Psoriatic nail disease: quality of life and treatment

The Impact of Onychopathies on Quality of Life: A Hospital-based, Cross-sectional Study

Background:

Onychopathies or nail disorders are associated with social stigma and causes limitation of daily activities by hampering the function of both fingers and toes.

Aim:

To evaluate the impact of onychopathies on quality of life (QoL) and compare the severity of impact on QoL in various nail disorders.

Materials and Methods:

A hospital-based cross-sectional study consisting of 540 patients with onychopathies was conducted in the dermatology outpatient department. Patients were requested to complete a nail-specific QoL questionnaire consisting of 24 and 16 questions, respectively, for fingernails (group F) and toenails (group T) with five possible responses to each question. A score of 1-5 was given to each response. Statistical analysis was done to compare the impact of QoL on the different types of onychopathies.

Results:

We found that onychopathies have a significant impact on QoL. QoL was significantly more affected when multiple nails were involved (P = 0.020 for group F and P = 0.001 for group T). QoL impact was statistically more significant in women (P = 0.038 for group F and P < 0.001 for group T) and in younger people aged <20 years in group F and 20-39 years in group T (P < 0.001 for both groups F and T). Patients with onychomycosis, structural nail defects, and psoriasis had a more significant impact than other diseases (P < 0.001 for both groups F and T).

Conclusion:

Onychopathies have a significant adverse effect on QoL because of their serious physical, psychological and social impact. Hence, clinicians should treat the nail disorders with utmost seriousness.

Oral tofacitinib efficacy, safety and tolerability in Japanese patients with moderate to severe plaque psoriasis and psoriatic arthritis: A randomized, double-blind, phase 3 study

Tofacitinib is an oral Janus kinase inhibitor that is being investigated for psoriasis and psoriatic arthritis. Japanese patients aged 20 years or more with moderate to severe plaque psoriasis and/or psoriatic arthritis were double‐blindly randomized 1:1 to tofacitinib 5 or 10 mg b.i.d. for 16 weeks, open‐label 10 mg b.i.d. for 4 weeks, then variable 5 or 10 mg b.i.d. to Week 52. Primary end‐points at Week 16 were the proportion of patients achieving at least a 75% reduction in Psoriasis Area and Severity Index (PASI75) and Physician's Global Assessment of “clear” or “almost clear” (PGA response) for psoriasis, and 20% or more improvement in American College of Rheumatology criteria (ACR20) for patients with psoriatic arthritis. Safety was assessed throughout. Eighty‐seven patients met eligibility criteria for moderate to severe plaque psoriasis (5 mg b.i.d., n = 43; 10 mg b.i.d., n = 44), 12 met eligibility criteria for psoriatic arthritis (5 mg b.i.d., n = 4; 10 mg b.i.d., n = 8) including five who met both criteria (10 mg b.i.d.). At Week 16, 62.8% and 72.7% of patients achieved PASI75 with tofacitinib 5 and 10 mg b.i.d., respectively; 67.4% and 68.2% achieved PGA responses; all patients with psoriatic arthritis achieved ACR20. Responses were maintained through Week 52. Adverse events occurred in 83% of patients through Week 52, including four (4.3%) serious adverse events and three (3.2%) serious infections (all herpes zoster). No malignancies, cardiovascular events or deaths occurred. Tofacitinib (both doses) demonstrated efficacy in patients with moderate to severe plaque psoriasis and/or psoriatic arthritis through 52 weeks; safety findings were generally consistent with prior studies.

Severe Nail Fold Psoriasis Extending from Nail Psoriasis Resolved with Ustekinumab: Suggestion of a Cytokine Overflow Theory in the Nail Unit

Because nail psoriasis is difficult to treat, therapy with many biological drugs has been attempted. Ustekinumab is approved for chronic plaque psoriasis and psoriatic arthritis (PsA), with some trials reporting nail improvement using this agent. A 51-year-old man with severe chronic plaque psoriasis had severe involvement of all fingernails and toenails, with accompanying nail fold psoriasis. He also had PsA of the small joints of the fingers. Despite multiple conventional therapies, the nail lesions did not improve, and his nail psoriasis severity index score was 97. After a fourth ustekinumab injection, most of the fingernail psoriasis was resolved, and only hyperkeratosis remained on both large toenails. Because the nail plate, nail fold, and small joints of the fingers are closely apposed structures within a small area, cytokines produced from the nail units overflow to the nail fold and small joints and can induce nail fold psoriasis and PsA.

Single Blinded Left-to-Right Comparison Study of Excimer Laser Versus Pulsed Dye Laser for the Treatment of Nail Psoriasis

Introduction

Nail psoriasis is relatively difficult to treat. Excimer laser has been approved for the treatment of psoriasis since 2000. Pulsed dye laser (PDL) in psoriasis therapy has shown good response rates, with extended remissions. This is the first study assessing both the excimer and PDL lasers in nail psoriasis.

Methods

In a comparison study, excimer laser versus PDL for the treatment of nail psoriasis was evaluated in 42 patients. The right hand nails were treated with excimer laser twice weekly and the left hand nails were treated with PDL once every 4 weeks, for total 12 weeks. The patients were then followed up after a further 12 weeks. Nail Psoriasis Severity Index (NAPSI) scores were recorded at baseline, weeks 4, 8, and 12, and then at week 24. Patients were also asked to grade the clinical response to each treatment.

Results

A total of 304 nail changes, 148 with excimer laser and 156 with PDL, were treated. The mean NAPSI score in nails treated with excimer laser was 29.8 at baseline, reduced to 16.3 at week 24. In PDL-treated nails, the NAPSI scores dropped from 29.5 at baseline to 3.2 at week 24. NAPSI improvement was significantly greater in PDL than excimer (P = 0.001; Wilcoxon signed-rank test). Thirty-four (81%) hands achieved NAPSI-50, and 23 (55%) achieved NAPSI-75 at week 12, while complete nail recovery was shown in 6 (14%) hands treated with PDL. Regarding the hands treated with excimer laser, only 16 (38%) hands achieved NAPSI-50, while no hands achieved NAPSI-75 at week 12. In general, subungual hyperkeratosis and onycholysis improved significantly, while nail pitting was least responsive. Oil drops and splinter hemorrhages showed moderate response.

Conclusions

When compared to excimer laser, PDL demonstrated a good response for treating nail psoriasis, with minimal side effects.

Electronic supplementary material

The online version of this article (doi:10.1007/s13555-014-0057-y) contains supplementary material, which is available to authorized users.

Randomized controlled trial of a water-soluble nail lacquer based on hydroxypropyl-chitosan (HPCH), in the management of nail psoriasis

Background

Nail psoriasis occurs in up to 50% of patients affected by psoriasis, with a significant impact on quality of life that leads to a real clinical need for new therapeutic options.

Aim

To confirm whether the strengthening and hardening properties of the hydroxypropyl-chitosan (HPCH) nail lacquer could improve the structure of the nail plates on psoriatic nails.

Materials and methods

A randomized, double-blind, placebo controlled, parallel-group trial was carried out to evaluate the efficacy and tolerability of a hydrosoluble nail lacquer containing HPCH, Equisetum arvense, and methylsulfonylmethane on nail psoriasis. The test product or a placebo was applied once daily for 24 weeks to all fingernails. Efficacy assessments were performed on the target fingernail by means of the modified Nail Psoriasis Severity Index score. A cut-off score of 4 was considered to define the clinical cure rate (ie, Cure ≤4, Failure >4).

Results

After 24 weeks, the clinical cure rate showed the statistically significant superiority of the HPCH nail lacquer compared to placebo in both the intention-to-treat (Fisher’s exact test, P=0.0445) and the per protocol population (Fisher’s exact test, P=0.0437). This superiority was already present after 16 weeks of treatment. Moreover, the analysis of the modified Nail Psoriasis Severity Index-50 showed a statistically significant clinical improvement after 12 weeks of treatment in comparison to the results obtained after 8 weeks (Fisher’s exact test, P<0.05).

Conclusion

The trial showed that HPCH nail lacquer could be a new, valid, effective, and safe option for decreasing the signs of nail dystrophy in psoriatic patients.

Utility of gel nails in improving the appearance of cosmetically disfigured nails: experience with 25 cases

Background:

Gel nails are a commonly used cosmetic procedure, though their use by dermatologists has not been evaluated. These can be used to improve the appearance of cosmetically disfigured nails where other treatment options have failed; the condition is self-limiting or irreversible; or to camouflage the dystrophy until healing.

Materials and Methods:

A prospective, uncontrolled, open-label study on 25 participants presenting with cosmetically disfigured nails was undertaken. Mycologically negative, consenting patients with various nail plate surface abnormalities like trachyonychia (n =8); superficial pitting (n =6); onychorrhexis (n =4); superficial pitting with onychoschizia (n =3); Beau's lines (n =3) and pterygium (n =1) were included. The patients received gel nail application using Ranara gel nail kit^®. Extra care was taken to avoid any damage to cuticle. Standard pre- and post-treatment photographs were taken to assess improvement. Patient satisfaction score (1-10); Global assessment score of improvement (no improvement to excellent improvement) and any side effects reported were recorded.

Results:

The average age of treated patients was 30.44±11.39 years (range 18-60 years). A total of 69 nails were treated (average of 2.76 per patient). Post-procedure, the average patient satisfaction score was 9.08 ± 0.86 (range 7-10). The Global assessment showed excellent improvement (40% cases); good improvement (56% cases) and mild improvement in the single case of pterygium treated.

Conclusions:

The use of Gel nails in patients with cosmetically disfiguring nail plate surface abnormalities (like trachyonychia, onychoschizia, pitting, etc.) was found to produce good to excellent improvement in most of the cases. The patient satisfaction with the procedure was rated as high. This, coupled with absence of side effects, make gel nails a valuable tool in improving cosmesis and satisfaction among patients presenting with nail plate surface abnormalities. Further studies with larger number of patients are required to assess the impact these prostheses can have.

Identification of psoriatic patients at risk of high quality of life impairment

Psoriasis is a systematic chronic disease with large influence on patients' quality of life (QoL). The aim of this study was to assess the QoL of patients with psoriasis using generic, dermatology-specific and psoriasis-specific instruments simultaneously, to investigate the relationships between dimensions or subscales of the questionnaires and to identify categories of patients at risk of a high QoL impairment. The study comprised 100 consecutive patients with psoriasis treated at the Department of Dermatology, Clinical Center "Zvezdara", Belgrade, from January to December 2011. Three QoL questionnaires were administered: the EuroQol-5D (EQ-5D), the Dermatological Life Quality Index (DLQI) and the Psoriasis Disability Index (PDI). The Psoriasis Area and Severity Index was used in evaluating disease severity. According to our results the QoL of psoriatic patients was impaired (the overall DLQI and PDI scores were 10.5 ± 7.2 and 13.4 ± 8.7, respectively, while EQ visual analog scale score was 48.8 ± 25.1). The most predictive factor of QoL impairment was disease severity, followed by sole and nail involvement. Psoriatic arthritis and bleeding were also associated with impaired QoL. Significant correlations between the instruments used in this study were in the expected directions. Mainly strong and moderate significant correlations ranging 0.26-0.84 were seen between DLQI and PDI instruments. A detailed approach to QoL assessment may give to the dermatologist useful information that could be of help in identifying patients belonging to categories at risk of high QoL impairment due to psoriasis, thus guiding them in clinical practice.

Treatment of severe nail psoriasis with acitretin: an impressive therapeutic result

Nail psoriasis is common in adult psoriatic patients. Although several new drugs have recently been introduced for the treatment of skin psoriasis, treatment of nail psoriasis still remains a challenge. Topical treatments (e.g., corticosteroids, tazarotene, 5-fluorouracil, calcipotriol) are the first line in the management of skin psoriasis. The efficacy of these drugs in nail disease, however, is limited, mainly due to the difficulty in penetrating the nail bed and nail matrix. In cases of nail disease resistant to topical treatment, methotrexate, ciclosporin, acitretin, or biological agents can be used. The present authors introduce a 73-year-old patient affected by impressive psoriatic nail disease involving all her fingernails and toenails treated by acitretin, a traditional systemic treatment. After 2 months of treatment there was a marked improvement. The clinical improvement of the nails was progressive and 6 months later it was stable and satisfactory. The remarkable response to treatment in this case suggests that oral acitretin, in association to urea nail lacquer, might be useful in the management of disabling severe nail psoriasis even in absence of severe cutaneous involvement.

Ultrasonography reveals nail thickening in patients with chronic plaque psoriasis

Nail psoriasis is usually investigated and diagnosed by clinical examination. Ultrasonography is a non-invasive imaging technique for studying soft tissue involvement. The objective of this study was to estimate nail involvement in patients with chronic plaque psoriasis by ultrasonography. Prevalence, clinical type and severity of nail involvement according to nail psoriasis and severity index (NAPSI) were investigated in 138 patients with psoriasis. The thickness of the plate and bed of the fingernails was measured in 54 patients with psoriasis, 46 healthy controls and 37 patients with chronic eczema, using an ultrasonographic system equipped with a frequency transducer of 18 MHz. The prevalence of nail psoriasis was 73 % (102 out of 138). Onycholysis and thickening of the nail plate were the most common clinical type affecting 56 and 50 % of patients, respectively; splinter haemorrhages was the less common involving 10 % of patients. The mean NAPSI score was 18.4 ± 17.5 (SD; range 0-107). The thickness of fingernail plate and bed was significantly higher in patients with psoriasis with nail disease compared to healthy controls and patients with chronic eczema (p < 0.001). There was a linear correlation between NAPSI and plate and bed nail thickness (r = 0.52 and r = 0.38, p = 0.001). Increased nail plate and bed thickness was observed also in patients with psoriasis without clinically apparent nail involvement. In conclusion, thickening of the nail is a common feature of nail psoriasis also in patients without clinically apparent nail involvement.

Marked improvement in nail psoriasis during treatment with etanercept

Psoriasis is a chronic inflammatory skin condition that affects approximately 3% of the population. Up to 50% of patients with psoriasis have concurrent nail psoriasis, up to 30% of patients with skin psoriasis also have psoriatic arthritis and of these, approximately 80% have nail disease. The treatment of nail psoriasis is often challenging, and there is a need for new therapeutic options. Effective biological agents used in the treatment of moderate to severe chronic plaque psoriasis may represent a new therapeutic modality for this disease. A case of rapid improvement is reported in nail psoriasis under etanercept monotherapy with maintained efficacy following the withdrawal of continued therapy.

Health-related quality of life in patients with nail disorders

Fingernails and toenails are important organs of our body, serving as protection for the tips of fingers and toes. Fingernails also enhance fine touching and tactile sensitivity, as well as aid in the picking up of small objects. Healthy-looking nails are an important part of an individual's body image, and any nail abnormalities may be considered by patients as a significant cosmetic problem, markedly influencing their self-esteem. However, recent data have indicated that nail lesions are not only important because of cosmetic disfigurement, but may be a symptom of significant morbidity. Severe nail involvement was also shown to negatively impair social functioning and to interfere with work ability, thus markedly influencing a patient's well-being. Based on literature data and our own experience we conclude that nail diseases cause a marked decrease in health-related quality of life in a substantial percentage of patients. Nail changes are an important medical concern for patients and, therefore, nail diseases should raise attention and receive proper care from both physicians and other healthcare providers.

Dramatic response of nail psoriasis to infliximab

Nail psoriasis, affecting up to 50% of psoriatic patients, is an important cause of serious psychological and physical distress. Traditional treatments for nail psoriasis, which include topical or intralesional corticosteroids, topical vitamin D analogues, photochemotherapy, oral retinoids, methotrexate, and cyclosporin, can be time-consuming, painful, or limited by significant toxicities. Biological agents may have the potential to revolutionize the management of patients with disabling nail psoriasis. We present another case of disabling nail psoriasis that responded dramatically to infliximab.

Nail psoriasis as a severity indicator: results from the PsoReal study

BACKGROUND

Although nail psoriasis affects a substantial proportion of psoriasis patients and causes significant psychologic distress, few epidemiologic data characterizing patients with nail involvement are available. The aim of this research was to elucidate differences between patients with nail psoriasis and those without any nail involvement, taking quality indicators of health care from the patient's perspective into account.

METHODS

In total, 2449 patient members of the Deutscher Psoriasis Bund, the largest patient organization for psoriasis in Germany, were interviewed in this nationwide, noninterventional, cross-sectional study. Patients with nail psoriasis were compared with patients without any nail involvement with regard to gender, age, disease duration, affected body surface area, health-related quality of life (Dermatology Life Quality Index [DLQI] ED-5D), patient-defined treatment benefit, amount of inpatient treatments, disease duration, and numbers of work days lost.

RESULTS

Data from 2449 patients with psoriasis were analyzed. Overall, 44.8% (1078) of patients were female, mean age was 57.0 ± 11.7 years, and 72.8% had nail involvement and showed higher values for affected body surface area than those without nail involvement (8.3% versus 5.6%, respectively; P < 0.004). Health-related quality of life was significantly lower in patients with nail psoriasis (DLQI 7.2 versus 5.3; ED-5D 60.1 versus 67.3), who had more days off work (9.8 versus 3.3).

CONCLUSION

Nail involvement is an important symptom of psoriasis and is associated with greater disease severity and quality of life impairment. Accordingly, management of psoriasis should include a special focus on nail involvement.