemically, cyclosporin A (CyA) is highly active against psoriasis, but topical application of CyA showed ambiguous results.¹¹ The new calcineurin inhibitor tacrolimus shows much better skin and nail penetration. It demonstrated good activity on nail bed and matrix psoriasis in a controlled study.³⁸ No studies with pimecrolimus were published until now.¹¹

Tazarotene is a synthetic retinoid with antiinflammatory and antiproliferative actions on keratinocytes. Tazarotene 0.1% was used for the treatment of nail psoriasis. The results were variable, but one study compared it with clobetasol showing equal results.²⁵ It was also used in childhood nail psoriasis.³⁹ Side effects are mainly skin irritation with redness and desquamation.¹¹

5-Fluorouracil (5-FU) is an antimitotic and antiproliferative agent, which is active against disorders with a high proliferative activity, such as psoriasis. Only one study of topical 5-FU with 20% urea as a penetration enhancer showed good effects on nail psoriasis, but inflammation, infection, onycholysis, and discoloration were observed as adverse effects.⁴⁰ Other investigators did not see a beneficial response. This does not make 5-FU a favorite nail psoriasis agent.¹¹

Dithranol was once the most commonly used antipsoriatic topical, but because of its unpleasant cosmesis, it is rarely used nowadays. One study reported some improvement of nail bed lesions, but the staining of the nails made it unacceptable.⁴¹

Indigo naturalis extract regulates proliferation and differentiation of epidermal keratinocytes, restores the epidermal barrier function, and inhibits inflammatory reactions. Twice daily application of an oily extract reduced nail bed lesions such as hyperkeratosis and onycholysis by about one half; it was thus more effective than calcipotriol solution.^42,43 Studies are in progress to make it colorless and cosmetically more acceptable (CH Yang, Chang Gung Memorial Hospital, personal communication, May 8, 2017).

Methotrexate was also used for perimatrical and nail bed injections with acceptable results. The dose was 0.1 mL of a 25 mg/mL solution. Good results were seen after 6 months and 15 weeks, respectively.^44,45

Systemic treatments are indicated in widespread psoriasis. Those therapies proven successful for skin lesions usually also improve nail psoriasis. However, many physicians and patients are reluctant to treat isolated ungual psoriasis systemically. A European Consensus Paper on the treatment of psoriasis defines the involvement of particularly sensitive areas such as the head and neck, genito-anal area, and nails as moderate to severe. The selection of the mode of treatment then depends on the severity of the nail disease, its impact on quality of life, on professional, sports, and social activities, and in particular on potential associated psoriatic arthritis.

Systemic corticosteroids are not a good option for psoriasis vulgaris and in particular for nail psoriasis. High doses are necessary with a considerable risk of serious side effects, break-through phenomena, and development of pustulation of hitherto not pustular psoriasis.

Methotrexate has been introduced into the treatment of cutaneous psoriasis and psoriatic arthritis in the 1960s. It is an inexpensive drug with good efficacy in skin lesions; however, as an antimetabolite, it slows down the nail growth rate and improvement in nail lesions is therefore often slow and seen very late (Figure 3). Furthermore, there is a risk of severe side effects such as hepatotoxicity, lymphopenia, lekopenia, nausea, and erosive stomatitis. Long-term toxicity includes liver, lung, and heart fibrosis. The dose is usually slowly increased to reach ~10–20 mg/week. Both oral and injection therapies are possible with virtually equal doses as the bioavailability of methotrexate is very good.^46–48 NAPSI improvement is between 25 and maximally 50%. Methotrexate has also been injected intralesionally with a good result.^44,45

Ciclosporin A is another established systemic antipsoriatic drug. It is a calcineurin inhibitor with strong immunosuppressive action. Its positive effect on cutaneous and ungual psoriasis is well established, both in single-drug studies as well as in comparative ones.^49,50 The dose is usually 3–5 mg/kg daily, but half the dose is often given in Japan after initial improvement.⁵¹ Although ciclosporin is probably the most active “classical” systemic antipsoriatic drug, it is limited to a treatment period of 6–12 months because of potentially serious adverse effects such as disturbance of renal function, arterial hypertension, diabetes mellitus, nausea, hypertrichosis, gingival hyperplasia, paresthesia, fatigue, and headache.

Synthetic retinoids have been used to treat extensive skin psoriasis. The first of these drugs was etretinate. Although it had a good effect on nail changes in some cases,^52,53 etretinate is no longer used and substituted by its derivative acitretin.

Acitretin is the follower product of etretinate with a shorter half-life in the body. It is usually given in a dose of 0.5–1 mg/kg/day.^54,55 Its action is slow and, in most cases, does not reach >50% improvement of nail psoriasis.⁵⁶ All retinoids have a number of side effects, particularly when given in a dose >0.5 mg/kg/day, such as dry and cracking lips, dry mouth, hair loss, and in children ossification disturbances. High-dose retinoids can have an onychodestructive effect and are no longer recommended as the first-line nail psoriasis treatment;⁵⁷ however, good results were seen in generalized pustular psoriasis and acrodermatitis continua suppurativa.⁵⁷ Acitretin is occasionally used in combination with photochemotherapy with ultraviolet (UV) A and narrow band UV B.

Fumaric acid esters are used for psoriasis treatment in some countries, mainly in Europe, but their use was somewhat controversial. A case report described a good effect on nail psoriasis.⁵⁸ Side effects are mainly gastrointestinal, flushing, lymphopenia, and rarely renal dysfunction.

Leflunomide is a disease-modifying antirheumatic agent with an effect on psoriatic arthritis and also a modest action on nail psoriasis.⁵⁹ Sulfasalazine was used in one patient with a beneficial effect.⁶⁰ Silicic acid was given orally and topically on skin lesions. Ten of the 12 patients treated had nail lesions, and five of them cleared completely, although the nails were not treated with the silicic acid gel; thus, a systemic effect was postulated.⁶¹

Apremilast is a new small-molecule oral phosphodiesterase 4 inhibitor reducing the expression of several proinflammatory mediators; it is more an antiinflammatory than immunosuppressive agent distinguishing it from most other systemic antipsoriatic compounds. It has an excellent safety profile with no known organ toxicity, thus obviating the need for laboratory controls.⁶² It is approved for the treatment of cutaneous psoriasis and psoriatic arthritis and has shown a good effect in nail psoriasis, although only after 32 weeks. Its cost may, however, limit its widespread use.^63,64 A nail lacquer containing apremilast is being developed;⁶⁵ however, human studies on nail psoriasis have not yet been published.

Tofacitinib is a small-molecule oral Janus kinase inhibitor interfering in the JAK–STAT pathway. It is active against psoriasis and alopecia areata including their nail manifestations. In four Phase III randomized controlled studies and compared to etanercept, a twice daily dose of 5 or 10 mg was shown to be noninferior to etanercept injected subcutaneously twice weekly with sustained effects up to 52 weeks.^66–69

Biologicals are a new development in the treatment of many, mainly immunologically mediated diseases, among them also psoriasis. There are several classes, both concerning the nature of the antibody as well as their target, such as humanized and fully human antibodies and antibodies to tumor necrosis factor-α, various interleukins, and T-cell inhibitors, respectively. They all have profound immunosuppressive actions and are thus not without risk, particularly concerning infections and re-activation of tuberculosis, to mention but a few.¹¹ Biologicals are usually considered second- or third-line treatments when other established topical and systemic antipsoriatic drugs were not or not sufficiently active in suppressing nail lesions.⁷⁰ In contrast, nail psoriasis was found to be an indicator of poor prognosis for the treatment of psoriasis with biologicals independent of the specific substance used.⁷¹ In most cases, nail psoriasis responses lag behind those of cutaneous psoriasis, which can in part be explained by the slow growth of nails as nail plate changes have to grow out, whereas nail bed changes may be seen earlier. In comparison with “classical” systemic drugs, eg, methotrexate and cyclosporin, biologicals often show a dramatic and more rapid improvement. However, only 20–57% of the patients reach a 90% improvement of their NAPSI score with biologicals and the effect is lost after 47 months in average.^72,73 The most likely mechanism is the formation of antidrug antibodies, but compensatory production of other proinflammatory cytokines and a particular individual reaction may be the cause that many patients stop this treatment.⁷⁴ In many countries, biologicals are not automatically reimbursed by the social health insurance and patients and physicians have to give evidence that previous, less expensive treatments were not sufficiently efficacious.

TNF-α inhibitors were the first biologicals developed for psoriasis treatment. TNF-α is a cytokine with proinflammatory action that induces keratinocyte proliferation and prevents apoptosis. Most experience was gained with infliximab, the first of this group, but in general, the efficacy of all TNF-α inhibitors currently available for psoriasis treatment is virtually comparable. Also their side effects and limitations are the same. Activation of opportunistic infections, congestive heart failure, demyelinating disorder, antibodies against TNF-α inhibitors, and rarely lupus erythematosus may occur.¹¹

Infliximab is a chimeric human-mouse IgG1 antibody binding membrane-bound and soluble TNF-α. This reduces epidermal T-lymphocyte infiltration. It exhibits certain antigenicity and may thus induce autoantibodies that may reduce its effectiveness thus requiring higher doses with time. It has to be given intravenously, and ~16% of the patients develop infusion reactions such as fever, chills, flush, urticaria, myalgia, arthralgia, nausea, hypotension, and dyspnea.⁷⁵ Infliximab was associated with a higher rate of onychomycosis compared to the other TNF-α inhibitors.⁷⁶ Patients with a high psoriasis area severity index (PASI) response also show a good NAPSI response. Almost one half of the patients demonstrated complete nail clearance after 50 weeks. NAPSI reduction by 50% was achieved by almost all patients, 80% reached NAPSI-75, 30% reached NAPSI-90, and 10% cleared completely.⁷⁷ Infliximab appears to be the fastest acting TNF-α inhibitor. Its dosage is usually 5 mg/kg given on weeks 0, 2, and 6 and if necessary 8.

Adalimumab is a human monoclonal IgG1 antibody against TNF-α. It binds to cell surface proteins of the TNF-α receptor preventing its action. Its mechanism of action is similar to that of infliximab. Roughly 50–60% of NAPSI improvement are achieved.^11,78

The combination with cyclosporin was shown to be particularly effective reaching a reduction of the NAPSI score of 100%.⁷⁹ Adalimumab did not increase the rate of onychomycoses.⁷⁶ The dose is 80 mg at baseline, then 40 mg every 2 weeks, but some authors gave 40 mg from the beginning (Figure 4).¹¹

Certolizumab pegol is a PEGylated TNF-α inhibitor that is Fc free. It is effective in the treatment of rheumatoid arthritis and psoriasis with efficacy in nail psoriasis, enthesitis, and dactylitis.^80,81

Being a fusion of the TNF receptor with the Fc part of the IgG1 antibody etanercept blocks the action of TNF-α. Thus, its mechanism of action is similar to that of infliximab and adalimumab. Several reports on its use in nail psoriasis demonstrated good results.⁸² There was no statistically different outcome with 50 mg once or twice weekly after 12 weeks and target NAPSI improvement between 71 and 76%.⁸³ It was also effective in refractory acrodermatitis continua suppurativa.⁸⁴

Golimumab is another TNF-α inhibitor approved for psoriatic arthritis with an effect on nail psoriasis. Target NAPSI improvement was over 40% after 24 weeks and 52% after 52 weeks of treatment with 50 mg every 4 weeks.^85,86

All TNF-α inhibitors have the potential to paradoxically worsen psoriasis or even induce it.^87,88 In many cases, this regresses despite continuation of the therapy or when another biological is used. This is apparently independent from the condition for which TNF-α inhibitors were administered.^88–91 The mechanism of action may be an unabated interferon-α production by plasmacytoid dendritic cells, which might result in psoriasis flares and induction of psoriasiform lesions.^91,92

T-cell inhibitors such as alefacept and efalizumab are not widely used because of their considerable adverse effect profile.⁹³ Efalizumab is a monoclonal CD11a antibody and was withdrawn from the market because of cases of leukencephalopathy observed under treatment with this molecule. Alefacept is a fusion protein binding at the CD2 portion of the leukocyte function antigen-3 linked to the Fc portion of human IgG1 and targets T lymphocytes. No studies to evaluate the efficacy of these drugs in nail psoriasis were published.

Rituximab causes B-cell depletion. Its role in the treatment of nail psoriasis is not yet examined.^93,94

New biologicals focus on the inhibition of interleukins involved in the propagation of the psoriatic process. Their nonspecific immunosuppressive action is less pronounced compared with the TNF-α inhibitors. The targets are mainly IL-12/IL-23 and IL-17. However, it was shown that anti-IL-12 action might be proinflammatory under certain circumstances and thus counterproductive for the therapy of psoriasis.⁹⁵

Anti-interleukin 17 therapy is based on the fact that IL-17 plays a central role in the development of psoriatic lesions, but IL-17 is also important for the defense against extracellular pathogens and recruits neutrophils.

IL-17 inhibitors are secukinumab, ixekizumab, and brodalimumab, but there are no ongoing studies with the last one.

Secukinumab is a human monoclonal IL-17A antibody approved for plaque psoriasis and psoriatic arthritis that has also shown good efficacy in nail psoriasis. It has an early onset action and a sustained effect. Its safety profile is acceptable. It is administered subcutaneously with a 300 mg dose at weeks 0, 1, 2, 3, 4, and then every 4 weeks. At 16 weeks, both 150 and 300 mg secukinumab were superior to placebo with further improvement with longer treatment periods.^96,97

Ixekizumab is another humanized monoclonal antibody directed against IL-17A recently approved for psoriasis. It demonstrated significant improvement of the NAPSI score as early as 2 weeks after start of the treatment, which sustained to week 20 when given in a dose of 75 mg at weeks 0, 2, 4, 8, and 12 and then 120 mg every 4 weeks from week 20 onward.^98,99

Brodalumab is a human monoclonal IL-17A antibody active against plaque psoriasis. It was more active than ustekinumab in a head-to-head comparison. Although approved in the US and Japan, the clinical development was terminated as suicidal ideation and behavior were observed.¹⁰⁰

IL-23 is another important proinflammatory cytokine involved in the pathogenesis of psoriasis.

Antibodies targeting the p40 subunit of IL-23 also have an action against IL-12 as they both share this subunit. Antibodies directed against the p19 subunit are selective for IL-23.

Ustekinumab is a monoclonal antibody directed against the p40 subunit of IL-12/23. It is active against psoriasis and psoriatic arthritis and was also shown to have a good action on nail psoriasis. Nail improvement was observed from week 4 onward with significant improvement of 90% at week 40. NAPSI and PASI improvement ran parallel. The dose is 45 and 90 mg if the weight is over 100 kg, usually at weeks 0, 4, 16, and 28.^101–103 Efficacy and side effects are comparable to the other IL inhibitors.

Briakinumab was another monoclonal antibody directed at p40. After showing good clinical results, its development was stopped because of severe infections and a higher incidence of other severe side effects.¹⁰⁴

Guselkumab is a fully human IgG1k monoclonal IL-23 antagonist directed against the unique p19 subunit of IL-23; it has no anti-IL-12 component. It has a profound action on moderate-to-severe plaque psoriasis and was superior to adalimumab.¹⁰⁵ The dose given was 100 mg at weeks 0, 4, 12, 16, and 20 and then every 8 weeks.

Tildrakizumab and BI-655066 are also targeting the p19 subunit of IL-23. They are currently being studied for various indications including psoriasis.^106,107 No results are yet available concerning nail psoriasis.

In summary, most new biological drugs have a good and reliable action on nail psoriasis with an acceptable adverse effect profile. They are more active than most of the classical systemic antipsoriatic drugs.

Radiotherapy is an “old“ treatment modality, which has come out of time not only because of potential long-term adverse effects but also because most dermatologists no longer operate X-ray machines because of the difficulties to comply with the bureaucratic challenges associated with the use of therapeutic ionizing rays. However, some studies report favorable results with Grenz rays,¹⁰⁸ superficial X-rays,^109,110 and electron beam therapy.¹¹¹

Light has been used for a long time, but as nails are virtually impermeable for UV B and allow <2% of UV A to penetrate, the effect is rather limited.¹¹² Potentiation of UV by specific photosensitizers, called photochemotherapy, was beneficial in some studies^48,113 but is often associated with multiple melanonychias.¹¹⁴

Intense pulsed light (IPL) is a broad-spectrum light source with a high-energy intensity. With a 550 nm filter, it has been used for the treatment of plaque psoriasis. A trial on 20 patients with finger and toenail psoriasis using IPL with a cutoff filter of 550 nm and a median of 8.6 sessions resulted in significant improvement in the NAPSI with nail bed lesions showing a reduction of 71% and matrix lesions of 32%. A relapse was seen in three patients after 6 months.¹¹⁵

Lasers have also been used to treat nail psoriasis. The pulsed dye laser (PDL) is the device of choice as it targets the dilated capillaries in the matrix and nail bed. In many studies, 1.5–6 ms pulses were used with a good effect on matrix and nail bed lesions.^116,117 A comparative study using 6 ms pulse length and 9 J/cm² and 0.45 ms and 6 J/cm² gave almost the same improvement of matrix and nail bed lesions with significantly less pain with the shorter pulse.¹¹⁸ Side effects are mainly pain, hemorrhage, and pigmentation. These results were confirmed in another trial.¹¹⁹ PDL with tazarotene was significantly more effective than tazarotene alone.¹²⁰ A comparison of the PDL with the excimer laser gave significantly better improvement with the PDL.¹²¹ In another comparative study, PDL was compared with the Nd:YAG laser. Both groups were treated with calcipotriol betamethasone in addition. Whereas the results were comparably good, the Nd–YAG was significantly more painful.¹²²

Photodynamic therapy (PDT) uses light and a photoactive substance that both generate reactive oxygen species able to kill those cells that accumulated the photosensitizer. In a comparative study, no difference was found between PDL and PDT.¹¹⁷ However, there is considerable heat development during the illumination of the target and this is often not tolerated by the patients.

Conclusion

Nail involvement in psoriasis is common. It is an indicator of poor prognosis and of a higher risk to develop psoriatic arthritis. Surprisingly, nail psoriasis is only briefly mentioned in most national and European guidelines on the diagnosis and treatment of psoriasis; however, the European Nail Society is now working on recommendations for the treatment of nail psoriasis.

The many treatments available give evidence that hitherto none is the ideal therapy. Topicals have to fight with the difficulties to get through the nail and nail fold to the diseased structures. Injections that bring the remedy to the site of the disease process and greatly avoid systemic effects are painful and carry the risk of local side effects. Systemic drugs are often not used for isolated nail psoriasis, although this is accepted as a severe psoriasis considerably impairing quality of life. However, it is known that virtually all systemic treatments that improve the skin lesions are also beneficial for the nails, although often with a delayed and less pronounced response. The potential systemic adverse effects have to be kept in mind before and during such a therapy. The development of new biologicals has revolutionized psoriasis treatment and thus also that of ungual psoriasis. Finally, there are some physical modalities such as ionizing rays, various light qualities including photodynamic treatment, and lasers.

Many treatment possibilities may make it delicate to choose the right approach. It is certainly wise to begin with a topical antipsoriatic preparation (Table 2). This has to be used for a minimum of 4–6 months before its efficacy can be evaluated. If this does not help sufficiently, a classical antipsoriatic drug such as methotrexate, fumaric acid ester, and cyclosporine would be the second choice while keeping in mind all potential contraindications. If the results are not satisfying a biological may be chosen. Again, there are many contraindications that have to be carefully looked for before starting such a treatment. The choice is huge now, and the treating physician has to select among TNF-α blockers, agents interfering with T-lymphocyte functions, and IL-23 and IL-17 inhibitors.

In summary, nail psoriasis is still an underestimated part of psoriasis, but the outlook is bright with many new treatments available.

Disclosure

The author reports no conflicts of interest in this work.

References

Psoriasis – American Family Physician

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Nail Involvement in Patients with Psoriatic Arthritis in Northern Iran

Background. Psoriatic arthritis (PsA) results in an increased burden of psoriasis and impairs both quality of life and an individual’s functional capacity. The relationship between nail involvement and PsA in psoriasis is not fully characterized. Aim. To evaluate the frequency and characteristics of nail involvement in psoriatic patients and to assess the relationship with joint involvement. Methods. A total of 197 patients with moderate-to-severe psoriasis were consecutively invited to participate in this cross-sectional study. The patients are divided into two groups: those with and those without psoriatic arthritis. Results. 69.5% of psoriatic (137 out of 197) patients had nail involvement. The most common nail abnormality was onycholysis, followed by pitting and oil droplet changes. Nail involvement was more common in patients with psoriatic arthritis (82.1% versus 57.8%, p=0.001). Conclusion. Nail involvement is commonly associated with PsA. Onycholysis, splinter hemorrhage, and oil drop were significantly more common in the PsA group as opposed to patients with just skin findings. In general, psoriatic patients with arthritis had more severe disease.

1. Introduction

Psoriasis is a chronic inflammatory disease affecting up to 3% of the general population. It has a substantial negative impact on health-related quality of life (HRQOL), especially when it involves visible areas of the body such as the face, hands, and nails [1]. Psoriatic arthritis (PsA) has been defined as inflammatory arthritis, usually seronegative, associated with psoriasis [1]. The exact prevalence of PsA is unknown but up to 30% of patients with psoriasis develop psoriatic arthritis [2, 3].

A substantial number of psoriatic patients have nail involvement, varying from 10% to 80%, with an estimated lifetime incidence of 80–90% [4–6].

Nail involvement may be considered an indicator for patients at risk for future psoriatic joint damage [7, 8]; however, this relationship has not been proven [9]. The aim of this study was to assess the overall prevalence of nail involvement in patients with moderate-to-severe psoriasis and to achieve more details on the possible relationship between nail psoriasis and PsA.

2. Materials and Methods

2.1. Patients

This cross-sectional study was conducted from January 2017 to December 2017. During this period, all eligible patients with moderate-to-severe psoriasis who attended to our psoriasis clinic and were candidates for systemic therapy were enrolled in the study. Moderate-to-severe psoriasis was defined as body surface area (BSA) >10% or psoriasis area and severity index (PASI) >10 [10]. The study was approved by the Shahid Beheshti institutional board committee. Informed consent was obtained from each subject.

A detailed history was recorded for all subjects, including gender, age, age at the time of onset of the disease, phenotype of psoriasis, disease duration, extent, and severity of the disease. We diagnosed psoriasis according to the clinical findings, and if necessary, a skin biopsy was performed. All patients underwent dermatological examination by a dermatologist (O.Z.). The following nail changes were recorded: pitting, crumbling, onycholysis, oil drop, subungual hyperkeratosis, and splinter hemorrhage.

Psoriasis skin severity was assessed by using psoriasis area and severity index (PASI) at the time of the physical examination. Mycological investigations were performed in patients with nail changes suspicious for fungal infection such as onychorrhexis, hyperkeratosis, thickening, or crumbling. Nail clippings and subungual scrapings were collected. One part of nail specimens was exposed to direct microscopic examination with 10% potassium hydroxide aqueous solution and the other part was cultured on Sabouraud’s dextrose agar medium with cycloheximide. Also, other causes of nail changes, like congenital and traumatic dystrophy were excluded from the study. Isolated nail psoriasis patients were not included in the study.

On the basis of musculoskeletal findings, patients with arthralgia or other joint symptoms were referred to a rheumatologist. The diagnosis of psoriatic arthritis was established in accordance with the Classification Criteria for Psoriatic Arthritis (CASPAR).

2.2. Statistical Analysis

Statistical analysis was performed using software SPSS 18.0 (SPSS Inc., IBM Corporation, Armonk, New York). Categorical variables were expressed as frequencies and percentages and analyzed by Chi-square test or Fisher’s exact test. Normality of variables was verified by Kolmogorov-Smirnov test. Continuous variables were given as means (SD) or medians (range). Student t-test was used for continuous variables with normal distribution. For continuous variables with an abnormal distribution, the Mann–Whitney test was performed. Statistical significance was considered at a level of 5% (p<0.05) for all tests.

3. Results

In total, 197 patients participated in the study. There was a slight female preponderance in our sample with 54 % (n = 107) female patients and 46% (n = 90) male patients.

The mean duration of the disease was 15 years (SD: 11 years; ranging from one month to 46 years) and the mean age of disease onset was 30 ±17 years. The subjects were divided into two groups: those with and those without psoriatic arthritis. In the study population, 95 patients (48%) had psoriatic arthritis. Of these, 56 patients were women and 39 patients were men (Table 1).

We found no significant difference between the two groups in terms of age, gender, the presence of comorbidities, alcohol intake and smoking. However, patients with PsA had lower median age of onset [26.91 ± 16.65 versus 31.87 ± 17.06 years, p=0.04] and longer disease duration [17.24 ± 10.79 versus 13.06 ± 10.42, p=0.006]. Also, the frequency of facial involvement was higher in those with PsA (74.7% versus 54.9%, p=0.001). In general, patients with PsA had more severe psoriasis reflected by higher median PASI scores [20.05 ± 11.54 versus 15.37 ± 8.97, p=0.016]. Also, positive family history for psoriasis was more often reported in those with PsA (49.5% versus 34.3%, p=0.03).

Overall, methotrexate was the most used medication among patients (88.3%). Patients in PsA group had a higher rate for the history of using different systemic treatments.

Prevalence of plaque-type psoriasis was significantly higher in patients with PsA (Table 2).

Nail involvement was present in 69.5% (137 out of 197) of patients. The most common nail abnormality was onycholysis, followed by pitting and oil drop (68.4%, 34.7%, and 30.5%, respectively). Nail changes were more common in patients with PsA (82.1% vs. 57.8%, p=0.001). Prevalence of onycholysis, splinter hemorrhage, and oil drop were significantly higher in PsA patients in comparison with patients without psoriatic arthritis (Table 3). Figure 1, illustrates pitting and onycholysis in a patient.

4. Discussion

The prevalence of nail changes in psoriatic patients reportedly presents great variety in the literature. Nail involvement in psoriasis usually is divided into two major groups: (a) signs of involvement of nail matrix including pitting, leukonychia, red spots of the lunula, transverse grooves (Beau’s lines), and crumbling of the nail plate and (b) signs of involvement of the nail bed which present as oil-drop discoloration, splinter hemorrhages, subungual hyperkeratosis, and onycholysis [5].

The most common psoriasic nail features were dissimilar in different studies. In a report by Kyriakou et al., oil droplet changes were the most common finding [11]. In another study, by Kaur et al. nail pitting was the most common finding [12]. On the other hand, there are reports showing that subungual hyperkeratosis is the most common feature [13]. Our study was in concordance with Grover’s paper [14] that the most common nail finding was onycholysis, which was present in 54.8% of our patients (108 out or 197) and significantly was more prevalent in the PsA group.

Pits can be seen in normal individuals as well as those with chronic eczema, alopecia areata, and lichen planus. Therefore, seeking other psoriatic nail features would be helpful for the identification of psoriatic nail pitting. Also, it is suggested that pits in patients with nail psoriasis are typically deeper than those observed in association with other dermatological conditions [10, 15].

Forty-eight percent of our patients had PsA. This figure is slightly higher than previous studies, which suggest a prevalence of around 30% [16, 17]. The higher rate of PsA in our patients is probably due to the selection of relatively more severe cases in this study.

Our study revealed that the prevalence of nail changes is higher in PsA, than has been suggested by some previous observations [18, 19]. We found that onycholysis, oil drop, and splinter hemorrhage, in particular, were significantly more prevalent in PsA patients. Fonseca et al. found no statistical difference in NAPSI (Nail Psoriasis Severity Index) values among patients with or without psoriatic arthritis [20]. Perhaps, the type of nail involvement is more important than the severity of nail changes in terms of correlation with PsA.

The pathophysiology of nail dystrophy has been postulated to be more closely associated with joint symptoms than with skin symptoms [21]. However, there is still no clear explanation for this association and some believe that this association is limited only to distal interphalangeal (DIP) joints [22]. The suggested theories are (a) having a common (and yet unknown) autoantigen in both nail apparatus and synovial membrane, (b) anatomic connection between nail structures and DIP joints, and (c) the common role of trauma (Koebner phenomenon) in both nail and arthropathic psoriasis [20, 23, 24].

In this study, patients with PsA had more severe psoriasis and an earlier age of onset and longer duration than those without PsA. Also, they had a higher rate of facial involvement. To our knowledge, this association has not been reported previously and further studies are needed to corroborate this association.

We excluded all psoriatic patients with onychomycosis from the study after positive direct examination, KOH smear and/or fungal culture. However, onychomycosis may present with clinical features similar to nail psoriasis. In addition, it is anticipated that the prevalence of onychomycosis is about 4.6 to 30% of psoriatic patients with nail involvement [25, 26].

Our study had certain limitations. One of them was lack of information about the subtypes of PsA. Also, we have not recorded the severity of nail involvements. Furthermore, previous medications may have interfered with the degree of nail changes in our patients.

5. Conclusion

In summary, we have shown that there is an association between nail involvement and PsA and this association is most significant for onycholysis. Also, patients with PsA have a higher probability of positive family history for psoriasis, earlier onset, longer duration, more severe psoriasis and a higher rate of facial involvement. It should be kept in mind that while there is a strong association between PsA and nail changes, every psoriasis patient should be asked about joint symptoms even if they have no nail changes.

Data Availability

The data and analysis used to support the findings of this study are available from the corresponding author upon request.

Disclosure

Earlier version of this work was presented at “5th World Psoriasis & Psoriatic Arthritis Conference, Stockholm, Sweden, 2018”.

Conflicts of Interest

The authors have no conflicts of interest to disclose.

Acknowledgments

The authors are grateful to Professor A. Menter and Professor S. Feldman for their review of the manuscript and insightful suggestions.

Nail psoriasis as a predictor of the development of psoriatic arthritis

Introduction

Psoriasis is a chronic, systemic, inflammatory disorder, affecting 2–3% of the population worldwide.1 Psoriatic arthritis (PsA) is a psoriasis-related spondyloarthropathy that presents with typical signs and symptoms of both psoriasis and arthritis and, like psoriasis, follows a chronic course.2-4 An estimated 20–30% of psoriasis patients may develop PsA.5,6 Imaging studies have demonstrated the existence of considerable number of patients with psoriasis and undiagnosed PsA, a reflection of the presence of subclinical arthritic disease in clinically normal joints.7,8

Persistent joint inflammation can lead to bone damage, and it is estimated that half of PsA patients develop irreversible joint lesions within the first few years of disease.9,10 Therefore, PsA is a severe, erosive and deforming condition.2

PsA patients have an increased burden of disease, impairment in quality of life, and diminished functional capacity, all reflected in a lower general health state.4,11,12 Overall, this results in great physical, psychological, and ultimately economic burden of the disease to the individual and society.13 There is therefore a need to establish a clinical indicator to detect risk and ensure early diagnosis of PsA. Early detection and treatment of PsA could, ultimately, allow the prevention of clinical and radiologic progression of the disease. For this reason, predictors for the presence of subclinical PsA are of considerable clinical interest. If validated properly, such indicators may help identify patients with subclinical disease at risk of deterioration, and allow an early intervention.2,4

Nail changes are observed in about 40% of psoriasis patients, a percentage that increasers to about 80% in patients with PsA. Nail disease in psoriasis has long been proposed as a predictor for the development of PsA.14–17

Since skin lesions precede articular symptoms in more than 75–80% of patients with PsA, with a mean estimated delay of 10 years, there is a potential window of opportunity for the early diagnosis and management PsA.2,4,18 This represents a unique occasion to document the clinical changes predictive of the development of PsA, or its subclinical presence.19 As dermatologists usually see patients with psoriasis before arthritis develops, they are in a unique position to diagnose PsA in its earliest phase, by detecting the precocious silent alterations of the disease even before radiological signs and symptoms have become manifest.20,21 The ultimate goal is early detection and appropriate treatment, avoiding disease progression and irreversible bone damage.

Psoriatic arthritis: clinical findings

PsA is a seronegative spondyloarthropathy, whose central defining feature is inflammation involving the entheses (enthesitis). PsA often presents in a characteristically asymmetrical manner, commonly involving the distal joints of the hands and feet. This specific distal joint affection points toward the presence of some factors, intrinsic to the target joint itself, which act as key drivers in the onset and perpetuation of the disease process.20,22,23

A common defining feature of PsA is the clinical presence of dactylitis, which represents inflammatory involvement (often with diffuse swelling) of the distal interphalangeal (DIP) joint. The DIP joint involvement begins as inflammation of the entheses, the main change in PsA. This perpetuated, chronic inflammatory process may ultimately culminate in joint cavity involvement, with osteolysis and periarticular new bone formation.23

With the purpose of creating a uniform and established definition of PsA, a Classification Criteria for Psoriatic Arthritis – the CASPAR classification – was introduced. This classification is found to be highly specific for the diagnosis of PsA (98.7%), and easier to use than other existing classification criteria. In this classification, diagnosis of PsA is supported by the combined presence of a certain number of clinical features, such as: (a) established inflammatory joint disease; (b) current psoriasis; (c) history of psoriasis; (d) family history of psoriasis; (e) dactylitis; (f) radiographic evidence of juxta-articular new bone formation; (g) negative rheumatoid factor, and (h) typical psoriatic nail dystrophy.24 As suggested by these criteria, nail disease in PsA is given a prominent role in diagnosis, and is given an equal footing to other important clinical and radiographic criteria.

Entheses: the anatomical site of joint inflammation

Enthesis is the term used for the attachment site of ligaments, tendons, and joint capsules to bone. This anatomical structure appears to share microanatomical features with the skin, both assisting in the resilience to regional compressive and shear force applications, helping preserve tissue homeostasis.25

As mentioned earlier, several imaging and histological studies have defined enthesitis (inflammation of the entheses) as the central, early inflammatory change in PsA.20,26,27

With the aim of characterizing arthritis in PsA patients, several investigators studied the DIP joint with imaging techniques such as ultrasonography and magnetic resonance imaging (MRI). The extent of the enthesis-associated disease in PsA became evident, as these techniques allowed to detect subclinical imaging features of inflammation of the entheses in clinically normal joints. Furthermore, these entheseal changes were found to be consistently identified when clinically evident nail disease was present.7,22,27,28 These imaging studies not only sustained the now established notion that enthesopathy is the major feature of PsA, but also suggested that nail disease in psoriasis may be associated with subclinical entheseal disease.

The entheses appear to derive their nourishment from the adjacent synovium, reflecting the anatomical proximity these structures.22 As such, inflammation and consequently altered entheseal function affects not only fibrous fibers in the entheses but the synovium as well and, by consequence, the contents of the synovial compartment, the joint surfaces.

As mentioned above, like the skin, the entheses are the anatomical structures that respond to both shear and compressive forces, and is now considered a prominent target of the early inflammatory process in PsA. As in the skin, changes observed in the nail-entheseal-joint apparatus could be explained by a Koebner response phenomenon. This hypothesis defines the occurrence of a common Koebnerization phenomenon – the appearance of lesions at previous sites of microdamage and trauma – and ultimately, inflammatory changes resulting from this stress could be responsible for the development of both nail disease and PsA joint changes.4,29 This concept of joint Koebnerization can ultimately be considered an aberrant response to mechanical stress.4,25,30

The link between psoriasis and HLA-Cw6 is well established, the latter representing the strongest genetic risk factor for the development of psoriasis.31 Nonetheless, joint and nail psoriasis-related changes appear to lack this association. Currently, studies so far have attested the presence of a prominent innate inflammatory infiltrate in PsA joints. This helped emphasize the emerging notion that, unlike psoriasis (in which an autoimmune response phenomenon, whose main participants are innate, but most importantly the adaptive immunity), PsA results from a Koebnerization phenomenon triggering an auto-inflammatory reaction of neutrophils in a tissue prone to stress lesions. In conclusion, the adaptive immune response that is presumed to be related to skin disease may not play a prominent role in PsA.22

Nail apparatus relation to arthritis: the entheseal complex

Of all the clinical indicators studied so far in the prediction of the development of PsA, the most strongly associated has been undoubtedly nail disease.4 An incidence study that followed a cohort of 1593 psoriatic patients for 30 years concluded that, compared to subjects without nail disease, psoriatic patients with nail dystrophy were almost 3 times more likely to develop PsA, with an attributed hazard ratio (HR) of 2.93 (95% CI, 1.68–5.12).19 Additionally, a retrospective analysis of 4146 psoriatic patients pointed to nail involvement as the strongest predictor for concomitant PsA, with an odds ratio (OR) of 2.93 (95% CI, 2.51–3.42).4 In addition, a prevalence study that aimed to determine the clinical implications of nail disease in 661 psoriasis patients found an association between nail changes and PsA, with an OR of 3.25 (95% CI, 2.16–4.90).32

The nail unit is formed by: (1) the nail plate; (2) proximal nail fold; (3) matrix; (4) nail bed and (5) hyponychium. The resulting specific nail lesion differs according to the nail structure primarily affected by the inflammatory process.23

Thus, the characteristics of nail involvement are determined by the extension and site of the inflammatory reaction. If the nail matrix is involved, there may be development of pitting, leukonychia, red patches (erythema) in the lunula, onychorrhexis, and onychodystrophy. In contrast, if the nail bed is affected, oil spots, splinter hemorrhage, onycholysis and subungual hyperkeratosis may develop.4,23,30,33 Although various studies differ in terms of the most prevalent nail change detected in PsA patients, pitting and onycholysis are defined as the most common modifications (Fig. 1).33

Anatomical and imaging studies have made a substantial contribution to our current understanding of the nail unit and its intrinsic connections to the DIP joint. These studies provided an anatomical link between the DIP extensor tendon enthesitis and the nail changes in PsA (Fig. 2).26

The nail is just as much an integral part of the entheseal unit as it is of the skin.4,26 At the microanatomical level, a close relationship exists between the nail and the DIP extensor tendon enthesis. As represented schematically in Fig. 3, the DIP extensor tendon attaches distally to the DIP joint, to a region located on the dorsal surface of the distal phalanx (DP). Arising from this attachment site, fibrous connections link nail structures, namely the nail matrix, to the periosteum of the DP.22 The DIP joint is therefore linked to the nail structures via the entheseal unit of the DIP extensor tendon.26,34

Recognition of this joint-entheseal-nail apparatus highlights the importance of entheseal inflammatory changes in PsA. This close structural relationship helps us understand why PsA patients, who typically present enthesitis of the DIP joint, concurrently develop inflammatory nail changes.4

As noted above, clinically unrecognized enthesitis is commonly observed in early PsA and, at this stage, crude radiographic signs are usually absent.30

In patients with psoriasis, imaging indicators of joint inflammation were found more frequently in patients with nail disease in comparison with those who presented no nail dystrophy signs. For example, the presence of extensor tendon entheseal thickening by ultrasound was observed in 42% of psoriatic patients (35/83) with clinical nail changes, while only 17.4% of patients (15/86) without nail lesions were found to have ultrasonographic findings. Entheseal changes are therefore more frequently observed in patients with nail changes, highlighting the relationship between nail and entheseal inflammation.20,27

In a study that evaluated the nail and DIP joint in patients with PsA using MRI, it was observed that nail involvement was present in almost all PsA patients (95.7%), even when the presence of clinical onychodystrophy was not evident.28 These findings suggest that nail disease is virtually always present in PsA patients, although not always clinically obvious. Patients could therefore benefit from close follow-up and evaluation by an expert in the nail area.

Furthermore, this group found that inflammatory signs of DP involvement always overlapped with nail involvement and cases of DIP joint changes alone were reported (that is, without nail and DP inflammatory changes). This enabled the formulation of a theory in which DIP joint involvement may arise as a result of nail and DP affection.28 In conclusion, the clinical and imaging findings of this study suggested psoriatic nail changes and distal phalanx inflammatory involvement precede DIP joint changes. These observations prompted the idea that nail dystrophy in psoriatic patients could be an indicator of ongoing inflammatory involvement of the distal phalanx, the site of attachment of entheseal structures of the DIP extensor tendon.28 Other studies corroborated this theory, providing strong evidence that nail disease is a predictor of PsA before arthritic changes occur.35,36

For this reason, nail disease in psoriasis may represent an accessible and readily observable indicator of future inflammatory joint affection. It could therefore be used as a sensitive clinical predictor of PsA.

Nail assessment: the dermatology–rheumatology gap

Studies have shown that, when assessing psoriatic nail disease, imaging findings of nail changes correlate well with clinical nail assessments.27

Studies that assessed PsA severity did not observe a direct relation between the degree of nail affection and DIP joint inflammation.37 From this assessment, one can conclude that the smallest nail changes, which may go unnoticed to the untrained observer with the naked eye, could be an important indicator of the presence of major disease. Expert examination, particularly dermatologists who can readily detect such changes, is therefore important. In this setting, the dermatological examination is of prime importance as a detector of a silent disease manifestation requiring referral (in this case, to the rheumatologist).

In a comparison between nail change detection, about 15% of patients classified by rheumatologists as having clinically evident nail disease, had another specific nail diagnosis unrelated to psoriasis, such as onychomycosis or onychoschizia, when observed by dermatologists.16 This underscores another essential characteristic of the dermatological assessment – high specificity.

In this view, psoriatic nail disease represents an area of overlap between dermatology and rheumatology. Mutual awareness of this overlap by dermatologists and rheumatologists, along with referral of psoriatic patients deemed to be at risk for arthritic disease, is of particular importance for the prevention of a serious, mutilating, chronic disease.38

Dermatologists can, therefore, play a central role in the early detection and management of PsA.

Conclusion

Specific imaging techniques have shown that the central inflammatory change in PsA takes place in the entheseal compartment. This structure is present in virtually every joint, but enthesitis manifests clinically in PsA especially in those structures subject to major shear and stretch forces.

Nail disease in PsA results from the close relationship between this structure and the enthesis of the DIP extensor tendon – one of the main entheseal compartments affected in PsA. The inflammatory change begins in the entheses, affecting the nail according to the degree and site (matrix vs nail bed) of inflammatory activity, and progresses proximally to affect the DIP joint. This results ultimately in the final anatomical, radiological and clinical changes of PsA in the joints.

In this view, the ability to detect nail changes by dermatologists gives them a strategic role in the early detection of subclinical entheseal disease and in the referral and management of early PsA, thereby preventing severe, erosive and deforming joint lesions.

In conclusion, the dermatological assessment in psoriatic patients represents a unique opportunity to prevent serious and functionally limiting disorders, thereby benefiting the health system in general and, most importantly, improving the patient’s quality of life.

Ethical responsibilitiesProtecting people and animals

The authors declare that no experiments were performed on humans or animals for this study.

Data privacy

The authors declare that no patient data appear in this article.

Right to privacy and informed consent

The authors declare that no patient data appear in this article.

Conflict of interests

The authors declare no conflict of interests.

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Nail Psoriasis: A Review of Treatment Options

90,000 Psoriasis of nails – what is it, symptoms and types, methods of treatment and prevention

This disease is a specific form of common psoriasis, in which skin cells form and die 5 times faster than usual. According to medical statistics, lesions of the nail plates on the upper or lower extremities are observed in 80-90 percent of all patients suffering from psoriasis, because nails are formed from the epidermis – the outer layer of the skin.

Causes of the disease

Psoriasis belongs to the group of autoimmune diseases, when the human immune system begins to destroy the tissues of its own body.The reasons for this unnatural reaction are not fully understood. There is also no way to get rid of the disease forever. The main factor in the appearance of the disease is hereditary predisposition. Almost 40 percent of patients have close relatives who also suffer from psoriasis. In addition, the disease can be provoked by:

• HIV, human papillomavirus, other infectious diseases;
• unfavorable weather conditions, abrupt climate change;
• injuries of the nail plates;
• long-term use of antibiotics, non-steroidal anti-inflammatory drugs, pressure-lowering drugs, beta-blockers;
• Frequent stress, prolonged emotional stress.

Types and symptoms of nail psoriasis

Psoriasis-affected nails are an unsightly sight. Among the main types of lesions, there are:

• thimble syndrome – characteristic pits randomly appear on the surface of the nail, resembling grooves in appearance, with which the well-known thimble is equipped;
• onycholysis – in this case, there is a gradual painless separation of the nail plate from its bed, a pink border appears around the affected nail;
• onychomadesis – the separation of the plate from the base of the nail is rapid;
• subungual hemorrhages – destruction of blood capillaries under the nail plate, visible through it in the form of pink or red spots or vertical bright red stripes, subsequently changing color to black;
• trachyonychia – the nail becomes rough, uneven, unnaturally thickened.Curving up over time, it takes the shape of a spoon;
• psoriatic paronychia is a generalized pustular type of disease, in which the nails enlarge and crumble strongly, the periungual ridges become inflamed, and pus oozes from under the cuticle. As a result, the inflammation affects the entire finger, and the nail plate is completely destroyed.

Also typical symptoms of the disease include the appearance of impressive grooves on the nails and hypertrophied keratinization of the end of the nail. Toenails suffer more from psoriasis.

The disease is not contagious, but it strongly interferes with social contacts: ugly nails traumatize the psyche of its victims, causing depression and loneliness. Others also instinctively try to avoid communicating with such people. In addition, the affected nail plates often cause pain and restrict the movement of the fingers, which limits the ability to carry out daily activities.

In addition to nail deformities, severe forms of the disease cause:

weakness, constant fatigue

temperature jumps

disturbances in the absorption of folic acid by the body

exacerbation of chronic ailments

Any form of psoriasis up to the cardiovascular system – , and can be a trigger for cancer, as well as diabetes.

How and with what to treat?

It is impossible to completely cure nail psoriasis with the means available to medicine today. The disease is chronic. But it is quite possible to increase the periods of remission and alleviate the condition with appropriate treatment during exacerbations. The real result is positive changes in the appearance of the affected nails.

The same medications are used as systemic drugs as in the fight against skin psoriasis: retinoids, drugs Cyclosporin, Otesla, Methotrexate.Self-medication is categorically contraindicated, since the drugs have dangerous side effects.

There are many ointments, creams, lotions and sprays in the local antipsoriasis category. They have proven themselves well:

• ointments, which are based on medical solid oil – Magnipsor, Kartalin, solid oil ointment with anti-inflammatory, exfoliating and restorative action;
• hormonal ointments containing corticosteroids – they soothe pain, relieve inflammation and redness;
• Creams Calcipotriol, Daivonex with the inclusion of a synthetic analogue of vitamin D.They are able to slow down hypertrophied division of nail cells and regulate immune processes;
• ointments Zorak, Tazaroten – retinoids in their composition, exfoliating damaged cells of the epidermis, help smooth out the deformed surface;
• Keratolytic varnishes, gels with the inclusion of urea – nourish, exfoliate and smooth the surface of the affected nail plate.

Means for external use are well supplemented with vitamin complexes and immunomodulators.

Traditional medicine also has recipes that alleviate the patient’s condition. Hot baths of bay leaves, soda compresses, lotions with corn and oat flour help to achieve remission.

Effective ways to prevent nail psoriasis

Extend the duration of remission correct preventive measures, including:

• special diet with the exception of allergic products – chocolate, eggs, citrus fruits, whole milk. At the same time, a ban is imposed on alcohol, fatty, fried, smoked, salty and flour foods;
• Thorough protection of nails from injury, dampness and dirt, including the mandatory use of protective gloves when working with the ground, household chemicals, washing dishes, etc.etc .;
• proper care – use a short haircut of nails with filed edges, do not remove cuticles, disinfect manicure tools;
• refusal from decorative and gel varnishes;
• Daily lubrication of hands and feet with moisturizing cream.

Psoriasis

IMPORTANT!

The information in this section cannot be used for self-diagnosis and self-medication. In case of pain or other exacerbation of the disease, diagnostic tests should be prescribed only by the attending physician.For a diagnosis and correct prescription of treatment, you should contact your doctor.

Psoriasis: causes, symptoms, diagnosis and treatment.

Psoriasis is a chronic non-infectious disease that can affect various organs: skin, joints, heart, kidneys.

Most often, mild psoriasis manifests itself on the skin in the form of well-defined pink-red papules (nodules that rise above the surface of the skin), which merge into plaques with silvery-white scales.

In moderate and severe forms of the disease, the inflammatory process leads to damage to the musculoskeletal system and the cardiovascular system. Psoriasis has a recurrent course (recurrence of symptoms after complete or partial recovery) and a tendency to cause comorbidities, which worsens the quality of life of patients.

Causes of psoriasis

Several triggers may be at the heart of the disease. However, it is still not known exactly which of them are primary and which are secondary.Dysfunction of the immune system is considered as the leading cause explaining the onset of psoriasis. Cells, aimed at destroying disease-causing agents, begin to attack their own cells (primarily the skin). As a result, an inflammatory process develops, which causes an accelerated division of epidermal cells (epidermal hyperplasia) and the formation of psoriatic papules and plaques.

An inadequate immune response is most often due to genetic characteristics.

Psoriasis is very often inherited.

Currently, more than 40 chromosome regions have been identified that are associated with the risk of developing psoriasis. The onset of the disease can be caused by a weakening of the immune system against a background of stress, infectious, endocrine diseases. Psoriasis often accompanies allergic and immunodeficiency conditions, which are based on an impaired immune response. In addition, certain medications (antidepressants, beta-blockers, nonsteroidal anti-inflammatory drugs) can provoke psoriasis.

Classification of psoriasis

Depending on the localization of the pathological process, various types of psoriasis are distinguished. Most often, vulgar, or ordinary, psoriasis occurs, when clearly outlined pink papules appear on the skin, which merge into plaques covered with silvery-white scales. When the scalp is affected ( seborrheic psoriasis ), rashes in the form of yellowish scales can descend on the forehead, forming a seborrheic “crown”.In patients with metabolic disorders, exudate may appear on the plaques – fluid released during inflammatory processes (exudative psoriasis ). In childhood and adolescence, especially after streptococcal infections, the disease can turn into an acute form, while many bright red teardrop-shaped papules with slight peeling and infiltration appear on the skin ( teardrop-shaped psoriasis ). Sometimes there is pustular psoriasis, which is characterized by the appearance of pustules against the background of reddened skin, more often in the area of ​​the arch of the feet or palms. Psoriatic erythroderma can occur against the background of exacerbation of ordinary psoriasis under the influence of provoking factors. Dry white scales cover the skin, it becomes bright red, swollen and hot to the touch. Very difficult generalized psoriasis Tsumbusha . It is characterized by the fact that small purulent vesicles appear on the reddened skin, which, merging, form “purulent lakes”. Psoriatic arthritis is accompanied by joint damage and develops simultaneously with or precedes the rash.

Symptoms of psoriasis

The cutaneous form of psoriasis is accompanied by the appearance of bright pink pinpoint papules, sometimes in the form of droplets. Merging, they form plaques covered with silvery-white scales.

The rashes are located on the extensor surfaces of the arms and knee joints, on the scalp, on the lower back and sacrum.

The upper layer of plaques is formed by easily removable scales of dead epidermis. First, they occupy the center of the plaque, and then fill its entire area.Removing the scales reveals a shiny, bright red surface. Sometimes the plaque is surrounded by a pink rim – a zone of further growth, while the surrounding skin does not change. The rash is accompanied by severe itching. With psoriatic erythroderma in patients, against the background of rashes all over the skin, fever (fever with chills) and severe itching are noted, and lymph nodes are enlarged.

With a prolonged course of the disease, hair and nails may fall out.

Generalized psoriasis of Tsumbush is very difficult.Purulent eruptions cover the entire skin and are accompanied by severe fever and intoxication. Psoriatic joint damage is characterized by pain and redness of the skin over the articular surfaces. Any movement is difficult, inflammation of the ligaments and tendons develops. In psoriasis, the nail plates are very often affected, while point depressions appear on the surface of the nail (a symptom of a “thimble”).

Small, reddish and yellowish-brownish spots appear under the nail plate at the base (symptom of “oil stain”).Dystrophic changes in nails and hair often develop.

In children, especially infants, the symptoms of psoriasis have their own specifics.

In the area of ​​redness that occurs in the skin folds, effusion and slight flaking of the upper layer of the epidermis may occur. This picture resembles diaper rash or candidiasis. Sometimes rashes appear on the skin of the face or genital area.

Diagnosis of psoriasis

The disease can be identified on the basis of the symptoms of the psoriatic triad (white stearic surface of the papule; reddish shiny film after desquamation of scales and pinpoint protrusion of blood after its removal).

An additional feature is considered the Kebner phenomenon. It consists in the fact that in the area of ​​skin irritation after 7-12 days, erythematous-scaly rashes (areas of redness and peeling in the area of ​​scratches, scratches) appear. Sometimes a histological examination of a biopsy specimen of the affected skin area is performed to confirm the diagnosis. In addition, a clinical and laboratory examination is necessary: ​​a clinical blood test, a biochemical blood test (total protein, protein fractions, C-reactive protein, ALT, AST, LDH, creatinine, electrolytes: potassium, sodium, chlorine, calcium).
90,000 What is psoriatic arthritis?

Psoriatic arthritis is an inflammatory arthritis associated with a skin disorder known as psoriasis. The symptoms of this disease can be similar to those of rheumatoid arthritis. The exact cause of psoriatic arthritis has not been established. As a rule, it begins between the ages of 30-50. The severity of the disease varies from mild to disabling. Psoriatic arthritis is associated with psoriasis, a chronic condition of the skin and nails.

The disease often occurs with lesions of the peripheral joints and the spine. Moreover, the symptoms of psoriatic arthritis and rheumatoid arthritis are very similar, and almost everyone affected by this ailment has psoriasis. Approximately 10-25% of people with psoriasis develop arthritis with pain and swelling in one or more joints.

The etiology of the disease has not been established. However, psoriatic arthritis is thought to be caused by a combination of immune, genetic, and environmental factors.

Who is at risk? Psoriatic arthritis affects men and women equally between the ages of 30 and 50. Although the possibility of the development of this disease in childhood is not excluded. Compared to the many other types of arthritis, psoriatic arthritis is relatively less common. The cutaneous manifestations of psoriasis tend to occur months or years earlier than arthritis. Despite this trend in the development of the disease, in 15% of cases, the diagnosis of arthritis precedes the diagnosis of psoriasis.

Symptoms listed below will indicate the presence of psoriasis and psoriatic arthritis. Red scaly patches on the scalp, elbows, knees, or buttocks, but maybe one small speck appearing on the scalp. In some cases, the rash covers a large area of ​​the body. Pain and swelling in one or more joints (most commonly the distal joints of the arms, legs, wrists, knees, or ankles). Swelling of the fingers or toes, making them look like sausages. Stiffness in joints, which can also appear in the morning.The disease can start suddenly, sometimes the development of the disease occurs gradually, over several months or years.

Diagnosis of the disease. The presence of psoriasis of the skin or nails, on the background of which articular symptoms join. Genetic predisposition is an important factor. Since the symptoms of psoriatic arthritis may resemble other types of arthritis (gout, reactive arthritis and rheumatoid arthritis), additional examination is necessary: ​​X-ray examination to detect changes in bones and joints, laboratory tests: complete blood count, biochemical blood test, immunological blood tests, in order to exclude other causes of joint damage.It is important to understand that the diagnosis is made on the basis of a clinical examination, data from instrumental and laboratory studies.

Treatment of psoriatic arthritis is prescribed by a rheumatologist taking into account the course of the underlying disease.

What is the threat of psoriatic arthritis? Generally, the disease is mild to moderate in severity. With appropriate treatment, joint stiffness and pain can be relieved and controlled for psoriasis in the skin.However, in some cases, psoriatic arthritis can lead to more serious complications, so combination medication is required to control symptoms and prevent joint destruction.

When to see a doctor? Thickened, inflamed spots on the skin, pain and stiffness of the joints are alarm bells, when they appear, you should consult a doctor. Changes in nails, swollen fingers, a rash on the body – these symptoms should also bring you to the doctor’s office.

Doctor-rheumatologist, health care institution “Zhodinskaya Central City Hospital” Kosovets O.E.

Nail psoriasis

Today, doctors define psoriasis as a common chronic skin disease. A person with psoriasis most often has patches of thickened red skin with silvery scales. These lesions are usually located on the elbows, knees, scalp, and trunk. Sore skin may look shiny and red, or even pustular, depending on the type of psoriasis.In Ukraine today, about 1.5 million people suffer from psoriasis. Psoriasis can also affect the nail plates on the hands and feet, resulting in pitting, thickening and crooked nail contours.

Most people who suffer from nail psoriasis also have skin psoriasis. If nail psoriasis is at an advanced stage and is not treated, then this can lead to functional problems (inconvenience and limitations in everyday life), as well as to social problems that arise due to the patient’s non-perception of society.

Causes and risk factors

Whatever they say about psoriasis, psoriasis is not contagious! The same statement applies to nail psoriasis. To date, it is not known exactly how this disease develops. It is believed that nail psoriasis is the result of a combination of genetically inherited, immunological and environmental factors.

It is because of the genetic component that psoriasis tends to develop in the same family. About 40% of people with psoriasis have first-degree relatives who also have the disease.For example, from father to child, or even to children, if there are several of them in the family. If both parents have psoriasis, the child’s risk of developing the disease is up to 75%. The ratio of psoriasis in both sexes is about the same. Also psoriasis can occur in people of all genders, peoples and races.

Symptoms and signs

As a rule, people who have nail psoriasis also have skin symptoms as well. If someone has psoriasis of the nails but does not have symptoms of skin psoriasis, the condition can be difficult to diagnose by a doctor as the symptoms of nail psoriasis resemble the fungal infections that affect the nails.It is very important to tell your doctor if psoriasis is present not only in you but also in other family members.

In order to determine the symptoms of psoriasis, the following signs of nail psoriasis can be distinguished:

• Bright yellow-red spots on a colorless nail that look like a drop of blood congealed under the nail plate. Such a stain is known in medicine as a “oil stain symptom” or “stearin stain”, which is the main visible symptom of nail psoriasis.

• Small pits in the nails or a curved, wavy nail plate. Such pits develop when cells begin to exfoliate from the surface of the nail.

• Bo transverse lines running across the nails (from side to side, not root to tip), also known medicinally as Bo Reil furrows.

• White dots on the nail plate, otherwise known as leukonychia.

• Thickening of the skin under the surface of the nail.A doctor may diagnose this as subungual hyperkeratosis, which can lead to loosening of the nail plate.

• Loose nails. Doctors call this condition onycholysis of the nail bed or nail hyponium. An area may appear on the nail where the nail is separated from the subungual skin, also called the hyponium. Typically, this condition starts at the tip of the nail and spreads to the root. Thus, nail psoriasis can spread to the subungual skin, which can cause cutaneous psoriasis.

• Destruction of the nail. The nail can be brittle and weakened because its underlying structural constituents are not healthy.

• Small black lines towards the tip of the nail and towards the cuticle. They are called splinter hemorrhages or are also known as dilated tortuous capillaries. This condition begins when tiny capillaries burst at the tips of the fingers under the nail plate.

• Redness of the pale, arched area located at the bottom of the nail, also called a macular lunula.This condition is observed when the capillaries are overloaded.

• Arthritis of the fingers with changes in the nail plates. Nails are affected in 53% -86% of people who have psoriatic arthritis.

Psoriasis of the nails can occur together with fungal infections of the nails (onychomycosis) and inflammation of the skin along the edges of the nails (paronychia).

When to seek medical attention

If the nails show changes such as discoloration (white spots or yellowed areas), pits, or if the nails appear infected, painful, see a doctor.

How do doctors diagnose nail psoriasis

If a person has nail psoriasis and has characteristic nail changes, the diagnosis is usually clear. In some situations, the doctor may do a biopsy (take a small sample of the skin under the nail to determine if the nail is psoriasis).

Treatment of nail psoriasis

To date, no single cure for nail psoriasis, which will cure the patient forever, has not been found. The aim of the treatment is only to improve the functionality and appearance of the nails.But if the nails are infected with a fungal infection, the doctor will definitely prescribe an antifungal drug.

The main remedies for nail psoriasis

There is no single home remedy to permanently cure nail psoriasis. In areas where the nail plate is weakened, you need to manually gently cut the nail back into the skin where it is attached to it. This will allow the drugs to work more effectively. All nail care activities should be very soft and delicate. Vigorous rubbing of nails, rough impact on the nail can cause flare-ups of nail psoriasis.Try to care for your nails so that they do not damage, weaken, or spread the psoriasis to an even larger area.

A doctor may recommend that you remove a nail or part of it, either chemically or surgically. Chemical nail removal involves applying an ointment to the nails for seven days. This way the nail will come off on its own without bleeding.

Even with effective treatment, it can take a long time for the symptoms of nail psoriasis to improve. So, it can take from eight to twelve months to form and grow a new nail.

For the treatment of nail psoriasis, the doctor may prescribe any of the following types of drugs:

Creams or ointments rubbed on and around the nail, including steroids, topical treatment with creams containing vitamin A or vitamin D derivatives, antimetabolic drugs, or sometimes antifungal solutions if fungal infection is present. However, the absorption of drugs into the nails is not always effective due to the obstruction presented by the nail plate. Local treatment, which is applied directly to the nail, cannot be effective in all cases, without exception.

Steroids can be applied to the skin under the nail or injected under the nail; under the nail may be more effective than steroids, which are given in the form of a cream or ointment.

PUVA: This treatment is a combination of a prescription drug, psoralen, and exposure to UVA light.

Systemic therapy may be appropriate if there are symptoms of nail psoriasis and arthritis, skin and nail psoriasis symptoms. Systemic therapy is a treatment that spreads throughout the body and affects the entire body as a whole.Often used in pill or injection form.

In our online store you can purchase a wide range of natural preparations for nail psoriasis: Kartalin ointment, Magnipsor ointment, Antipsor cream, Citapsor ointment, Akrustal cream, Antipsoriasis ointment, Solipsor cream, Solidin cream

Surgical intervention for nail psoriasis

If other treatments fail, your doctor may surgically remove the nail. Local anesthesia is given before the nail is removed.

Prevention of nail psoriasis

Psoriasis is highly dependent on heredity, genes, and the prevention of psoriasis is impossible. However, to prevent psoriasis flare-ups and to avoid nail damage, nails must be kept dry and protected from damage.

Prognosis for nail psoriasis

Nail psoriasis is not completely cured, but the treatments mentioned above can improve the appearance and function of nails.

Support and counseling for people suffering from nail psoriasis.

Education is one of the foundations for the management of this chronic and usually relapsing disease. People with psoriasis need to be familiar with treatment options in order to make the right informed decisions about therapy. Various medical institutions and associations can provide support for people with psoriasis. They can also clarify the characteristics of your illness to family and friends, in order to avoid emotional stress with society.

Read also:

Local treatment of psoriasis 90,000 Treatment of psoriasis at Es Class Clinic Tula at an affordable price

Psoriasis, also known as scaly lichen, is a severe chronic skin disease, the causes of which are still debated by scientists.Some believe that this is a primary disease that develops due to a violation of the process of maturation and multiplication of skin cells. Others consider it an autoimmune disorder. Mostly women are ill with it. Lack of therapy can lead to disability. Patients experience enormous psychological discomfort, especially if the plaques (protruding areas of the skin, very dry, itchy and flaky) are located in a conspicuous place: face, head, hands, etc.

Despite the fact that the disease is incurable, the treatment of psoriasis on the head and other parts of the body can significantly improve the patient’s quality of life and simplify his social adaptation.This is important because sometimes it comes to serious psychological problems, up to and including dysmorphic and social phobia. Treatment is rather complicated, but usually begins with the use of external ointments. If the condition does not improve, the dermatologist will prescribe phototherapy. If this does not help, then medication remains. The more severe the form, the more toxic drugs have to be used. Often, patients are also prescribed antidepressants to help them cope with oppressive thoughts, especially during periods of exacerbation.

Few people know that this disease can affect not only the skin, but also the nails. Psoriasis of the nails, the treatment of which is not much different from that described above, consists in changing – compaction and yellowing – of the nail plates of the hands and feet. Moreover, in some forms of the disease, inflammation of the connective tissues and joints is possible. That is why it is so important to see a doctor on time and strictly follow his recommendations, even if you suspect you have psoriasis on your feet.Treatment will definitely be effective if you maintain a positive attitude and do everything to combat the disease!

If the problem is familiar to you, our dermatovenerologist is ready to accept and examine you, as well as prescribe a suitable therapy. Make an appointment using a special online form.

Psoriatic arthritis – FGBNU NIIR them. V.A. Nasonova

What is psoriatic arthritis?

Psoriatic arthritis is a chronic inflammatory disease of the joints, spine and ligaments, which often develops in patients with psoriasis.

Psoriatic arthritis develops in about a third of patients with psoriasis. Therefore, all patients with psoriasis should be screened for psoriatic arthritis at least once a year using a self-questionnaire.

Main manifestations of psoriatic arthritis

The cause of the development of psoriatic arthritis and psoriasis is still unknown. The provoking factors are often trauma, stress and infectious diseases.A genetic predisposition to the development of psoriasis and psoriatic arthritis was noted.

Symptoms

As a rule, skin manifestations of psoriasis precede the development of psoriatic arthritis (often for many years), less often arthritis and psoriasis develop simultaneously. In some patients, arthritis occurs earlier than psoriasis. In about 80% of cases, psoriatic nail damage occurs.

The main symptoms of psoriatic arthritis are pain, stiffness and swelling of the joints of the hands and feet, inflammation of the fingers like a “sausage” with swelling and purplish-bluish discoloration of the skin, pain in the heels when walking, pain and stiffness in the neck and lower back in the second half nights and mornings, ameliorated by waking and exercising.

Diagnostics

In a clinical blood test for psoriatic arthritis, an increase in ESR (erythrocyte sedimentation rate) may be observed. In biochemical analysis – an increase in the titers of C-reactive protein. There is usually a direct relationship between the activity of psoriatic arthitis and the degree of increased ESR and C-reactive protein.

Unlike rheumatoid arthritis, in psoriatic arthritis, rheumatoid factor, a special type of antibody, is rarely found in the blood.The presence or absence of rheumatoid factor in the patient’s blood is sometimes used in differential diagnosis (to distinguish one type of arthritis from another). Psoriatic arthritis can be either a slow or a rapidly progressive disease that leads to destruction and deformation of the joints. Sometimes there are signs of damage to internal organs: eyes, myocardium, intestines. Often patients with psoriatic arthritis are obese, high blood pressure.

Psoriatic arthritis and psoriasis are chronic diseases that accompany the patient throughout his life, however, these diseases can be controlled using modern therapies, which are fully mastered by the specialists of the psoriatic arthritis laboratory.

The methods of drug therapy that we use are scientifically substantiated and included in the Federal clinical guidelines. Significant progress has now been made in the treatment of PsA and psoriasis, modern high-tech targeted drugs have been developed that allow you to manage the disease, completely removing almost all symptoms. The sooner you are consulted by specialists, the better the prognosis of the disease in the future.

If the patient agrees and there are no contraindications, the doctor can offer the patient participation in Russian and international clinical trials of the latest innovative drugs for the treatment of psoriatic arthritis and psoriasis, which will soon enter clinical practice.Participation in a clinical research study is a way to get the latest therapy under the supervision of specialists.

If you have psoriatic arthritis and psoriasis and you want to receive qualified medical care at the level of Russian and international standards, make an appointment with the specialists of the laboratory of spondyloarthritis and psoriatic arthritis.

Make an appointment with a specialist:

90,000 nail psoriasis is… What is nail psoriasis?

• coin-shaped psoriasis
• papillomatous psoriasis

See what “nail psoriasis” is in other dictionaries:

• Psoriasis – Psoriatic lesions of the back and arms … Wikipedia

• PSORIASIS – PSORIASIS, psoriasis vulgaris, chron. skin disease, the main symptom is pink-red, slightly raised papules, covered with loose white shiny scales.P. frequent b n; according to European and American authors, it ranges from … … Great Medical Encyclopedia

• Psoriasis – I Psoriasis (psoriasis; Greek psōra skin disease, scabs; synonym scaly lichen) is a chronic skin disease characterized by papular eruptions; possible damage to nails and joints. Psoriasis is one of the most common skin … Medical Encyclopedia

• PSORIASIS – honey.Psoriasis is a chronic recurrent multifactorial hereditary dermatosis characterized by hyperproliferation of epidermal cells. Frequency 1 2 cases / 100 population. Classification • By clinical form • Disc-shaped (monotonic) … Handbook of diseases

• PSORIASIS is a skin disease characterized by the appearance of reddish plaques, mostly dry and scaly. Most often, psoriasis occurs in adults, especially in situations of mental stress or increased anxiety.Often it occurs … Collier Encyclopedia

• PSORIASIS – – a chronic inflammatory skin disease characterized by a monomorphic papular rash; joints and nails are also affected. Hereditary, viral, neurogenic, metabolic genesis of the disease is assumed. Skin rashes usually … … Encyclopedic Dictionary of Psychology and Pedagogy

• Onychia – This article is being proposed for deletion.