Nail Psoriasis Severity Index Research Articles

Dermoscopic Features of Nail Psoriasis: Revisited

Introduction: Nail psoriasis poses a diagnostic challenge in a context of clinical findings that are not evident. We aimed at exploring dermoscopic findings of nail psoriasis and assessing the relationship between these features with disease severity and the risk of arthritis. Methods: We enrolled 35 patients (26 men, 9 women) with severe nail psoriasis (Nail Psoriasis Severity Index [NAPSI] score of more than 50). A complete clinical evaluation, including musculoskeletal assessment and videodermoscopic examination of all nails, was carried out for each patient. Results: Splinter haemorrhage was the most common finding (94.3%), followed by distal onycholysis (88.6%) and pitting (74.3%). The presence of subungual hyperkeratosis (SUH) and the absence of mottled lunula were associated with disease severity (p < 0.05). Both SUH and nail plate crumbling (NPC) were observed more in patients with arthritis. The presence of a combination of SUH and NPC was associated to a 15-fold increase in the risk of arthritis (%95 confidence intervals: 1.55–145.2, p < 0.05). Discussion/Conclusion: This study presents preliminary evidence for the use of dermoscopy as a first step in the diagnosis of nail psoriasis. Dermoscopy is an indispensable tool in the primary evaluation of patients with nail psoriasis, which provides predictive information about the course of the disease.

Fractional CO2 Laser-Assisted Delivery Versus Intralesional Injection of Methotrexate in Psoriatic Nails.

Nail psoriasis has a major negative impact on physical and psychological aspects of the patient's life. Treatment is often unsatisfactory because of difficult penetration of the drug into the nail. To evaluate and compare the efficacy of laser-assisted delivery of methotrexate versus its intralesional injection in fingernail psoriasis. Twenty-eight patients with fingernail psoriasis were divided into 2 groups of 14 patients each. Group A was treated with intralesional injection of methotrexate while Group B received fractional CO2 laser followed by topical application of methotrexate. The treatment was given at a 2-week interval for 6 sessions. The improvement of nail psoriasis was assessed by clinical and dermoscopic evaluation. At the end of treatment, both laser-assisted delivery and intralesional injection of methotrexate were associated with statistically significant improvement of psoriatic signs. No statistically significant difference was found between the 2 groups regarding total nail psoriasis severity Index (p = .18), matrix score (p = .38), bed score (p = .23), and dermoscopic score (p = .78). However, the pain and subungual hematoma were significantly less in the laser group (p < .001 and p = .03, respectively). Fractional CO2 laser-assisted delivery of methotrexate can be an effective and well-tolerated alternative to intralesional injection in nail psoriasis.

Nail lesions in palmoplantar pustulosis and pustulotic arthro-osteitis impairs patients’ quality of life: Suggesting new assessment tool of PPP nail lesions

BackgroundPalmoplantar pustulosis (PPP) sometimes presents with nail lesions, which affect the patients’ quality of life (QOL). However, little is known about nail lesions in PPP, and there is currently no established method for assessing them. ObjectiveThis study aimed to analyze the impact of PPP-related nail lesions with the patients’ QOL. In addition, we considered whether they might constitute a risk factor of pustulotic arthro-osteitis (PAO).’ MethodsA total of 178 patients with PPP were enrolled. Among the 178 patients, 66 patients participated in the following quality of life questionnaires; GHQ28, DLQI, and Skindex-16. The severity of the nail lesions was classified according to the Nail Psoriasis Severity Index (NAPSI), and the types of nail lesion were investigated. ResultsThe DLQI, Skindex-16 and PPPASI scores were significantly higher in patients with nail lesions than in those without them. Indentions, transverse ridging, and nail thickening were relatively common in PPP. Nail lesions were unrelated to the presence of PAO complications, but leukonychia and discoloration were likely to be related to PAO lesion site. ConclusionsThe study demonstrated that the presence of nail lesions is associated with a decreased QOL regardless of the severity of the skin lesions. The nail lesions were not a risk factor of PAO, but a predictor of skin lesion severity and PAO lesion site. Given this association, indention, transverse ridging, and thickening of the nail, currently not included in the NAPSI, should be added as an assessment item in the evaluation of PPP nail lesions.

Comparison of the Objective Severity and the Esthetic Perception of Nail Symptoms in Psoriasis

Introduction: Nail changes are frequent in psoriasis, and the negative impact of nail psoriasis on patients’ quality of life is well known. No data are available however about the association of the objective severity of nail psoriasis and the subjective perception of these symptoms. The purpose of this study was to determine the correlation between the severity of psoriatic nail changes (as determined by the Nail Psoriasis Severity Index [NAPSI]) and the esthetic assessment of nail psoriasis. Methods: Participants (general population and psoriasis patients) were asked to rate 19 nail images (including psoriatic and healthy nails) on a 0–10 scale, based on how disturbing they considered them esthetically. Objective severity (NAPSI) scores of nails were compared to the subjective evaluation values. Results: Nail symptom severity correlated well with the subjective scores. However, while nails with low (0) and high (6–8) NAPSI values received consistent subjective scores, the esthetic perception of nails with moderate NAPSI scores was rather heterogeneous. The age of the respondents showed robust positive correlation with the subjective assessment of nail symptoms both within the psoriatic and the general population. Discussion: Gender, the presence of psoriasis, or medical education had no significant influence on the esthetic assessment of psoriatic nail changes.

A mask R-CNN based automatic assessment system for nail psoriasis severity

Nail psoriasis significantly impacts the quality of life in patients with psoriasis, which affects approximately 2–3% of the population worldwide. Disease severity measures are essential in guiding treatment and evaluation of therapeutic efficacy. However, due to subsidy, convenience and low costs of health care in Taiwan, doctor usually needs to manage nearly hundreds of patients in single outpatient clinic, leading to difficulty in performing complex assessment tools. For instance, Nail Psoriasis Severity index (NAPSI) is used by dermatologists to measure the severity of nail psoriasis in clinical trials, but its calculation is quite time-consuming, which hampers its application in daily clinical practice. Therefore, we developed a simple, fast and automatic system for the assessment of nail psoriasis severity by constructing a standard photography capturing system combined with utilizing one of the deep learning architectures, mask R-CNN. This system not only assist doctors in capturing signs of disease and normal skin, but also able to extract features without pre-processing of image data. Expectantly, the system could help dermatologists make accurate diagnosis, assessment as well as provide precise treatment decision more efficiently.

Guselkumab is efficacious and safe in psoriasis patients who failed anti-IL17: a 52-week real-life study

Background Interleukin (IL)23/Th17 axis is the leading actor of psoriasis pathogenesis. Guselkumab is the first anti-IL23 approved for psoriasis. Anti-IL23 and anti-IL17 partially share their therapeutic target currently appearing as the most efficacious available psoriasis treatments. Real-life data on guselkumab performance in anti-IL17 failure patients are scant. Methods A 52-week real-life single-center retrospective study was performed to evaluate the long-term efficacy and safety of guselkumab in patients who previously failed anti-IL17. Results A total of 44 patients were enrolled (28 male, 63.6%; mean age 59.0 ± 10.2 years). A statistically significant improvement of Psoriasis Area Severity Index (PASI) and Body Surface Area (BSA) was assessed at each follow-up (PASI decreased from 13.9 ± 8.1 to 0.9 ± 0.7 at week52 while BSA from 24.3 ± 19.6 to 1.3 ± 1.4, p < .001). Nail Psoriasis Severity Index (NAPSI) improvement was collected as well, even if being statistically significative only at week28 and thereafter [2.9 ± 6.2 at baseline, 0.9 ± 1.5 at week28, (p < .05)]. Only 3 (6.8%) patients discontinued guselkumab due to secondary inefficacy. No cases of serious Adverse Events were assessed. Conclusion Our real-life study confirmed the efficacy and safety of guselkumab in daily clinical practice suggesting it as a valuable weapon also in psoriasis patients who previously failed anti-IL17 treatments.

Study of Nail Psoriasis and Dermoscopic Correlation with Dermoscopic and Modified Dermoscopic Nail Psoriasis Severity Indexes (dNAPSI and dmNAPSI).

BackgroundNail involvement in psoriasis may be assessed clinically, ultrasonologically, and dermoscopically. The aim of this study was to assess the dermoscopic features of nails in psoriasis, to compare them with the clinical findings, and to correlate them with the Nail Psoriasis Severity Index (NAPSI) score.MethodsWe recruited 120 patients with psoriatic nail changes for the study. The Psoriasis Area Severity Index (PASI) was used to assess the severity of disease. Clinical and dermoscopic (Derm-Lite DL4, ×10, polarized and non-polarized) nail examination determined NAPSI, modified NAPSI (mNAPSI), and NAPSI determined with dermoscopic findings (dermoscopic NAPSI [dNAPSI] and dermoscopic modified NAPSI [dmNAPSI]) were used to assess severity of nail involvement.ResultsSubungual hyperkeratosis (50.8%) and nail plate thickening (56.7%) were the commonest clinical nail changes found, and dermoscopically, they were subungual hyperkeratosis and pitting (68.3% each). The average median with interquartile range of PASI and NAPSI scores were 7.5 [5.7–10.8] and 8.0 [6–12], respectively. NAPSI scores increased significantly with the increase in PASI scores (P < 0.001). A comparison of NAPSI and mNAPSI with dNAPSI and dmNAPSI revealed that NAPSI, mNAPSI, and dNAPSI increased significantly with an increase in PASI scores. The dNAPSI scores increased significantly with increased mNAPSI and dmNAPSI, and mNAPSI and dmNAPSI were significantly good predictors of joint involvement in psoriasis.ConclusionsDermoscopy allows for better visualization of nail findings. Evaluating NAPSI and mNAPSI scores in conjunction with dNAPSI and dmNAPSI increases their helps detect early psoriasis, detection of worsening moderate-to-severe psoriasis (PASI >10) and predict joint involvement and their severity.

Study of Clinical and Dermoscopic Features in Nails of Papulosquamous Disorders and their Correlation with Disease Severity: A Cross-Sectional Study.

As face is the index of the mind, so is the nail the index to health, as the nail is capable of mounting only a limited number of reaction patterns to the large number of disorders affecting it. Dermoscopy is thus a valuable aid not only in enhancing visible nail features but also in revealing cryptic features of diagnostic value. To study the clinical and dermoscopic features in nails of papulosquamous disorders and correlate it with disease severity. This was a cross-sectional study with convenient sampling. After obtaining ethical clearance, according to inclusion and exclusion criteria, papulosquamous disorders were enrolled in the study. Finger nails and toe nails were numbered 1-10. Detailed clinical examination was done. Wet and dry dermoscopic examination was made in both polarised and non-polarised mode using ultrasound (USG) gel. Psoriasis area and severity index (PASI) and body surface area (BSA) were compared with nail changes. Statistical analysis of data was performed using the Statistical Package for the Social Sciences (SPSS) version 26. Out of 203 patients, 117 were male. Psoriasis was the most common disease (55.6%). A total of 65.51% of patients had nail changes. Pitting was the most common finding in psoriasis, both dermoscopically and clinically. Splinter haemorrhage, oil drop, dilated capillaries, and pseudofibre sign were detected better on dermoscopy (P < 0.05). Positive correlation was found between PASI and nail psoriasis severity index (NAPSI). A strong correlation was also found between clinical (cNAPSI) and dermoscopic (dNAPSI). Thinning was the most common in lichen planus. No relation between BSA and nail changes was observed. Dermoscopy is thus a valuable aid not only in enhancing visible nail features but also in revealing cryptic features of diagnostic value and reducing the requirement for invasive procedures like nail biopsies, early diagnosis, directing management.

AN OPEN-LABEL RANDOMIZED CLINICAL STUDY OF TOPICAL NANOPARTICULATE ANTIPSORIATIC POLYHERBAL CREAM

Objective: Objective of the study was to investigate the safety, efficacy, and antipsoriatic activity of topical cream enriched with Nanostructured Lipid Carriers (NLC) of Azadirachta indica, Lawsonia inermis, and Mallotus philippensis through the controlled clinical study. Methods: The randomized controlled trial was performed for 12 months on 65 adult patients between the age group 20 and 60 years of either sex of diagnosed, uncomplicated cases of psoriasis Vulgaris. The Test group received a local application of the herbal antipsoriatic NLC enriched cream, while the Control group was treated with Clobetasol propionate 0.05% cream twice daily for 3 months. Both groups were assessed for parameters of skin and nail examinations, lab investigation, and Psoriasis Area and Severity Index (PASI) score. The data were analyzed and interpreted statistically. Results: Significant improvement in itching and PASI score was seen during successive visits in both groups. However, recurrence of mild itching and erythema in a few patients of the control group was seen after 2 weeks, whereas no such recurrence is seen in the test group. Statistically significant reduction in eosinophilia in the control group was observed before and after treatment. The efficacy of clobetasol in the control group and the prepared formulation in the test group both show statistical efficacy at par. Conclusion: The data suggest that the NLC enriched cream exhibited significant relief in all the symptoms of psoriasis and therefore can be used as a potent antipsoriatic agent due to the easy availability of the drugs and cultural affinity for herbal formulations.

Novel transdermal device for delivery of triamcinolone for nail psoriasis treatment

Nail psoriasis treatment is challenging due to difficult drug delivery and systemic therapy toxicities. Self-dissolvable microneedle patches embedded with corticosteroids offers a potentially rapid, minimally invasive drug delivery platform with good efficacy and minimal adverse side effects. We conducted a 4-month prospective randomised controlled trial. Subjects with psoriatic nails were randomised to receive microneedle device delivered topical steroids on one hand and control treatment (topical Daivobet gel) on the other. Two independent dermatologists blinded to the treatment assignment scored their Nail Psoriasis Severity Index (NAPSI) during visits at baseline, 2 and 4 months. All treatment was discontinued after 2 months. Average NAPSI score on each hand was analysed. A total of 25 participants were recruited, aged 22 to 73 years. Majority were Chinese (72%), followed by Indian and Malay. There was equal randomisation of treatment to the left and right nail. While there was a rapid significant improvement in average NAPSI score for the control arm at 2 months, the treatment arm had a greater, more sustained improvement of the NAPSI score at 4 months. The average NAPSI score improved for both treatment and control group at 4 months compared to baseline. However, only the NAPSI value improvement in the controls at 2 months compared to baseline was statistically significant (P=0.0039). No severe adverse effects were reported. To the best of our knowledge, this is the first prospective randomised control trial comparing microneedle technology against conventional topical steroids in nail psoriasis treatment. Our findings demonstrate microneedle technology is as efficacious as topical therapy.

Nail Lichen Planus Severity Index (NALSI): A Novel Severity Score for Nail Lichen Planus.

Clinical challenge Rigorous data on treatment options in nail lichen planus (LP) is lacking and even the existing studies do not offer robust scientific evidence.[1] This is primarily due to lack of a comprehensive severity scoring tool for enabling consistent, comparative and thorough evaluation. It is unlike nail psoriasis, where nail psoriasis severity index (NAPSI) is a commonly used objective, validated tool for assessing nail disease severity and response to treatment.[2] We propose a nail severity score for nail LP which takes into account the peculiarities of this disease e.g., only few features being responsive to therapy; presence of scarring and irreversible changes; and extensive involvement of the nail unit including nail folds. Solution The nail lichen planus severity index (NALSI) is to be scored in four quadrants per nail, like NAPSI where two imaginary lines, perpendicular to each other are drawn. We score nail matrix, nail bed, and nail fold features per quadrant. A score of 0 or 1 is assigned based on the absence or presence of nail matrix disease features [longitudinal ridging/fissuring, longitudinal melanonychia, thinning/thickening of the nail plate, trachyonychia, red/mottled lunula]; nail bed features [diffuse/longitudinal erythema, discoloration (yellow, black, or dyschromia), onycholysis and/or subungual hyperkeratosis, bullous/erosive lesions]; or nail fold features [pigmentation, swelling, LP lesions, and ragged cuticle] [Figure 1; Table 1]. Thus, a maximum score of 3 per quadrant and 12 per nail is possible. In addition, irreversible changes [dorsal pterygium, atrophy, anonychia, or disappearing nail bed] are recorded separately with the English alphabet ‘I’ (for irreversible) being added to the final score [Figure 2]. Thus, the worst possible score would be 12-I per nail and nails without the “I” score could be chosen for comparing treatment efficacy. NALSI can be an objective and simple scoring system estimating the extent of involvement and location of diseases within the nail unit, and is subject to change with both the progression of disease or its resolution with or without treatment.Figure 1: Clinical picture of nail lichen planus showing the Nail Lichen planus Severity Index (NALSI) scoring. Each small box in each of the four quadrants is scored as 1 (if any one of the nail matrix/nail bed/nail fold feature is present) or 0 (if no nail matrix/nail bed/nail fold feature is present). The score for this nail is 10Table 1: Parameters to be Recorded in Nail Lichen Planus Severity Index (NALSI) ScoringFigure 2: Clinical picture of nail lichen planus showing the Nail Lichen planus Severity Index (NALSI) scoring. Each small box in each of the four quadrants is scored as 1 (if any one of the nail matrix/nail bed/nail fold feature is present) or 0 (if no nail matrix/nail bed/nail fold feature is present). The score for this nail is 8-IFinancial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Comparison of quality of life, depression and fatigue in patients with psoriasis and psoriatic arthritis

Psoriatic arthritis (PsA) is a chronic inflammatory multisystemic disease. Limitations due to skin and joint involvement of the patients; can lead to negativie suffix in emotional state, social and physical activities. The aim of this study is to investigate the effects of parameters such as skin joint involvement and disease severity on factors such as fatigue, quality of life, depression, etc. in psoriasis and PsA patients. Thirty-four psoriasis and 48 PsA patients matched with each other in terms of age, sex, and other factors were included in the study. Disease severity was measured by Psoriasis Area Severity Index (PASI), Nail Psoriasis Severity Index (NAPSI), Disease Activity in Psoriatic Arthritis (DAPSA) and Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) scores. In order to determine the depression status, quality of life and fatigue levels of the patients, respectively; Beck Depression Inventory (BDI), Health Assessment Questionnaire (HAQ) and Functional Assessment of Chronic Illness Therapy - fatigue scale (FACIT) scores were used. SPSS 17 for statistical evaluation (SPSS Inc. Released 2007. SPSS for Windows, Version 17.0. Chicago, SPSS Inc.) software package was used for analyses. Written informed consent was obtained from all patients who were enrolled to the study. PsA patients were found to have worse quality of life scores than psoriasis patients who were similar in terms of age, gender and other demographic characteristics. (0.22±0.36-0-0.48±0.52 p=0.017 respectively). There was a strong correlation between DAPSA scores and HAQ scores of the cases in the PsA group (r:0 ,615 p&lt;0.05). Likewise, disease activity measured by DAPSA was found to have moderate correlation with FACIT score, and weak but statistically significant correlation with BDI score. (r: -0.578 p&lt;0.05 and r:0.346 p&lt;0.001, respectively). No correlation was found between NAPSI-PASI scores and HAQ, BDI - FACIT scores in both the psoriasis and PsA groups. Both psoriasis and PsA affect the quality of life, and our findings suggest that this effect is more pronounced in PsA patients. Our study supports that; the disease severity in PsA patients is related to depression, bad quality of life and fatigue level.

Higher rates of skin clearance and efficacy in challenging body areas are associated with better health‐related quality of life following ixekizumab maintenance treatment in pediatric patients with plaque psoriasis

Background/ObjectivesInformation is limited on the relationship between skin clearance, resolution of challenging body areas, and improvement of patient‐reported outcomes (PROs) in pediatric psoriasis. Ixekizumab, a high‐affinity monoclonal antibody that selectively targets interleukin‐17A, is approved for the treatment of moderate‐to‐severe psoriasis in patients aged 6 to <18 years. This study examines improvement in psoriasis clearance in challenging body areas in pediatric patients relative to health‐related quality of life.MethodsData from the IXORA‐PEDS trial (NCT03073200) were analyzed, and changes from baseline were measured for overall Psoriasis Area and Severity Index (PASI), static Physicians' Global Assessment of psoriasis (sPGA), Psoriasis Scalp Severity Index (PSSI), Palmoplantar Psoriasis Area and Severity Index (PPASI), and Nail Psoriasis Severity Index. Rates of Dermatology Life Quality Index (DLQI), or Children's DLQI (CDLQI), scores of 0 or 1 were evaluated using the Cochran‐Armitage trend test.ResultsHigher rates of DLQI/CDLQI (0,1) scores were significantly associated with greater PASI and PSSI responses at both Week 12 and Week 48 (p < .0001). A significant association was also observed between DLQI/CDLQI (0,1) and sPGA scores (p < .0001). Significantly higher rates of DLQI/CDLQI (0,1) scores were achieved in patients with greater levels of palmoplantar clearance as measured by PPASI at Week 12 (p = .0139), but significance was not sustained at Week 48 (p = .0896).ConclusionsGreater skin clearance and scalp resolution are associated with better PROs over a short‐term (12‐week) and long‐term (48‐week) period. This demonstrates that greater improvement of skin clearance and scalp resolution may benefit quality of life in pediatric patients with psoriasis.

The Effect of TNF-α Inhibitors on Nail Psoriasis and Psoriatic Arthritis-Real-World Data from Dermatology Practice.

Patients with psoriatic arthritis (PsA) often develop joint symptoms years after their initial diagnosis of psoriasis disease; therefore, dermatologists should test for and detect PsA early. In this study, we focused on patients with psoriasis with both nail and joint disease being treated with tumor necrosis factor-α inhibitors by dermatologists. We performed a noninterventional, prospective, multicenter, and open-label study to evaluate the effectiveness of adalimumab, etanercept, or infliximab over 24 months of continuous therapy in patients with moderate to severe plaque-type psoriasis (Pso) and PsA. Disease assessments with the Psoriasis Area and Severity Index, Nail Psoriasis Severity Index (NAPSI), joint assessment, Dermatology Life Quality Index (DLQI), and Health Assessment Questionnaire (HAQ) instruments were performed every 3 months for the first year and twice annually thereafter. The cohort included 100 patients with Pso, nail psoriasis, and PsA. A significant reduction of NAPSI was observed 3 months after therapy initiation compared with the baseline (mean ± SD, 22.9 ± 17.8 vs. 33.8 ± 21.4; p < 0.001). Similarly, the mean ± SD number of both tender and swollen joints decreased significantly within the first 3 months of treatment, from 10.8 ± 11.5 to 6.4 ± 10.3 (p < 0.001) and from 6.4 ± 9.5 to 3.1 ± 7.2 (p < 0.001), respectively. Additionally, the distal interphalangeal joint involvement improved throughout the observation time, and DLQI and HAQ scores decreased. Improvements in control of skin, nail, and joint symptoms were seen, as well as in patients’ quality of life and functionality. Dermatologists have an important role not only in PsA diagnosis but also in PsA long-term care.

Efficacy of combined fractional carbon dioxide laser and topical tazarotene in nail psoriasis treatment: A randomized intrapatient left-to-right study.

Treatment of nail psoriasis is disappointing; due to poor penetrability of topical therapies and variable efficacy of systemic therapies. Fractional carbon dioxide laser (FCL) may enhance penetration of topical therapy for nail psoriasis. To evaluate the efficacy and safety of FCL plus topical tazarotene versus tazarotene monotherapy in the treatment of nail psoriasis. Twenty-seven patients with bilateral fingernail psoriasis randomly received 3sessions of FCL at four-week interval plus once-daily tazarotene 0.1% gel for one hand, and once-daily tazarotene 0.1% gel only for 3months on the other hand. The primary outcome was modified Nail Psoriasis Severity Index (mNAPSI) at 3 and 6months compared to baseline, and the secondary outcomes included dermoscopic examination and patient global assessment. Adverse events were reported. The total, nail matrix, and nail bed mNAPSI scores were significantly improved at 3 and 6months by both regimens, but they decreased more after FCL/tazarotene combination (p = 0.001, p = 0.023, and p = 0.001, respectively). Combination therapy showed faster improvement of nail matrix signs and greater efficacy for nail bed signs. The dermoscopic features of the nail plate were the most responsive after both treatments. The combined therapy was more effective in improving the dermoscopic nail bed features. Patient's global assessment scores were significantly higher after the combined therapy. Both treatments were well tolerated. Fractional CO2 laser is an effective and well-tolerated treatment for nail psoriasis; it improves the outcomes of topical tazarotene especially in nail bed lesions.

Ultrasound in Evaluation of Subclinical Enthesitis of Extensor Digitorum Tendon and Nail Unit Changes in Psoriasis

Abstract Background Subclinical inflammation at entheseal level has been detected in patients with psoriasis without previous history of arthropathy or Psoriatic arthritis (PsA). Ultrasound (US) is a valid and sensitive tool for the assessment of inflammatory involvement at entheseal level in PsA patients. Objective To detect subclinical arthritis or enthesitis at distal interphalangeal (DIP) fingers and nail unit changes in psoriatic patient for early detection of PsA Patients and Methods This study included 30 adult psoriatic patients and 30 healthy matched controls. All underwent history, clinical examination, Psoriasis Area and Severity Index (PASI), Nail Psoriasis Severity Index (NAPSI) score calculation and musculoskeletal US both grey and power Doppler (PD) assessed at enthesis of extensor digitorum tendon insertion at distal phalanx, DIP joints from 2nd to 5th finger bilaterally examined for detection of synovitis and over the nail for morpho-structural evaluation. Results Patient’s ages ranged from 18-65 years and controls 20-60 years (mean ±SD 45.07 ± 13.52, 38.37 ± 11.96 respectively), male to female ratio 1:2. DIP joint affection in the form of synovial hypertrophy and effusion with PD was found in 13.3% of cases. Enthesophyte with PD in 56.7% of cases. On comparison between NAPSI score by clinical examination versus US examination, the sensitivity of US was 100%, all cases clinically positive by NAPSI were positively affected by US (20 cases). Also 30% of cases were negative by NAPSI and were positive by US (7cases). Three cases were negative by both NAPSI and US. A significant positive correlation was observed between disease duration and NAPSI Score (r = 0.429, pvalue&amp;lt;0.05), similarly between presence of enthesophyte with PD and PASI Score (r = 0.547, pvalue&amp;lt;0.02). Conclusion Detection of subclinical enthesopathy at DIP joint by ultrasound is not infrequent, so it is an important tool for examining enthesis in psoriatic patients. The presence of a high PASI score and long disease duration could be considered as predictive parameters for the presence of psoriatic enthesitis ongoing to arthritis.

Comparison between the Efficacy of Intense Pulsed Light (IPL) versus Photodynamic Therapy with Methylene Blue in the Treatment of Nail Psoriasis

Abstract Background Nail psoriasis is often refractory to traditional treatments, and patients with nail psoriasis usually demand a therapeutic option. Both photodynamic therapy (PDT) and intense pulsed light have been evaluated in nail psoriasis. Objective The objective of this study was to evaluate and compare the efficacy of IPL and methylene blue assisted photodynamic therapy in the treatment of nail psoriasis. Patients and Methods Twenty patients (15 males and 5 females) with mild to moderate psoriasis with nail affection were included in this study. Their age ranged from 24 to 71 years. The PDT used IPL as the light source and methylene blue as photosensitizer. Sessions were applied every 2 weeks for a maximum of 3 months, treating one hand with IPL and the other with PDT. The nails treated were evaluated at baseline, after 2 sessions, after 6 sessions and 3 months after the last treatment session according to the Nail Psoriasis Severity Index (NAPSI) score. Follow-up was performed after 2 sessions, after 6 sessions, and 3 months after the last treatment session. Results A decrease in NAPSI score was observed with both treatments and in both nail bed and nail matrix involvement. No statistically significant difference was found between PDT and IPL as regarding total NPASI score. However, total NAPSI score improved by 61% in MB-PDT group versus 47% in IPL group. Patient follow-up revealed the appearance of new lesions in 3 patients in the group of IPL, and in 1 patient in the MB-PDT after 6 months. Conclusion Intense pulsed light and methylene blue assisted PDT are a promising effective modalities of treatment of nail psoriasis, which are easy to use, safe, and nearly pain-free. This was confirmed by the improvement NAPSI score.

Challenge of Nail Psoriasis: An Update Review.

Nail psoriasis is a refractory disease that affects 50-79% skin psoriasis patients and up to 80% of patients with psoriatic arthritis (PsA). The pathogenesis of nail psoriasis is still not fully illuminated, although some peculiar inflammatory cytokines and chemokines seems to be the same as described in psoriatic skin lesions. Psoriatic nail involving matrix can cause pitting, leukonychia, red spots in lunula, and nail plate crumbling, while nail bed involvement can result in onycholysis, oil-drop discoloration, nail bed hyperkeratosis, and splinter hemorrhages. The common assessment methods of evaluating nail psoriasis includes Nail Psoriasis Severity Index (NAPSI), Nail Assessment in Psoriasis and Psoriatic Arthritis (NAPPA), Nail Psoriasis Quality of life 10 (NPQ10), and so on. Treatment of nail psoriasis should be individualized according to the number of involving nail, the affected site of nail and presence of skin and/or joint involvement. Generally, topical therapies are used for mild nail psoriasis, while biologic agents such as etanercept are considered for severe nail disease and refractory nail psoriasis. Even though the current literature has shown some support for the pathogenesis, clinical presentation, or therapies of nail psoriasis, systemic review of this multifaceted disease is still rare to date. We elaborate recent developments in nail psoriasis epidemiology, pathogenesis, anatomy, clinical manifestation, diagnosis, differential diagnosis, and therapies to raise better awareness of the complexity of nail psoriasis and the need for early diagnosis or intervention.

The relationship between the nail and systemic enthesitis in psoriatic arthritis.

ObjectivePsoriatic nail disease is more common in PsA than in isolated skin psoriasis (PsO). The nail is closely integrated to the DIP joint entheses. US data have shown that those patients with nail disease in PsO are more likely to have systemic enthesitis. We examined whether there was a relationship between nail disease, DIP enthesitis and systemic enthesitis in established PsA.MethodsForty-six PsA participants with nail disease underwent US scanning of the nail unit and the DIP entheses along with peripheral entheseal sites according to the Madrid sonographic enthesitis index (MASEI).ResultsAt the finger level, there was a mild to moderate correlation between nail US changes and both clinical nail disease and DIP enthesis changes (DIP US) [Spearman correlation (rS) = 0.30, P < 0.001 and rS = 0.16, P < 0.001, respectively]. At the patient level, there was a moderate correlation between the nail US score and nail psoriasis severity index score and DIP US (rS = 0.33, P = 0.024 and rS = 0.43, P = 0.003, respectively). At the patient level, there was also a positive correlation between a higher nail US score and the active peripheral enthesitis score (MASEI-active) (rS = 0.35, P = 0.018). When power Doppler was part of nail US score, similar results were demonstrated at both the finger and patient levels.ConclusionThis study has demonstrated the utility of nail US imaging and the close relationship, on scanning, between the DIP entheses and the nail unit. In PsA, we have seen a correlation between active US changes at the nail and peripheral enthesitis, which requires further analysis.Trial registrationClinicalTrials.gov, https://clinicaltrials.gov, NCT03955861.

Effect of baseline disease severity on achievement of treatment target with apremilast: results from a pooled analysis.

Treating to absolute treatment targets rather than relative measures such as Psoriasis Area and Severity Index (PASI)-75 is emerging as an important clinical concept included in psoriasis guidelines and clinical practice. Achieving treatment targets is associated with achievement of long-term outcomes. To evaluate the relationship between psoriasis severity, disease characteristics and achievement of PASI ≤2 with apremilast in a pooled analysis of the phase 3 ESTEEM 1 and 2 (NCT01194219 and NCT01232283), phase 3b LIBERATE (NCT01690299) and phase 4 UNVEIL (NCT02425826) clinical trials. Pooled data from patients with moderate-to-severe plaque psoriasis randomized to apremilast 30 mg BID were analysed by baseline PASI quartiles (Q1: 2.4-13.1; Q2: 13.2-15.9; Q3: 16.0-20.0; Q4: 20.1-57.8). Assessments included PASI, Dermatology Life Quality Index (DLQI), Scalp Physician's Global Assessment (ScPGA; ScPGA ≥1) and target (worst) Nail Psoriasis Severity Index (NAPSI; NAPSI ≥1). Of 1062 patients, 963 had ScPGA ≥1 and 643 had NAPSI ≥1; 771 patients with baseline and Week 32 PASI assessments were included in analyses of Week 32 PASI target achievement. Rates of PASI ≤2 at Week 32 were greater in lower PASI quartiles (Q1: 43.5%; Q2: 31.2%; Q3: 26.8%; Q4: 18.4%). Most patients achieving PASI ≤2 target (83.6%) achieved DLQI ≤5 at Week 32; 59.3% of patients who did not achieve PASI ≤2 target achieved DLQI ≤5. At Week 32, mean improvements in ScPGA and NAPSI were similar with more moderate vs. more severe disease (ScPGA, range: 1.1-1.4; NAPSI, range: 1.6-2.5). In a subgroup analysis, achievement of PASI ≤2 target was higher in the lowest PASI quartile and with disease duration <5 years. Greater achievement of PASI ≤2 was observed in patients with more moderate vs. more severe skin disease. Apremilast may be particularly beneficial in more moderate disease early in the treatment paradigm.