Psoriatic onychodystrophy

Psoriatic onychodystrophy or psoriatic nails is a nail disease. It is common in those with psoriasis, with reported incidences varying from 10% to 78%. Elderly patients and those with psoriatic arthritis are more likely to have psoriatic nails.[1]: 781–2 

Psoriatic onychodystrophy
Other namesPsoriatic nails
A picture of a pair of feet in sandals. Some of the nails appear diseased.
Psoriasis of the toenails
SpecialtyDermatology
CausesPsoriasis
Differential diagnosisOnychomycosis
TreatmentMedications, radiation
Frequency10% to 78% of those with psoriasis

Symptoms

Psoriatic nails are characterized by a translucent discolouration in the nail bed that resembles a drop of oil beneath the nail plate.[2] Early signs that may accompany the "oil drop" include thickening of the lateral edges of the nail bed with or without resultant flattening or concavity of the nail; separation of the nail from the underlying nail bed, often in thin streaks from the tip-edge to the cuticle; sharp peaked "roof-ridge" raised lines from cuticle to tip; or separation of superficial layers of the nail followed by loss of patches of these superficial layers, leaving thin red nails beneath; or nail pitting–punctate changes along the nail plate surface.

Causes

The causes of nail psoriasis are unknown. It has been suggested that fungi may play a role.[3]

Diagnosis

The Nail Psoriasis Severity Index (NAPSI) is a numeric, reproducible, objective, simple tool for evaluation of nail psoriasis.[4] It evaluates several signs separately, each on a 1–3 scale: pitting, Beau's lines, subungual hyperkeratosis and onycholysis. A 2005 study proposed a modified NAPSI scale for persons with psoriasis and named the title of their publication "Modification of the Nail Psoriasis Severity Index".[5] Then, in 2007, a study found that there was a high level of inter-rater variability of the 2003 NAPSI scale and proposed another index which was, like the 2005 article, a modification of the 2003 article, and was named modified NAPSI.[6]

A 2008 study found that Cannavo's qualitative system[7] correlated with NAPSI (P<0.001) and is less time-consuming.[8]

Onycholysis: Separation of the nail plate from the nail bed

There is a risk of misdiagnosis with onychomycosis.

Treatment

There exist numerous treatments for nail psoriasis but there is little information concerning their effectiveness and safety.[9] Treatments include topical, intralesional, radiation, systemic, and combination therapies.

Relative effectiveness of treatments

Available studies lack sufficient power to extrapolate a standardized therapeutic regimen.[9]

As of April 2009, an assessment of the evidence for the efficacy and safety of the treatments for nail psoriasis is in progress.[20]

  • Infliximab appears to be the most effective treatment for nail psoriasis to date.[21]
  • Results from low-dose acitretin therapy show NAPSI score reductions comparable with those studies evaluating biologic drugs for nail psoriasis and suggest that low-dose systemic acitretin should be considered in the treatment of nail psoriasis.[21]

A 2013 meta-analysis showed improvement of nail psoriasis with infliximab, golimumab, superficial radiotherapy, electron beam, and grenz rays compared to placebo.[22] Although systemic therapies have been shown to be beneficial, they may have serious adverse effects.[22] Topical treatments have not been well studied but may be beneficial.[22]

Research

Active clinical trials investigating nail psoriasis:[23]

Phase IV

Phase II

See also

References
  1. James, William; Berger, Timothy; Elston, Dirk (2005). Andrews' Diseases of the Skin: Clinical Dermatology. (10th ed.). Saunders. ISBN 0-7216-2921-0.
  2. Kouskoukis, C.; Scher, R.; Ackerman, A. (1983). "The "oil drop" sign of psoriatic nails. A clinical finding specific for psoriasis". The American Journal of Dermatopathology. 5 (3): 259–262. doi:10.1097/00000372-198306000-00012. PMID 6625117.
  3. Szepietowski, C.; Salomon, J. (Nov 2007). "Do fungi play a role in psoriatic nails?". Mycoses. 50 (6): 437–442. doi:10.1111/j.1439-0507.2007.01405.x. ISSN 0933-7407. PMID 17944702. S2CID 37127086.
  4. Rich, P.; Scher, R. (2003). "Nail Psoriasis Severity Index: A useful tool for evaluation of nail psoriasis". Journal of the American Academy of Dermatology. 49 (2): 206–212. doi:10.1067/S0190-9622(03)00910-1. PMID 12894066.
  5. Parrish, CA; Sobera, JO; Elewski, BE (October 2005). "Modification of the Nail Psoriasis Severity Index". Journal of the American Academy of Dermatology. 53 (4): 745–6, author reply 746–7. doi:10.1016/j.jaad.2004.11.044. PMID 16198816.
  6. Cassell, S.; Bieber, J.; Rich, P.; Tutuncu, Z.; Lee, S.; Kalunian, K.; Wu, C.; Kavanaugh, A. (2007). "The modified Nail Psoriasis Severity Index: Validation of an instrument to assess psoriatic nail involvement in patients with psoriatic arthritis". The Journal of Rheumatology. 34 (1): 123–129. PMID 17216680.
  7. Cannavò, S. P.; Guarneri, F.; Vaccaro, M.; Borgia, F.; Guarneri, B. (2003). "Treatment of Psoriatic Nails with Topical Cyclosporin: A Prospective, Randomized Placebo-Controlled Study". Dermatology. 206 (2): 153–156. doi:10.1159/000068469. PMID 12592084. S2CID 20866096.
  8. Kaçar, N.; Ergin, Ş.; Erdo?an, B. (2007). "The comparison of Nail Psoriasis Severity Index with a less time-consuming qualitative system". Journal of the European Academy of Dermatology and Venereology. 22 (2): 219–22. doi:10.1111/j.1468-3083.2007.02389.x. PMID 18211416. S2CID 41847018.
  9. Jiaravuthisan, M. M.; Sasseville, D.; Vender, R. B.; Murphy, F.; Muhn, C. Y. (2007). "Psoriasis of the nail: Anatomy, pathology, clinical presentation, and a review of the literature on therapy". Journal of the American Academy of Dermatology. 57 (1): 1–27. doi:10.1016/j.jaad.2005.07.073. PMID 17572277.
  10. Balbás, G. M.; Regaña, M. S.; Millet, P. U. (2009). "Tacalcitol ointment for the treatment of nail psoriasis". Journal of Dermatological Treatment. 20 (5): 308–310. doi:10.1080/09546630902787585. PMID 19367480. S2CID 208249471.
  11. Snchez Regaa, M.; Mrquez Balbs, G.; Umbert Millet, P. (2008). "Nail psoriasis: A combined treatment with 8 clobetasol nail lacquer and tacalcitol ointment". Journal of the European Academy of Dermatology and Venereology. 22 (8): 963–969. doi:10.1111/j.1468-3083.2008.02679.x. PMID 18410337.
  12. Fiallo, P. (2009). "Yellow nails as an adverse reaction to the topical use of 5-fluorouracil for the treatment of nail psoriasis". Journal of Dermatological Treatment. 20 (5): 299–301. doi:10.1080/09546630902773494. PMID 19363737. S2CID 42262387.
  13. Tzung, T.; Chen, C.; Yang, C.; Lo, P.; Chen, Y. (2008). "Calcipotriol used as monotherapy or combination therapy with betamethasone dipropionate in the treatment of nail psoriasis". Acta Dermato-Venereologica. 88 (3): 279–280. doi:10.2340/00015555-0401. PMID 18480933.
  14. Rigopoulos, D.; Gregoriou, S.; Daniel, III, C. R.; Belyayeva, H.; Larios, G.; Verra, P.; Stamou, C.; Kontochristopoulos, G.; Avgerinou, G.; Katsambas, A. (2009). "Treatment of Nail Psoriasis with a Two-Compound Formulation of Calcipotriol plus Betamethasone Dipropionate Ointment". Dermatology. 218 (4): 338–341. doi:10.1159/000202179. PMID 19212110. S2CID 36470967.
  15. Lamerson, C.; Stevens, G.; Sax, K. (2008). "Treatment of nail psoriasis with efalizumab: A preliminary study". Cutis; Cutaneous Medicine for the Practitioner. 82 (3): 217–220. PMID 18856162.
  16. Rigopoulos, D.; Gregoriou, S.; Stratigos, A.; Larios, G.; Korfitis, C.; Papaioannou, D.; Antoniou, C.; Ioannides, D. (2008). "Evaluation of the efficacy and safety of infliximab on psoriatic nails: An unblinded, nonrandomized, open-label study". British Journal of Dermatology. 159 (2): 453–456. doi:10.1111/j.1365-2133.2008.08686.x. PMID 18565184. S2CID 205257408.
  17. Clinical trial number NCT00265096 for "A Study of the Safety and Efficacy of Golimumab in Patients With Active Psoriatic Arthritis (GO-REVEAL)" at ClinicalTrials.gov
  18. Lee, Julia Yu-Yun (November 2009). "Severe 20-nail psoriasis successfully treated by low dose methotrexate". Dermatology Online Journal. 15 (11): 8. doi:10.5070/D32XF4V4PW. PMID 19951644.
  19. Saleem, K.; Azim, W. (2008). "Treatment of nail psoriasis with a modified regimen of steroid injections". Journal of the College of Physicians and Surgeons Pakistan. 18 (2): 78–81. PMID 18454890.
  20. Velema, Marieke; Hooft, Lotty; Lebwohl, Mark; Spuls, Phyllis I (2009). Spuls, Phyllis I (ed.). "Interventions for nail psoriasis". Protocols (1): CD007633. doi:10.1002/14651858.CD007633. hdl:2066/118676. PMID 23440816.
  21. Noiles, K.; Vender, R. (2009). "Nail psoriasis and biologics". Journal of Cutaneous Medicine and Surgery. 13 (1): 1–5. doi:10.2310/7750.2008.08012. PMID 19298765. S2CID 26612674.
  22. de Vries, Anna Christa Q; Bogaards, Nathalie A; Hooft, Lotty; Velema, Marieke; Pasch, Marcel; Lebwohl, Mark; Spuls, Phyllis I (2013-01-31). "Interventions for nail psoriasis". Cochrane Database of Systematic Reviews (1): CD007633. doi:10.1002/14651858.CD007633.pub2. hdl:2066/118676. ISSN 1465-1858. PMID 23440816.
  23. clinicaltrials.gov
  24. Clinical trial number NCT00581100 for "Effects of Etanercept on Nail Psoriasis and Plaque Psoriasis" at ClinicalTrials.gov
  25. Clinical trial number NCT00666354 for "Dose Response and Safety Study of Topical Methotrexate for the Treatment of Fingernail Psoriasis" at ClinicalTrials.gov


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