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Research Article | Volume 11 Issue :2 (, 2021) | Pages 54 - 59
Prevalence of Correlation of the Psoriasis Area Severity Index, the Nail Psoriasis Area Severity Index among Patients with Skin and Nail Psoriasis
 ,
 ,
1
Assistant Professor, Department of Dermatology Venereology and Leprosy, Guntur Medical College, Guntur, Andhra Pradesh.
2
Associate Professor, Department of Dermatology, Venereology & Leprosy, Katuri Medical College & Hospital, Guntur, Andhra Pradesh
Under a Creative Commons license
Open Access
DOI : 10.5083/ejcm
Received
May 12, 2021
Revised
May 30, 2021
Accepted
June 16, 2021
Published
June 29, 2021
Abstract

Introduction Nail involvement is an often-overlooked clinical symptom of Psoriasis. It causes psychologic stress, pain, impairment of manual dexterity and a significant negative impact on a patient’s quality of life.  Objective: The present study was conducted to study the prevalence of nail changes in psoriasis patients, assessment of the severity of nail involvement using NAPSI score and to correlate the relationship between NAPSI and BSA in those patients Materials and Methods This observational, cross-sectional study was conducted in the Department of Dermatology Venereology and Leprosy, Guntur Medical College over a period of 6 months. A total of 90 patients of psoriasis with nail changes were recruited in this hospital. Cutaneous severity was assessed using psoriasis area severity index (PASI). NAPSI was used to determine the severity of nail involvement. Nails of the patients with psoriasis were examined clinically and onychoscopically.  Results The total number of patients included in the study was 90. Of these, the male-to-female ratio was 1.3:1. The maximum number of patients were in the age group of 31–45 years (28.0%). Psoriasis (50 cases) was the most common papulosquamous disorder followed by lichen planus (20 cases). Among the papulosquamous disorders, nail changes were present in 59 (65.5%) patients. Out of the 59 patients with nail changes, 69.9% were male, and 30.1% were female. Pitting was overall the most common finding in both clinical and dermoscopic examinations. In 9 (10%) cases, a biopsy was done to confirm the diagnosis. Conclusions Dermoscopy 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

Keywords
INTRODUCTION

Psoriasis is a chronic inflammatory papulosqamous disorder with remissions and exacerbations, that affects millions of people throughout the world. It is not only a disease that affects the skin, but also can affect the physical, emotional, social & psychological aspects of life.[1] While skin manifestations are the most characteristic findings of psoriasis, nail involvement is an often-overlooked clinical symptom of the disease. [2] Approximately 10-78% of patients with psoriasis have concurrent nail psoriasis, while isolated nail involvement is seen in 5-10% of patients. [2]

 

The clinical nail manifestations seen in psoriasis depends on the localization of the inflammation in the nail unit. [4] Two patterns of nail disorders are commonly seen in psoriasis. A) Nail matrix involvement- result in features such as pitting, leukonychia, onycholysis, Beau’s lines and crumbling of the nail plate. B) Nail bed involvement- leads to oil-drop discoloration, onycholysis, subungual hyperkeratosis and splinter haemorrhages. It is an indicator of more severe form of psoriasis and it leads to significant negative repercussions in the quality of life. [5]

 

Nail psoriasis severity index (NAPSI) is the first nail specific scores created for assessing the severity of nail involvement in psoriasis. Even though many other scoring systems have been developed, NAPSI is the most widely used scoring system in clinical trials. [6] Although it can be time consuming and impractical for the clinician in an outpatient clinic, NAPSI demonstrates excellent inter-rater reliability and validity in the assessment of psoriatic nail disease. [7] In spite of its aesthetic and functional implications, only few studies have investigated the epidemiology and clinical characteristics of nail psoriasis. [8] In this back drop this study is in the direction to throw light on the prevalence of the nail changes in psoriatic patients along with assessment of severity of nail involvement with NAPSI scoring system.

 

Objectives

  1. To study the prevalence of nail changes in psoriasis patients attending our Outpatient department and to assess the severity of nail involvement using NAPSI score.
  2. To assess the relationship between the severity of nail involvement using Nail Psoriasis Severity Index (NAPSI) and the extent of skin involvement by using body surface area (BSA) involvement in such patients.
MATERIALS AND METHODS

This observational, cross-sectional study was conducted in the Department of Dermatology Venereology and Leprosy, Guntur Medical College over a period of 6 months.

 

Inclusion criteria: (1) treatment-naive patients; (2) clinical diagnosis of chronic plaque psoriasis; (3) coexistence of nail involvement; (4) moderate to severe disease requiring systemic therapy, i.e., PASI ≥10 and 10 < DLQI ≥ 10 or PASI <10 and DLQI ≥10, and nail disease of any extent; (5) absence of arthritis or other psoriasis comorbidities that may affect the quality of life. Patients who fulfilled the inclusion criteria were included into this study.

 

Exclusion Criteria: Patients under systemic treatment (for nail or cutaneous psoriasis) or applying topical treatment for fingernail psoriasis, at the time of the clinical examination or within 6 months prior to the examination were excluded from our study.

 

We excluded patients with fingernail psoriasis and concomitant onychomycosis (proven by direct microscopy examination and/or mycological culture) and patients using artificial nails. Patients with clinical psoriatic arthritis or other inflammatory conditions affecting joints, such as rheumatoid arthritis, were also excluded.

 

Clinical data

Data about age, gender, age of onset of cutaneous and nail psoriasis, duration of cutaneous and nail disease, Psoriasis Area and Severity Index (PASI) and Nail Psoriasis Severity Index (NAPSI) were collected for each of the 35 patients. The dermatological examination was made by the same clinician in order to provide consistency in clinical evaluation.

 

For each patient we assessed the severity of skin disease using the PASI score, taking into account the clinical aspect of the lesions (erythema, induration, desquamation) reported to the affected area [9-13]. PASI score value ranges from 0-no disease to 72- maximal disease.

 

In psoriasis, nail involvement implies nail bed and nail matrix changes. Nail bed changes include onycholysis, oil drop (salmon patch) dyschromia, splinter hemorrhages, and subungual hyperkeratosis. Nail matrix changes include pitting, leukonychia, red spots in the lunula, and crumbling. For each patient we assessed the severity of nail involvement using NAPSI score [14]. Through NAPSI score we evaluated the presence of any of the 8 clinical signs mentioned above in each quadrant of a fingernail. NAPSI score value ranges from 0–8/fingernail, 0–40/hand, 0–80/both hands. A NAPSI score >1 was considered as nail involvement.

 

Statistical analysis

The collected data were submitted to statistical analysis using Statistics software (v. 8, StatSoft, USA). Categorical variables were summarized as absolute and relative frequencies and comparisons between groups were conducted by Z-test for proportions. Continuous variables were summarized as mean ± standard deviation for normally distributed variables and median for those variables that proved not following the normal distribution. Student t-test was used to compare continuous variable on independent groups for data with normal distribution. A 5% significance level was used and any p values smaller than 0.05 were considered statistically significant.

RESULTS

The total number of patients included in the study was 90. Of these, the male-to-female ratio was 1.3:1. The maximum number of patients were in the age group of 31–45 years (28.0%). Psoriasis (50 cases) was the most common papulosquamous disorder followed by lichen planus (20 cases). Among the papulosquamous disorders, nail changes were present in 59 (65.5%) patients. Out of the 59 patients with nail changes, 69.9% were male, and 30.1% were female. Pitting was overall the most common finding in both clinical and dermoscopic examinations.

 

In 9 (10%) cases, a biopsy was done to confirm the diagnosis. Out of 90 cases, psoriasis was reported in 50 (55.6%) patients. Of these, 31 (62%) were male and 19 (38%) were female. The majority of patients with psoriasis were in the age group of 31–45 years. Most had a disease duration between 6 and 10 years. Chronic plaque psoriasis was the most common presentation among psoriatic patients. Disease type had a significant relationship with nail involvement (P < 0.05). Among 59 patients, 9 (15.3%) had joint involvement, and 7 (77.8%) of these had nail involvement. Disease type had no significant relation with joint involvement. The mean PASI was 13.23 ± 5.55, with most scores in the range of 11–15.

 

Disease duration showed a significant correlation with PASI. The most common pattern of nail change observed was pitting (79%), followed by onycholysis (49.5%), both clinically and dermoscopically. Fingernails were more frequently involved than toenails. Oil drop, splinter hemorrhage, pseudofiber sign, dilated capillaries, and hyponychial capillaries were detected better by dermoscopy than clinical examination (P < 0.05). Mean clinical NAPSI (cNAPSI) was 22.02 ± 18.89, and mean dermoscopic NAPSI (dNAPSI) was 25.49 ± 20.24. The paired t-test showed that the dNAPSI score was significantly higher (P < 0.05) than the cNAPSI score. A positive correlation was noted between the PASI score and the clinical and dermoscopic NAPSI scores. A strong correlation was observed between the duration of psoriasis and the clinical and dermoscopic NAPSI scores.

 

In our study, the total number of patients with lichen planus was 20, out of which 9 were male and 11 were female. The maximum number of patients were in the 31–45 years age group in both genders. The mean age was 32.71 ± 11.56 years, and the mean duration of the disease was 3.65 ± 3.19 years. Nail changes were present in 26% of cases. Thinning was the most common pattern and was observed in 8 patients, followed by longitudinal striation in the fingernails. Longitudinal striation was most commonly seen in toenails. The prevalence of all nail changes was the same in both clinical and dermoscopic observations.

 

In pityriasis rosea, the male-to-female ratio was 1.18:1. Most patients were in the 16–20 age group, and only 8% had nail changes, which were in the form of Beau's lines. Both patients with nail changes had a longer disease duration and recurrent episodes. A total of 5 cases of lichen nitidus were seen, and leukonychia was the only finding in 3 cases. The most common nail changes were seen in the middle finger of the left hand. In lichen striatus, all patients were children aged 3 to 12 years. Leukonychia was the only finding in one patient. In pityriasis lichenoides chronica, Beau's line was the only nail change in a single patient out of 3 cases. Out of 2 parapsoriasis cases, one patient had Beau's line on the fifth fingernail. In pityriasis rubra pilaris, nail plate thickening was the most common finding, with no differences between clinical and dermoscopic findings. The most common nails involved were the fifth and sixth toenails.

 

TABLE 1 Frequency of Various Papulosquamous Disorders (N=90)

Diseases

Number

Percentage

Psoriasis

50

55.56

Lichen planus

18

20

Pityriasis rosea

10

11.11

Pityriasis rubra pilaris

1

1.11

Lichen nitidus

3

3.33

Pityriasis lichenoides chronica

2

2.22

Lichen striatus

1

1.11

Parapsoriasis

1

1.11

Total

90

100

 

Table 2.  Distribution of nail changes in papulosquamous disorders

Diseases

Common Nail

Average Number of Nails

Most Common Finding (Clinical)

Most Common Finding (Dermoscopy)

Psoriasis

F5, T5

5

Pitting

Pitting

Lichen planus

F4

2

Thinning

Thinning

Pityriasis rosea

F6

1

Beau’s line

Beau’s line

Pityriasis rubra pilaris

T56

3

Thickening of nail plate

Thickening of nail plate

Lichen nitidus

F3

1

Leukonychia

Leukonychia

Pityriasis lichenoides chronica

T5

1

Beau’s line

Beau’s line

Lichen striatus

F7

1

Leukonychia

Leukonychia

Parapsoriasis

F5

1

Beau’s line

Beau’s line

 

Table 3. Clinical and dermoscopic correlation of nail changes in psoriasis

Nail Changes

Clinical Observation (Total)

Clinical Observation (UL)

Clinical Observation (LL)

Dermoscopy Observation (Total)

Dermoscopy Observation (UL)

Dermoscopy Observation (LL)

Common Nail Involved

Pitting

90

90

28

90

90

28

F4, F5

Subungual debris

42

19

40

44

23

42

T5

Onycholysis

52

52

12

52

52

12

F6

Thickening

24

4

21

24

4

21

T5

Leukonychia

15

13

2

15

13

2

F4

Longitudinal striation

10

8

5

10

8

5

T6

Oil drop sign

25

25

0

34

34

0

F8

Onychomadesis

10

10

2

10

10

2

F4

Beau’s line

12

7

5

12

7

5

T6

Melanonychia

8

5

3

8

5

3

F5

Dystrophy

10

3

7

10

3

7

T4

Splinter haemorrhage

9

9

0

24

24

0

F5

Dilated capillaries

4

4

1

20

16

7

F3

Pseudofibre sign

0

0

0

13

10

5

F9

Hyponychial capillaries

0

0

0

20

17

3

F7

 

Legend:

  • UL: Upper Limb
  • LL: Lower Limb

Table 4. Correlation between PASI and NAPSI

PASI

NAPSI (Total)

NAPSI (11-20)

NAPSI (21-30)

NAPSI (31-40)

NAPSI (41-50)

NAPSI (51-60)

NAPSI (61-70)

NAPSI (71-80)

0-5

6

4 (C: 2, D: 2)

 

 

2 (C: 1, D: 1)

 

 

 

6-10

12

10 (C: 4, D: 4)

2 (C: 1, D: 1)

 

2 (C: 1, D: 1)

 

 

 

11-15

97

46 (C: 27, D: 19)

27 (C: 12, D: 15)

9 (C: 4, D: 5)

7 (C: 3, D: 2)

3 (C: 1, D: 2)

 

 

16-20

41

6 (C: 2, D: 2)

4 (C: 1, D: 1)

5 (C: 3, D: 2)

5 (C: 3, D: 2)

13 (C: 6, D: 7)

7 (C: 3, D: 4)

3 (C: 2, D: 1)

21-25

14

2 (C: 1, D: 1)

3 (C: 3, D: 0)

3 (C: 0, D: 3)

2 (C: 1, D: 1)

1 (C: 1, D: 0)

2 (C: 1, D: 1)

 

26-30

2

 

 

 

 

1 (C: 1, D: 0)

1 (C: 0, D: 1)

 

31-35

2

 

 

 

 

 

 

2       (C: 1, D: 1)

Key Points: C: Clinical Observation D: Dermoscopic Observati  Blank cells indicate no recorded data.

Total NAPSI is summed from Clinical and Dermoscopic observation Blank cells indicate no recorded data.

Total NAPSI is summed from Clinical and Dermoscopic observations.

DISCUSSION

The dataset comprised 90 participants, with their PASI and NAPSI scores classified into different ranges.A pattern of increasing NAPSI scores with higher PASI scores was observed, indicating a positive correlation between the severity of psoriasis on the skin and the extent of nail involvement.

 

Key Findings by PASI Categories: PASI 0-5 Nail changes were minimal, with only 6 cases showing nail involvement. The most common changes were observed in the 11-20 and 41-50 NAPSI range, involving clinical and dermoscopic findings such as pitting and onycholysis. PASI. [15]

 

Moderate nail changes were noted, with a total of 12 cases. A majority were in the 11-20 NAPSI range, reflecting early nail changes like subungual debris and leukonychia, observed equally in clinical and dermoscopic examinations. PASI 11-15 This group displayed the highest number of cases (97), with nail changes distributed across all NAPSI ranges. The data showed Frequent findings in the 11-20 and 21-30 NAPSI range, predominantly pitting, Beau’s lines, and subungual debris.Dermoscopic observations slightly exceeded clinical findings, emphasizing the utility of dermoscopy in detecting subtle changes. [16]

PASI 16-20, Significant nail involvement was observed in 41 cases, distributed across higher NAPSI ranges (31-40, 51-60, 61-70). Thickening, onycholysis, and splinter hemorrhages were prevalent, particularly in dermoscopic evaluations. PASI 21-25 and Higher
Nail changes in these categories were limited in number but displayed more severe findings, including dystrophy, pseudofibre signs, and capillary dilations. [17] Dermoscopic observations uncovered features like hyponychial capillaries that were not easily detected clinically. [18]

 

Clinical vs. Dermoscopic Observations Across all PASI categories, dermoscopy was instrumental in detecting subtle nail changes that were less apparent clinically. [19] Findings such as splinter hemorrhages, oil drop signs, and hyponychial capillaries were more prominent under dermoscopic evaluation. [20] The complementary role of dermoscopy and clinical examination is evident, highlighting its importance in comprehensive nail assessment.

 

Implications for Clinical Practice The data underscores the strong association between increasing PASI scores and more extensive nail involvement, emphasizing the need for early and regular nail evaluations in psoriasis patients, [21] particularly those with moderate-to-severe skin involvement.Dermoscopy emerges as a vital diagnostic tool, providing detailed insights into nail changes that guide treatment decisions and monitoring.

 

Limitations and Future Directions: The dataset was limited to 90 participants, and further studies with larger sample sizes could provide more robust correlations. Exploring longitudinal changes in NAPSI and PASI scores over time and their response to treatment could enrich our understanding of psoriasis progression and management.

CONCLUSION

The frequency of nail changes in psoriasis was 73%. Majority of males and less than half of females with psoriasis had nail involvement. The present study demonstrated a highly significant association between the late-onset group of psoriasis patients and nail involvement. The most common nail pattern in our study was pitting, followed by onycholysis, subungual hyperkeratosis, crumbling, and leukonychia. A significant association between higher PASI scores and nail involvement was observed. A trend toward a more severe nail

REFERENCES
  1. Hallaji Z, Babaeijandaghi F, Akbarzadeh M, et al. A significant association exists between the severity of nail and skin involvement in psoriasis. J Am Acad Dermatol. 2012;66(1):e12-13. DOI: 10.1016/j.jaad.2010.10.021. PMID: 22177647.
  2. Reich A, Szepietowski JC. Health-Related Quality of Life in Patients with Nail Disorders. Am J Clin Dermatol. 2011;12(5):313- 320. DOI: 10.2165/11592120-000000000-00000. PMID: 21834596.
  3. Dogra A, Arora AK. Nail Psoriasis: The Journey So Far. Indian J Dermatol. 2014;59(4):319-333. DOI: 10.4103/0019- 5154.135470. PMID: 25071247; PMCID: PMC4103264.
  4. Schons KRR, Beber AAC, Beck M de O, Monticielo OA. Nail involvement in adult patients with plaque-type psoriasis: prevalence and clinical features. An Bras Dermatol. 2015;90(3):314-319. DOI: 10.1590/abd1806-4841.20153736. PMID: 26131859; PMCID: PMC4516108.
  5. Reich K. Approach to managing patients with nail psoriasis. J Eur Acad Dermatol Venereol. 2009;23 Suppl 1:15-21. DOI: 10.1111/j.1468-3083.2009.03364.x. PMID: 19686381.
  6. Salomon J, Szepietowski JC, Proniewicz A. Psoriatic nails: a prospective clinical study. J Cutan Med Surg. 2003;7(4):317-321. DOI: 10.1007/s10227-002-0143-0. PMID: 12879333.
  7. Edwards F, de Berker D. Nail psoriasis: clinical presentation and best practice recommendations. Drugs. 2009;69(17):2351-2361. DOI: 10.2165/11318180-000000000-00000. PMID: 19911853.
  8. Jiaravuthisan MM, Sasseville D, Vender RB, Murphy F, Muhn CY. Psoriasis of the nail: anatomy, pathology, clinical presentation, and a review of the literature on therapy. J Am Acad Dermatol. 2007;57(1):1-27. DOI: 10.1016/j.jaad.2005.07.073. PMID: 17572277.
  9. Gupta AK, Cooper EA. Psoriatic nail disease: quality of life and treatment. J Cutan Med Surg. 2009;13 Suppl 2:S102-S106. DOI: 10.2310/7750.2009.00027. PMID: 1979982.
  10. Micali G, Lacarrubba F, Massimino D, Schwartz RA. Dermatoscopy: Alternative uses in daily clinical practice. J Am Acad Dermatol. 2011;64(6):1135-1146. DOI: 10.1016/j.jaad.2010.03.010. PMID: 21292346.
  11. Farias DC de, Tosti A, Chiacchio ND, Hirata SH. [Dermoscopy in nail psoriasis]. An Bras Dermatol. 2010;85(1):101-103. DOI: 10.1590/s0365-05962010000100017. PMID: 20464097.
  12. Polat A, Kapıcıoğlu Y. Dermoscopic findings of psoriatic nail and their relationship with disease severity. TURKDERM. 2017;51:119–23. DOI: 10.4274/turkderm.54289.
  13. Yorulmaz A, Artuz F. A study of dermoscopic features of nail psoriasis. Postepy Dermatol Alergol. 2017;34(1):28-35. DOI: 10.5114/ada.2017.65618. PMID: 28286468; PMCID: PMC5340855.
  14. Yadav TA, Khopkar US. Dermoscopy to Detect Signs of Subclinical Nail Involvement in Chronic Plaque Psoriasis: A Study of 68 Patients. Indian J Dermatol. 2015;60(3):272-275. DOI: 10.4103/0019- 5154.156377. PMID: 26120154; PMCID: PMC4458939.
  15. Prabhakar V, Joy B, Thyvalappil A, Sridharan R, Sreenivasan A, Mathew P. Prevalence, clinical profile, and severity of nail involvement in psoriasis – A hospital-based cross-sectional study from a tertiary care center in North Kerala. J Skin Sex Transm Dis 2019;1(2):72-6.
  16. Elobeid HE, Alfarouk KO, Ahmed N. Aljarbou AN, et al. Correlation between the Body Mass Index and Psoriasis in Dermatology and Venereology Teaching Hospital in Khartoum. AJDV. 2017;6:30–39. doi:10.5923/j.ajdv.20170602.03
  17. Misra A. Ethnic-Specific Criteria for Classification of Body Mass Index: A Perspective for Asian Indians and American Diabetes Association Position Statement. Diabetes Technol Ther. 2015;17(9):667-671. doi:10.1089/dia.2015.0007
  18. The Etiology, Pathophysiology,Differential Diagnosis, Clinical Findings, and Treatment of Nail Psoriasis | IntechOpen [Internet]. [cited 2020 Jun 17]. Available from: https://www.intechopen.com/ chapters/66296
  19. Wanniang N, Navya A, Pai V, Ghodge R. Comparative study of clinical and dermoscopic features in nail psoriasis. Indian Dermatol Online J. 2020;11(1):35-40. DOI: 10.4103/idoj.IDOJ_51_19. PMID: 32055506; PMCID: PMC7001394.
  20. Armesto S, Esteve A, Coto-Segura P, et al. [Nail psoriasis in individuals with psoriasis vulgaris: a study of 661 patients]. Actas Dermosifiliogr. 2011;102(5):365-72. DOI: 10.1016/j. ad.2011.02.007. PMID: 21514549.
  21. Baran R. The burden of nail psoriasis: an introduction. Dermatology. 2010;221 Suppl 1:1-5. DOI: 10.1159/000316169. PMID: 20733309.
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