Nail Psoriasis Severity Research Articles

Automatic evaluation of Nail Psoriasis Severity Index using deep learning algorithm.

Nail psoriasis is a chronic condition characterized by nail dystrophy affecting the nail matrix and bed. The severity of nail psoriasis is commonly assessed using the Nail Psoriasis Severity Index (NAPSI), which evaluates the characteristics and extent of nail involvement. Although the NAPSI is numeric, reproducible, and simple, the assessment process is time-consuming and often challenging to use in real-world clinical settings. To overcome the time-consuming nature of NAPSI assessment, we aimed to develop a deep learning algorithm that can rapidly and reliably evaluate NAPSI, thereby providing numerous clinical and research advantages. We developed a dataset consisting of 7054 single fingernail images cropped from images of the dorsum of the hands of 634 patients with psoriasis. We annotated the eight features of the NAPSI in a single nail using bounding boxes and trained the YOLOv7-based deep learning algorithm using this annotation. The performance of the deep learning algorithm (DLA) was evaluated by comparing the NAPSI estimated using the DLA with the ground truth of the test dataset. The NAPSI evaluated using the DLA differed by 2 points from the ground truth in 98.6% of the images. The accuracy and mean absolute error of the model were 67.6% and 0.449, respectively. The intraclass correlation coefficient was 0.876, indicating good agreement. Our results showed that the DLA can rapidly and accurately evaluate the NAPSI. The rapid and accurate NAPSI assessment by the DLA is not only applicable in clinical settings, but also provides research advantages by enabling rapid NAPSI evaluations of previously collected nail images.

Predictors of initiating biologics in the treatment of psoriasis.

Biologics are among the most effective therapies for psoriasis. However, many patients are only introduced to them at advanced stages of the disease course. Our aim was to identify predictors of initiating biologic therapy in patients with psoriasis and compare patients initiating biologics early versus late in their disease course. Kaplan-Meier curves visualized time to biologic initiation, while Cox regression models further explored variables as predictors of biologic initiation. Mann-Whitney U and chi-squared tests compared patients who started biologics early with those who began biologics later in the disease course. Our primary analysis included 233 psoriasis patients. Cox regression showed that age at diagnosis (P = 0.007), general physical well-being (P = 0.02), and nail psoriasis severity (P = 0.02) were significantly associated with time to biologic initiation. Our secondary analysis, the comparisons between patients starting biologics early versus later in the disease course, included a total of 378 patients. The median (interquartile range [IQR]) age at diagnosis was 34.5 (25.0-51.2) years for patients initiating biologics within 5 years, compared to 22.0 (15.0-32.8) years for patients initiating biologics later (P < 0.0001). The median (IQR) age at initiation was 37.0 (27.0-53.2) and 45.0 (36.0-55.0) years for patients initiating biologics earlier versus later than 5 years (P = 0.04). Age at diagnosis, general well-being, and severity of nail psoriasis significantly predicted future initiation of biologic treatment. Patients initiating biologics early in their disease course were generally older at diagnosis but younger at the time of biologic initiation compared to patients initiating biologics later in their disease course.

Therapy of netakimab in nail psoriasis

Introduction. The nail psoriasis severity does not always correspond to the skin process intensity, but often correlates with a more severe, prolonged and aggressive course of the disease.Materials and methods. 48 adult patients (n = 48) with nail psoriasis were under observation. The severity of the psoriatic lesion of the nails was determined using the NAPSI index (Nail Psoriasis Severity Index). The assessment was carried out before the start of treatment, in the first week, and then every 4 weeks up to and including 52 weeks. The Dermatological Quality of Life Index (DLQI) were determined by questionnaires before the start of treatment, at the 12th and 52nd weeks. All patients on an outpatient basis received netakimab monotherapy at a dose of 120 mg in the form of two subcutaneous injections of 1 ml (60 mg) of the drug, each administered once a week at weeks 0, 1 and 2, then 1 time every 4 weeks. The total duration of treatment for each patient was 52 weeks. The safety of netakimab was evaluated based on the development of adverse events and local reactions to the administration of the drug.Results. The results of the study for 52 weeks showed high efficacy of netakimab. Average NAPSI score improved – 33.1% by the week 12 of treatment and – 72.3% by the week 52 compared to baseline, the quality of their life improved. During the 52 weeks of the study, there were no cases of early withdrawal due to adverse events and cases of serious adverse events.Conclusion. Based on the study results we recommend netakimab for medical use among patients with moderate and severe nail psoriasis.

Predicting Psoriatic Arthritis in Psoriasis Patients - A Swiss Registry Study.

Psoriatic arthritis (PsA) is a prevalent comorbidity among patients with psoriasis, heavily contributing to their burden of disease, usually diagnosed several years after the diagnosis of psoriasis. To investigate the predictability of psoriatic arthritis in patients with psoriasis and to identify important predictors. Data from the Swiss Dermatology Network on Targeted Therapies (SDNTT) involving patients treated for psoriasis were utilized. A combination of gradient-boosted decision trees and mixed models was used to classify patients based on their diagnosis of PsA or its absence. The variables with the highest predictive power were identified. Time to PsA diagnosis was visualized with the Kaplan-Meier method and the relationship between severity of psoriasis and PsA was explored through quantile regression. A diagnosis of psoriatic arthritis was registered at baseline of 407 (29.5%) treatment series. 516 patients had no registration of PsA, 257 patients had PsA at inclusion, and 91 patients were diagnosed with PsA after inclusion. The model's AUROCs was up to 73.7%, and variables with the highest discriminatory power were age, PASI, physical well-being, and severity of nail psoriasis. Among patients who developed PsA after inclusion, significantly more first treatment series were classified in the PsA-group, compared to those with no PsA registration. PASI was significantly correlated with the median burden/severity of PsA (P = .01). Distinguishing between patients with and without PsA based on clinical characteristics is feasible and even predicting future diagnoses of PsA is possible. Patients at higher risk can be identified using important predictors of PsA.

Successful reduction of NAPPA score (Nail Assessment in Psoriasis and Psoriasis-Arthritis) under secukinumab in severe nail psoriasis

Successful reduction of NAPPA score (Nail Assessment in Psoriasis and Psoriasis-Arthritis) under secukinumab in severe nail psoriasis

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.

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.

Overall Prevalence and Prevalence Compared among Psoriasis Treatments of Onychomycosis in Patients with Nail Psoriasis and Fungal Involvement.

Background Whether nail psoriasis can increase the risk of onychomycosis is still being debated, and data relating to the prevalence of onychomycosis among psoriasis patients receiving different treatments is limited. Objectives To investigate the overall prevalence and prevalence compared among psoriasis treatments of onychomycosis in patients with nail psoriasis and fungal involvement. Methods A prospective study of three groups of nail psoriasis being treated with only topical medication, methotrexate, or biologics (25 patients per group, 150 nails) was conducted at Siriraj Hospital (Bangkok, Thailand) during November 2018 to September 2020. Demographic data, psoriasis severity, and nail psoriasis severity were recorded. The nail most severely affected with psoriasis on each hand was selected for mycological testing. Potassium hydroxide, periodic acid-Schiff stain, and fungal culture were performed. Results The prevalence of onychomycosis in nail psoriasis was 35.3%. Among the treatment groups, the prevalence of onychomycosis was significantly higher in the methotrexate group than in the topical treatment and biologic treatment groups (p = 0.014). Candida spp. was the main causative organism, followed by Trichophyton rubrum. Thumb was most commonly affected (59.3%). The most common abnormality of the nail matrix and the nail bed was pitted nail (71.3%) and onycholysis (91.3%), respectively. Multivariate analysis revealed diabetes, wet-work exposure, and methotrexate treatment to be predictors of onychomycosis. Conclusions Several factors, including psoriasis treatment, were shown to increase the risk of onychomycosis in nail psoriasis. Further research is needed to determine whether biologic agents, especially interleukin-17 inhibitors, can increase risk of onychomycosis and Candida infection/colonization of the nails.

Severe Nail Psoriasis: A Case Report

Treatment of severe nail psoriasis poses a particular challenge due to the anatomy of the nail, small surface area involved, and frequent irritation to fingertips from use of the hands.1,2 Nail psoriasis can be particularly devastating to affected patients as it is easily visible, leading to emotional distress, potential social ostracization and loss of work opportunities and loss of function with performing fine work with the hands.1,2 Being aware of which nail manifestations will present clinically depending on the nail structure affected by psoriasis, which first-line treatments are most efficacious, and when to consider systemic treatments can help guide treatment based on a patient’s preferences and other health conditions

Ultrasound-aided diagnosis of preclinical phases of psoriatic arthritis in biologic-naïve psoriasis patients with or without arthralgia.

The evolution of psoriasis (PsO) to psoriatic arthritis (PsA) has been proposed recently. There are three phases that occur in sequence prior to classifiable PsA: PsO patients, PsO patients with a positive imaging, and PsO patients with arthralgia not explained by other diagnosis. The purpose of this study was to compare the differences among preclinical phases using ultrasound and clinical assessment. Patients with psoriasis were recruited. Patients who had been previously diagnosed with psoriatic arthritis or who had used biologics were excluded. A 52-joint ultrasound (52j US) assessment and clinical assessments including the swollen joint count, tender joint count, erythrocyte sediment rate, C-reactive protein, dactylitis score, enthesitis score, psoriasis severity, and nail psoriasis severity, were performed. A total of 188 eligible psoriasis patients were enrolled. Physical examination revealed 39 patients (20%) with at least one swollen joint. The 52j US assessment demonstrated 90 patients (47%) having at least one joint with grey-scale score 2-3. All patients were further stratified into PsO patients (n=58), PsO patients with a positive imaging, (n=59), PsO patients with arthralgia not explained by other diagnosis (n=27), and classifiable PsA (n=39). There were no differences in clinical characteristics other than tender joint count found among the three preclinical phases of PsA. Dactylitis score, swollen joint count and heatly assessment questionnaire score were significantly higher in classifiable PsA. Nearly half of the psoriasis patients without previously diagnosed psoriatic arthritis would be classified into the preclinical phases of psoriatic arthritis based on the 52j US and clinical assessments. Ultrasound assessment is helpful for identifying psoriasis patients who are in the preclinical phases of psoriatic arthritis, particularly for those without arthralgia.

Experience in using secukinumab in patients with axial psoriatic arthritis

Axial skeletal injury is observed in 25–70% of patients with psoriatic arthritis (PsA). Spondylitis frequently occurs subclinically, which leads to serious structural and functional disorders over time. An update shows that axial skeleton involvement in PsA is characterized by a more severe clinical course: these patients are observed to have a greater severity of peripheral arthritis, enthesitis, and dactylitis, skin and nail psoriasis, a higher CRP level, and worse functional status. In addition, the disease is more severe according to the patients' subjective assessment, as evidenced by questionnaires. Synthetic disease-modifying antirheumatic drugs used to treat peripheral PsA are not recommended for axial injury. When nonsteroidal anti-inflammatory drugs are ineffective, biological drugs (tumor necrosis factor-α inhibitors or interleukin-17A (IL-17A) inhibitors) should be prescribed immediately to patients with psoriatic spondylitis. The paper describes two clinical cases demonstrating the successful use of the IL-17A inhibitor secukinumab (SEC) in patients with axial PsA (axPsA). Given the positive experience with SEC in real clinical practice, it seems reasonable to prescribe it to patients at earlier stages of axPsA.

Results of direct comparison of the clinical efficacy of ixekizumab and adalimumab: data from the SPIRIT H2H study

Objective: to analyze the data available in the literature on the efficacy and safety of ixekizumab (IXE) and adalimumab (ADA) via their direct comparisons in the treatment of psoriatic arthritis (PsA).Patients and methods. The results of the SPIRIT H2H study were analyzed, the aim of which was to investigate the potential superiority of IXE to ADA for arthritis and skin manifestations in a group of patients with active PsA, stable plaque psoriasis with an inadequate response to synthetic disease-modifying antirheumatic drugs (sDMARDs) who had not previously received biological agents (BAs).Design: a 52-week multicenter, randomized, parallel-group study. The patients were randomized 1:1 to open IXE or ADA administration groups for 52 weeks. This review presents the data obtained at 24-week follow-up.Of the 684 screened patients, 566 (82.7%) were included in the study; moreover, the distribution of the patients was equal between the ADA (n=283) and IXE (n=283) groups. At 6 months, 269 (95%) patients in the ADA group and 262 (93%) in the IXE one continued to participate in the study. Efficacy analysis was made based on the achievement of the primary endpoint that was considered to be related to the relative number of patients, who had simultaneously achieved improvements in the joints and skin according to the ACR50 and PASI100 criteria.Results and discussion. At 24 weeks, the proportion of patients who had simultaneously achieved ACR50 and PASI100 responses was significantly higher in the IXE group (36%) than in the ADA one (28%) (p=0.036). It was found that the IXE group was not inferior to the ADA one in terms of ACR50 response rates (in 51% (IXE) and 47% (ADA) patients) and was superior in achieving PASI100 response rates (in 60% (IXE) and 47% (ADA) patients) (p=0.001). The IXE group was recorded to have a higher response than the ADA group and in terms of other manifestations of the disease: the severity of skin and nail psoriasis, enthesitis, remission achievement, minimal and very low disease activity, and improved quality of life. Comparable effectiveness was noted for the effect of the drugs on dactylitis, as well as for the simultaneous achievement of remission and low disease activity in psoriatic arthritis according DAPSA. Serious adverse events (SAEs) were recorded in 8.5% (ADA) and 3.5% (IXE) patients.The safety and tolerability of both BAs corresponded to their previously presented safety profile. The findings were also confirmed at 52-week follow-up, presented at the Meetings of the American College of Rheumatology in November 2019 and the European League Against Rheumatism in June 2020, and published in the leading journals of rheumatology.Conclusion. The first randomized placebo-controlled study (SPIRIT H2H) directly comparing the two BAs with different mechanisms of action demonstrated the advantage of IXE over ADA in simultaneously reducing the activity of arthritis and psoriasis and showed their comparable efficacy comparable efficacy regarding joint symptoms. The use of IXE versus ADA was accompanied by the more frequent achievement of a combined endpoint related to the signs of joint and skin damages in patients with PSA, as well as by the quantitatively lower frequency of SAEs in patients with active PSA who had failed previous sDMARD therapy. The findings are of great importance for clinical practice from the point of view of the reasonable choice of a treatment strategy in these patients.

Clinical parameters associated with severity of nail psoriasis and therapeutic efficacy.

Nail involvement is common in psoriasis patients, however, there are few detailed studies of clinical parameters related to disease severity and therapeutic efficacy. Our retrospective study aimed to describe the prevalence and clinical characteristics in nail psoriasis patients and determine possible associations between multiple clinical parameters and disease severity or therapeutic efficacy. A total of 89 nail psoriasis patients were included and investigated using dermoscopy. The Nail Psoriasis Severity Index (NAPSI) and the Nijmegen-Nail Psoriasis Activity Index tool (N-NAIL) were used to measure the severity and improvement of nail psoriasis. Severity and efficacy-related parameters were also analysed. Subungual hyperkeratosis (94.4%) was the most commonly observed nail feature. Coexistence of pitting and leukonychia, transverse grooves and thickening were more commonly observed in juveniles than adults. Patients with more severe nail psoriasis were more likely to have more nails affected and develop discolouration. The efficacy of treatment after fixed intervals of treatment was analysed. Most clinical parameters were not related to therapeutic efficacy, including disease duration, age at onset and number of nail signs. However, after six months of treatment, the presence of transverse grooves was shown to be associated with better efficacy. Based on comparison of NAPSI and N-NAIL scores relative to the first visit, the presence of transverse grooves, longitudinal ridges or discolouration were associated with better efficacy. Clinicians should be aware of the clinical parameters related to severity and the use of therapeutic efficacy in choosing individualized treatment and predicting prognosis.

A Comparison of The Effects of Clobetasol 0.05% and Photodynamic Therapy Using Aminolevulinic Acid With Red Light in the Treatment of Severe Nail Psoriasis.

Introduction: The treatment of nail psoriasis is often difficult and unsatisfactory due to therapy resistance. This study aimed to compare the efficacy of clobetasol 0.05% ointment and photodynamic therapy (PDT) using aminolevulinic acid (ALA) and red light in the treatment of severe nail psoriasis. Methods: This open-trial study included 69 nails of 8 patients with severe nail psoriasis. Thirty-four nails were treated with clobetasol 0.05% ointment and 35 nails were treated with ALA-PDT. ALAPDT treatment was performed every 3 weeks for 5 cycles; the nails were treated with clobetasol under occlusion every day during the study. All the patients were followed up after 24 weeks. The severity of nail involvement was measured by the Nail Psoriasis Severity Index (NAPSI) scores at the baseline and during the treatment. Results: There were no significant differences in the NAPSI scores between the treatment groups in the baseline and weeks 3, 6 and 9 (all P>0.05), although significant differences were found in weeks 12, 15 and 24 (follow-up) (P<0.001). A significant time-effect improvement was found in all the nailmatrix, nail-bed and total NAPSI scores in both treatment groups (all P<0.001). The patients did not report intense pain and discomfort during irradiation. Conclusion: Clobetasol 0.05% ointment seems to be effective in treating nail psoriasis after a treatment period of 15 weeks. However, the efficacy of ALA-PDT at a 24-week follow-up was greater than that of clobetasol.

EVALUATION OF THE EFFECTIVENESS OF TOPICAL TREATMENT COMBINATION OF BETAMETHASONE DIPROPIONATE 0.05%/CALCIPOTRIOL MONOHYDRATE 0.005% GEL AND CLOBETASOLE PROPIONATE 0.05% OINTMENT IN PATIENTS WITH PSORIATIC ONYCHODYSTROPHY

Psoriatic onychodystrophy is a comorbidity that often occurs in patients with psoriasis, affecting their quality of life. Although success has recently been achieved in the treatment of the cutaneous form of psoriasis, there are few publications about nail therapy with proven effectiveness. The development of effective and safe therapies remains relevant for nail psoriasis. Objective. to evaluate the effectiveness and tolerability of the fixed combination of betamethasone dipropionate 0.05%/calcipotriol monohydrate 0.005% gel and clobetasole propionate 0.05% ointment in patients with psoriatic onychodystrophy. Material and methods. the study included 50 patients with psoriasis vulgaris, mild to moderate severity with lesions of the nail plates. Patients were divided into two groups and used betamethasone dipropionate 0.05%/calcipotriol monohydrate 0.005% gel (group A) and clobetasole propionate 0.05% ointment with occlusion (group B) for 24 weeks with hardware treatment of nail plates at 0, 8, 16 weeks. They did not receive any other local or systemic treatment. The severity of nail psoriasis was assessed by the NAPSI index at week 0, 8, 16, and 24, and by the IGA after treatment. results. 43 patients completed the study. At the beginning of the study, the average NAPSI was 32.8 ± 10.3 in group A and 33.1 ± 9.8 in group B. At week 24 the average NAPSI score decreased to 12.8 ± 7.2 in group A and 11.8 ± 68 in group B. IGA for evaluation treatment score was 3 ± 0.74 in group A and 3.1 ± 0.79 in group B. Conclusions. Combined treatments in the form of hardware processing nail plates with betamethasone dipropionate 0.05%/calcipotriol monohydrate 0.005% gel and clobetasol propionate 0.05% ointment are effective and can be used in patients with moderate and severe nail psoriasis, which is confirmed by the results in clinical improvement of 60.8% and 64.5%, respectively, based on a decrease in NAPSI at 24 weeks and an assessment of the therapeutic response after treatment using the IGA.

Prevalence, clinical profile, and severity of nail involvement in psoriasis – A hospital-based cross-sectional study from a tertiary care center in North Kerala

Objectives: Nail changes are present in 25–50% of psoriatic cases. Nail Psoriasis Severity Index (NAPSI) assess the extent of the involvement of the psoriatic nail unit. This study was conducted with the aim of finding the prevalence, clinical characteristics and severity of nail psoriasis. Methods and Materials: In this cross-sectional study, a thorough clinical examination was done to determine the type and extent of skin disease including PASI (psoriasis area severity index) score, and all the fingernails and toenails were examined in a well-lit environment, under a magnifying lens to visualize the nail findings, and NAPSI score was calculated for each patient. Statistical Package for the Social Sciences (SPSS v. 11.0) software was used to analyze the data collected. Results: Of the100 patients studied, 73% of patients with psoriasis had nail involvement. Mean total NAPSI was 30.97 ± 30.79. Mean age of onset of psoriasis was 43.62 ± 15.31 and 33.04 ± 12.80 in those with and without nail involvement respectively (P-value 0.002). The majority without nail involvement (77.8%) belonged to the early- onset group, while 22.2% of those without nail involvement had late-onset psoriasis (P-value 0.001). The most common nail pattern in our study was Pitting (93.2%). Limitation: Nail changes in severe forms of disease could not be studied since patients receiving systemic drugs for the disease were excluded from the study. Conclusion: The mean duration of psoriasis in those with nail involvement in our study was 5 years more than in those without nail disease. Our study demonstrated a significant association between higher PASI scores and nail involvement. All patients with severe psoriasis (PASI &gt;20) in our study had nail involvement.

Severe nail psoriasis managed succesflly with apremilast

Severe nail psoriasis managed succesflly with apremilast

Coexistence of Fungal Infections in Psoriatic Nails and their Correlation with Severity of Nail Psoriasis.

Background:Nail involvement in psoriasis is often complicated by concomitant fungal infections. The aim of this study was to investigate the prevalence of fungal infections in nail psoriasis and correlate it with the severity of nail psoriasis.Materials and Methods:This retrospective study included patients with nail psoriasis aged ≥18 years with at least one fingernail and one toenail involvement who were treated at Siriraj Hospital from September 2012 to January 2014. Severity of nail psoriasis was assesed by Nail Psoriasis Area Severity Index (NAPSI) score. The nail clippings from the the least and most severely involved psoriatic fingernails and toenails were cultured to determine the presence of coexisting fungal infections and isolate the fungal species.Results:Sixty-two patients (33 males, 29 females) fulfilling the inclusion criteria were included in the study. The mean age at the time of presentation was 51.3 years mention SD. The most common nail change consistent with psoriasis was onycholysis, followed by subungual hyperkeratosis. The most commonly isolated fungi in the most severely affected fingernails were Candida spp. (41.9%) manifesting as paronychia in 5 patients (19.2%). The most commonly isolated fungi in the most severely affected toenails were nondermatophytes (NDMs) other than candida (32.3%). Dermatophytes were not detected from any of the psoriatic nails. The fungal species isolated from the most severely affected fingernails were significantly different than the isolated fungal species in the most severely affected toenails (P = 0.026). Fungal organisms were identified in 32.3% of the most severely affected fingernails and in 27.4% of the most severely affected toenails. The overall rate of isolation of fungus was significantly significantly higher in severely affected nails than in the least affected nails (P < 0.005).Conclusion:A high rate of concomitant fungal infections, especially yeasts and NDMs, was found in psoriatic nail patients. The rate of isolation of fungal species was higher in severely involved psoriatic nails than mildly involved ones. The spectrum of fungal species isolated from the the severely involved toenails and fingernails were also different from each other. These organisms may be true pathogens that cause onychomycosis or their presence may reflect colonization, contamination, or concurrent infection.

Identification of nail features associated with psoriasis severity.

There are no detailed studies of the prevalence of nail psoriasis and clinical characteristics of psoriatic nail involvement, including nail features associated with disease severity. Therefore, we designed a study to investigate the prevalence and characteristics of psoriatic nail involvement in patients with psoriasis and determine the relationship between psoriatic nail features and severity of nail psoriasis and cutaneous psoriasis. The Nail Psoriasis Severity Index (NAPSI) was used for evaluation of the severity of nail lesions. The presence of nail fold psoriasis (NFP) was also assessed. The severity of psoriasis was evaluated by calculating the Psoriasis Area and Severity Index (PASI). As a result, the prevalence of nail psoriasis was 85.5%. Pitting was the most common clinical feature (55.6%). The severity of nail psoriasis was not affected by medical parameters, although patients with localized pustular psoriasis tended to have more severe nail psoriasis than did those with chronic plaque psoriasis. When comparing the mean NAPSI and the mean PASI according to nail lesions, we found that subungual hyperkeratosis (SH) and NFP were significantly associated with the severity of both nail psoriasis and cutaneous psoriasis. Psoriatic nail changes were most common in the first digit. Conclusively, the majority of patients with psoriasis had psoriatic nail involvement, and Koebner's response seems to be closely related to the induction of nail psoriasis. To limit progression of the disease, psoriatic patients with SH or NFP should be examined thoroughly because those clinical features reflect the levels of severity of both nail and cutaneous psoriasis.

Patient-relevant needs and treatment goals in nail psoriasis.

Patient-centered health care implies that medical decisions are made jointly by physician and patient, based on patient needs. Aims were to (a) identify treatment goals for a new questionnaire on patient needs and benefits in nail psoriasis treatment; (b) analyze the importance of treatment goals in patients with nail psoriasis in general and in defined subgroups; and (c) determine the association between overall treatment goal importance and quality of life. The study comprised the following steps: qualitative survey on needs and burdens in 120 patients; development of items by an interdisciplinary expert group; item testing in 55 patients in four countries; revision of the questionnaire and assessment in 203 patients in six countries (Germany, Denmark, Italy, Spain, USA, Japan). The percentage of patients rating the goals as 'quite/very important' was compared between various patient subgroups. Based on 692 free-text statements, 26 items were developed which were reduced to 24 items after pilot testing. Each of these treatment goals applied to the majority of patients in the multi-center study. Goal importance increased with severity of nail psoriasis, but not with age or disease duration. Manual dexterity and social interaction were of particular importance. Goal importance and quality of life were associated, but not redundant (r = 0.612, p < 0.001). Patients with nail psoriasis have manifold and specific treatment goals. Goal importance is a construct different from disease-specific quality of life and should be assessed separately. The new questionnaire can support goal setting in clinical practice.