Nail changes and disorders in elderly Egyptians

More than meets the naked eye: an unusual psoriatic arthritis mimicry and the important role of dermoscopic examination

Background

Psoriatic arthritis (PsA) can manifest in various forms. This includes mimicry of other diseases. We describe an unusual mimicry of PsA.

Case presentation

We report a case of a middle-aged lady who presented with severe pain and morning stiffness over the small joints of the left hand for 3 months and painless deformity of the affected joints 1 year before. She was under treatment for pruritic rash over her ankles and knees for the past 1 year as well. Physical examination revealed a fixed flexion deformity, swelling and tenderness of the left ring and little fingers’ distal interphalangeal (DIP) joints. Left hand radiograph showed sclerotic joint margin, narrowed joint space and marginal osteophytes of the affected DIP joints. Dermoscopic examination showed red- violaceous, flat-topped papules and plaques with minimal scales on both ankles; hyperpigmented scaly plaques over both knees and vertical fingernail ridges. Serum autoimmune screening and inflammatory markers were unremarkable. Left ankle skin biopsy showed features consistent of psoriasis. PsA was diagnosed. Weekly titrated oral methotrexate and topical steroid were started. The patient showed significant improvement after 1 month of treatment.

Conclusion

PsA is a great mimicker. Dermoscopy is an accessible and valuable tool to assess skin lesions in greater detail. Clinicians should be aware of coexisting diseases or misdiagnosis when patients do not respond to treatment.

Nail Psoriasis in Older Adults: Epidemiology, Diagnosis, and Topical Therapy

Nail involvement is common in patients with cutaneous psoriasis, which is prevalent among older adults. Nail psoriasis greatly impacts patients' quality of life and self-esteem. Concomitant psoriatic arthritis is common. Treating nail psoriasis in the geriatric population may be challenging. General nail care measures may prevent exacerbations. Topical therapy is relatively effective, with a low rate of adverse events and little to no risk of systemic toxicity or drug interactions. However, application under occlusion may be cumbersome. There is a need for randomized controlled clinical trials in the elderly population to make more evidence-based treatment guidelines.

Psoriatic Nail Changes Are Associated With Clinical Outcomes in Psoriatic Arthritis

BACKGROUND

Nail changes are common in psoriatic arthritis (PsA), with varying relationships existing between skin, nail, and joint disease.

OBJECTIVE

To further characterize relationships between nail changes, psoriasis, and joint involvement in PsA patients.

METHODS

One hundred eighty-eight PsA patients had skin, fingernail, and rheumatological assessments completed. Hand and fingernail photographs were taken and reviewed by a dermatologist.

RESULTS

Higher swollen joint counts were associated with distal interphalangeal (DIP)/periungual psoriasis (P=.001), more splinter hemorrhages (P=.006), and any nail bed change (P=.03). Higher tender joint counts were associated with rough onychorrhexis (P<.001), DIP/periungual psoriasis (P=.03), red lunula (P=.001), nail crumbling (P=.046), any nail matrix (P=.03), and nail bed change (P=.03). Joint involvement was associated with same-digit nail changes; strongest association was swollen or tender DIP with subungual hyperkeratosis, odds ratio=26.6 (95% CI, 5.1-139.1).

CONCLUSION

The DIP/periungual psoriasis and specific nail changes were associated with higher joint counts and certain nail changes with same-digit joint involvement.