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