A study of dermoscopic features of nail psoriasis

Dermoscopic Nail Changes in Psoriasis, Lichen Planus, and Lichen Striatus

Background

Onychoscopy is a noninvasive method helpful in diagnosing nail disorders. The aim of the study was to review literature on the usability of onychoscopy in nail psoriasis, nail lichen planus, and nail lichen striatus.

Summary

Onychoscopic features of nail psoriasis are pitting, onycholysis with erythematous border, salmon patches, splinter hemorrhages, dotted vessels in lateral and proximal folds, and hyponychium. Onychoscopic features of nail lichen planus are onychorrhexis, onycholysis, longitudinal melanonychia, and red lunula. The literature on the usability of onychoscopy in nail lichen striatus is scarce.

Keynotes

Onychoscopy facilitates evaluation of nail abnormalities compared to the clinical examination. Lunular alterations, salmon patches, erythematous border of onycholysis as well as splinter hemorrhages in nail psoriasis are better visualized with onychoscopy compared to the naked eye. Onychoscopy enhances detection of melanonychia, dyschromia, and lunular changes in nail lichen planus. Onychoscopic features are different in fingernails and toenails.

Dermoscopic features of nail psoriasis: a systematic review

INTRODUCTION

Nail psoriasis is common in psoriasis vulgaris and even more prevalent in psoriatic arthritis. Dermatoscopy of the nail proves helpful in enhancing the visualization of psoriatic nail lesions.

OBJECTIVE

This systematic review aimed to summarize the existing studies published in the literature that reported the various dermoscopic features of nail psoriasis.

MATERIALS AND METHODS

A systematic search of two medical databases, PubMed and Scopus, was conducted in April 2023. In total, 11 records were included. The number of reported cases in the included studies was 723.

RESULTS

The average age was 42.39 years. Sixty percent of patients were males, and 40% were females. Pitting constituted the most common onychoscopic feature indicating nail matrix involvement, followed by various other features such as leukonychia, nail plate thickening, transverse and longitudinal ridges, and different lunula abnormalities. The predominant onychoscopic feature indicating nail bed involvement was onycholysis, followed by splinter hemorrhages, oil drop sign, subungual hyperkeratosis, dilated capillaries, agminated capillary dots, erythematous border, and pustules. Vascular abnormalities observed in all locations were present in 52% of patients.

CONCLUSIONS

The clinical signs of nail psoriasis are diverse, and for the majority, they are nonspecific. Nail dermoscopy is a noninvasive tool that enhances the visualization of the nail manifestations of psoriasis. It may facilitate the establishment of diagnostic criteria for this pathology without resorting to more invasive procedures, such as nail biopsy.

Matching between ctlinical examination and dermoscopy in patients with nail psoriasis: Should dermoscopy be used instead of clinical examination?

Background

Dermoscopy has emerged as a useful diagnostic tool to evaluate skin lesions, including psoriasis. We aimed to compare the clinical examination and digital dermoscopy findings of nail involvement in patients with psoriatic nails.

Methods

This study included 60 patients with clinically diagnosed psoriasis. The nail findings and NAPSI were evaluated clinically and via dermoscopy, and then the severity of the disease was calculated using PASI criteria.

Results

About 32 patients were males, with a median PASI score of 4.4, and pitting and subungual hyperkeratosis were the most common findings. The clinical and dermoscopic examination had a moderate diagnostic resemblance regarding onycholysis, subungual hyperkeratosis, and leukonychia. The resemblance between the two methods for the diagnosis of leukonychia in patients with a duration of disease <2 years (Kappa = 0.59) and 2-6 years was moderate (Kappa = 0.48), and for 6 years< was perfect (Kappa = 0.62). The resemblance for the diagnosis of subungual hyperkeratosis and onycholysis in subjects with a duration of disease <2 years was slight, and for 2-6 years and 6 years< were moderate. The resemblance between the NAPSI score by the two methods was also moderate (95%CI -0.89-0.81, P < 0.001).

Conclusion

Dermoscopy is an efficient, supportive, and non-invasive method providing a better diagnosis of nail psoriasis.

Intense pulsed light versus pulsed dye laser in the treatment of nail psoriasis: Intra-patient left to right comparative controlled study

Background Until now, the management of psoriatic nails has not been satisfactory. Pulsed dye laser (PDL) as well as intense pulsed light (IPL) have been evaluated separately for the management of psoriatic nails and proved to be effective. Aim This study aimed to measure and compare the usefulness as well as the safety of intense pulsed light versus pulsed dye laser for the management of psoriatic nails. Methods The psoriatic fingernails of 20 patients were managed using intense pulsed light on one hand and pulsed dye laser on the other. Two to three psoriatic nails were left without treatment as controls. The therapeutic sessions were conducted monthly for a period of 6 months. Evaluation of the clinical outcomes was assessed by a blinded dermatologist depending on the total, nail bed, nail matrix, modified and target NAPSI scores. Patient global assessment, in addition to Nail Psoriasis Quality of Life (NPQL10), was performed to assess the response to the therapy. Results A significant reduction in the total, target and modified NAPSI scores from baseline to the end of the study was detected, but no significant differences were detected between the two treatments. The responses of the nail matrix and bed lesions to both modalities were nearly the same. All patients stated that the two devices were efficient and improved their quality of life. The intense pulsed light treatment was more painful. Complete clearance of nail lesions was not obtained. Limitations Lack of long-term follow-up of cases and preset laser parameters were the major limitations of this study. Conclusion Intense pulsed light, like pulsed dye laser, is safe and efficient in treating nail psoriasis; however, the former is more painful. Dermoscopy had an additive function in analysing the response of nail psoriasis to therapy.

Clinical value of dermoscopy in psoriasis

BACKGROUND

Dermoscopy is a noninvasive technique that has attracted increasing attention in the field of inflammatory skin diseases (such as psoriasis) in recent years.

OBJECTIVE

This study aimed to provide an up-to-date overview of the role of dermoscopy in the diagnosis and extra-diagnosis of psoriasis.

METHODS

This study sought to review the published literature regarding use of dermoscopy in the evaluation of psoriasis.

RESULTS

The diagnostic value of dermoscopy in psoriasis vulgaris, nail psoriasis, and other types of psoriasis was summarized from the aspects of vascular pattern, scale pattern, and other features. Meanwhile, the application value of dermoscopy in the differential diagnosis, efficacy and severity assessment, prediction and monitoring of psoriasis was discussed.

CONCLUSION

Dermoscopy has good clinical value in the diagnosis and differential diagnosis of psoriasis and shows great prospects for severity assessment and efficacy prediction monitoring.

Dermoscopic Features of Psoriatic Nails and Their Correlation to Disease Severity

Background

Nail psoriasis is a challenging chronic condition affecting patients functionally and psychologically. Nail involvement is observed in 15-80% of psoriatic patients with occasional presence of isolated nail psoriasis.

Objectives

To evaluate dermoscopic features of nail psoriasis and correlate them clinically.

Methods

The study included fifty subjects with nail psoriasis. Psoriasis skin and nail severity was evaluated using psoriasis area severity index (PASI) and nail psoriasis severity index (NAPSI). Dermoscopy of the nails (onychoscopy) was performed, and features were recorded and analyzed.

Results

The most common clinical and dermoscopic findings were pitting (86%) and onycholysis (82%). Among all dermoscopic features of nail psoriasis, only longitudinal striations and subungual hyperkeratosis were significantly higher in patients with moderate to severe psoriasis than in patients with mild psoriasis (P=0.028; P=0.042, respectively). PASI scores correlated positively but none significantly with NAPSI scores (r = 0.132, P=0.360), and similarly, no significant correlation was observed between the duration of psoriasis and the dermoscopic NAPSI (r = 0.022, P=0.879).

Conclusion

Dermoscopy can serve as a useful tool for early diagnosis of psoriatic nail changes not always visible to the naked eye and is a non-invasive easy-to-use confirmatory tool for nail changes in psoriatic disease or in isolated nail involvement.

Dermoscopic Features of Nail Psoriasis: Revisited

Introduction

Nail psoriasis poses a diagnostic challenge in a context of clinical findings that are not evident. We aimed at exploring dermoscopic findings of nail psoriasis and assessing the relationship between these features with disease severity and the risk of arthritis.

Methods

We enrolled 35 patients (26 men, 9 women) with severe nail psoriasis (Nail Psoriasis Severity Index [NAPSI] score of more than 50). A complete clinical evaluation, including musculoskeletal assessment and videodermoscopic examination of all nails, was carried out for each patient.

Results

Splinter haemorrhage was the most common finding (94.3%), followed by distal onycholysis (88.6%) and pitting (74.3%). The presence of subungual hyperkeratosis (SUH) and the absence of mottled lunula were associated with disease severity (p < 0.05). Both SUH and nail plate crumbling (NPC) were observed more in patients with arthritis. The presence of a combination of SUH and NPC was associated to a 15-fold increase in the risk of arthritis (%95 confidence intervals: 1.55-145.2, p < 0.05).

Discussion/Conclusion

This study presents preliminary evidence for the use of dermoscopy as a first step in the diagnosis of nail psoriasis. Dermoscopy is an indispensable tool in the primary evaluation of patients with nail psoriasis, which provides predictive information about the course of the disease.

Study of Clinical and Dermoscopic Features in Nails of Papulosquamous Disorders and their Correlation with Disease Severity: A Cross-Sectional Study

Background

As face is the index of the mind, so is the nail the index to health, as the nail is capable of mounting only a limited number of reaction patterns to the large number of disorders affecting it. Dermoscopy is thus a valuable aid not only in enhancing visible nail features but also in revealing cryptic features of diagnostic value.

Aims

To study the clinical and dermoscopic features in nails of papulosquamous disorders and correlate it with disease severity.

Methods and Material

This was a cross-sectional study with convenient sampling. After obtaining ethical clearance, according to inclusion and exclusion criteria, papulosquamous disorders were enrolled in the study. Finger nails and toe nails were numbered 1-10. Detailed clinical examination was done. Wet and dry dermoscopic examination was made in both polarised and non-polarised mode using ultrasound (USG) gel. Psoriasis area and severity index (PASI) and body surface area (BSA) were compared with nail changes. Statistical analysis of data was performed using the Statistical Package for the Social Sciences (SPSS) version 26.

Results

Out of 203 patients, 117 were male. Psoriasis was the most common disease (55.6%). A total of 65.51% of patients had nail changes. Pitting was the most common finding in psoriasis, both dermoscopically and clinically. Splinter haemorrhage, oil drop, dilated capillaries, and pseudofibre sign were detected better on dermoscopy (P < 0.05). Positive correlation was found between PASI and nail psoriasis severity index (NAPSI). A strong correlation was also found between clinical (cNAPSI) and dermoscopic (dNAPSI). Thinning was the most common in lichen planus. No relation between BSA and nail changes was observed.

Conclusions

Dermoscopy is thus a valuable aid not only in enhancing visible nail features but also in revealing cryptic features of diagnostic value and reducing the requirement for invasive procedures like nail biopsies, early diagnosis, directing management.

Imaging of the Nail Unit in Psoriatic Patients - a Systematic Scoping Review of Techniques and Terminology

Background

The growing interest in the visualization of psoriatic nail unit changes has led to the discovery of an abundance of image characteristics across various modalities.

Objective

To identify techniques for non‐invasive imaging of nail unit structures in psoriatic patients and review extracted image features to unify the diverse terminology.

Methods

For this systematic scoping review, we included studies available on PubMed and Embase, independently extracted image characteristics, and semantically grouped the identified features to suggest a preferred terminology for each technique.

Results

After screening 753 studies, 67 articles on the visualization of clinical and subclinical psoriatic changes in the nail plate, matrix, bed, folds and hyponychium were included. We identified 4 optical and 3 radiological imaging techniques for the assessment of surface (dermoscopy [n = 16], capillaroscopy [n = 12]), sub‐surface (ultrasound imaging [n = 36], optical coherence tomography [n = 4], fluorescence optical imaging [n = 3]), and deep‐seated psoriatic changes (magnetic resonance imaging [n = 2], positron emission tomography‐computed tomography [n = 1]). By condensing 244 image feature descriptions into a glossary of 82 terms, overall redundancy was cut by 66.4% (37.5%–77.1%). More than 75% of these image features provide additional disease‐relevant information that is not captured using conventional clinical assessment scales.

Conclusions

This review has identified, unified, and contextualized image features and related terminology for non‐invasive imaging of the nail unit in patients with psoriatic conditions. The suggested glossary could facilitate the integrative use of non‐invasive imaging techniques for the detailed examination of psoriatic nail unit structures in research and clinical practice.

Clinical, dermoscopic, and histopathological evaluations of patients with nail disorders

OBJECTIVE

This study aimed to assess the possible role of dermoscopy in the diagnosis of different nail disorders compared with the clinical and histopathological diagnosis.

METHODS

This study included 104 patients with nail disorders of both sex and any age. All the patients were subjected to a detailed medical history taken, clinical general examination, clinical and dermoscopic examinations of 20 nails. Potassium hydroxide examination was used to examine all patients with suspicious of onychomycosis. Histopathological evaluation was used to examine clinically ambiguous nail disorders.

RESULTS

The most common nail diseases were onychomycosis (54.81%) followed by nail psoriasis (19.2%) and nail lichen planus (3.8%).

CONCLUSION

Clinical evaluation was important in the diagnosis of different nail diseases. Nail dermoscopy could confirm clinical diagnosis and help in getting an accurate diagnosis of nail diseases and guide in the management of nail diseases by permitting better visualization of nail structure and pathology. The histopathological examination provided the most definitive method in reaching an accurate diagnosis due to it could provide etiologic, diagnostic, and prognostic information. There was a good agreement between clinical, dermoscopic, and histopathological examinations for accurate diagnosis of different nail diseases.

Efficacy of combined fractional carbon dioxide laser and topical tazarotene in nail psoriasis treatment: A randomized intrapatient left-to-right study

BACKGROUND

Treatment of nail psoriasis is disappointing; due to poor penetrability of topical therapies and variable efficacy of systemic therapies. Fractional carbon dioxide laser (FCL) may enhance penetration of topical therapy for nail psoriasis.

OBJECTIVE

To evaluate the efficacy and safety of FCL plus topical tazarotene versus tazarotene monotherapy in the treatment of nail psoriasis.

METHODS

Twenty-seven patients with bilateral fingernail psoriasis randomly received 3 sessions of FCL at four-week interval plus once-daily tazarotene 0.1% gel for one hand, and once-daily tazarotene 0.1% gel only for 3 months on the other hand. The primary outcome was modified Nail Psoriasis Severity Index (mNAPSI) at 3 and 6 months compared to baseline, and the secondary outcomes included dermoscopic examination and patient global assessment. Adverse events were reported.

RESULTS

The total, nail matrix, and nail bed mNAPSI scores were significantly improved at 3 and 6 months by both regimens, but they decreased more after FCL/tazarotene combination (p = 0.001, p = 0.023, and p = 0.001, respectively). Combination therapy showed faster improvement of nail matrix signs and greater efficacy for nail bed signs. The dermoscopic features of the nail plate were the most responsive after both treatments. The combined therapy was more effective in improving the dermoscopic nail bed features. Patient's global assessment scores were significantly higher after the combined therapy. Both treatments were well tolerated.

CONCLUSION

Fractional CO₂  laser is an effective and well-tolerated treatment for nail psoriasis; it improves the outcomes of topical tazarotene especially in nail bed lesions.

Characterisation of the nail microbiome in psoriatic and nonpsoriatic patients with onychomycosis

BACKGROUND

Onychomycosis (OM) is the most common infectious nail disease, and it occurs frequently in patients with psoriasis. Microbial community shifts have been suggested to play a role in psoriasis and fungal infection occurrence.

OBJECTIVES

To investigate and compare nail microbial community compositions in psoriatic and nonpsoriatic patients with OM.

METHODS

Toenail samples were collected from nonpsoriatic patients with OM, psoriatic patients with nail psoriasis (NP) and OM, patients with only NP and healthy controls. Bacterial and fungal community compositions were analysed by amplicon sequencing of the V3-V4 regions of the 16S rDNA gene and the ITS1 region, respectively.

RESULTS

Psoriatic OM patients had higher bacterial and fungal alpha diversities. Taxonomic analysis revealed a significantly lower relative abundance of Trichophyton rubrum (32.88% vs 82.18%, p < .001) and an increased trend of the abundance of Candida in psoriatic patients with OM than in nonpsoriatic patients. Nonpsoriatic patients with OM had a higher abundance of Staphylococcus than healthy controls (59.66% vs 45.76%, p < .05). Trichophyton, Alternaria and Malassezia could accurately differentiate psoriatic and nonpsoriatic patients with OM, with an area under the curve (AUC) of 0.86. The severity of OM was positively correlated with the relative abundance of Trichophyton rubrum. Further, Trichophyton was positively correlated with Staphylococcus and negatively correlated with Corynebacterium, Anaerococcus, Malassezia and Alternaria.

CONCLUSIONS

The nail microbiome in psoriatic patients with OM has distinct bacterial and fungal signatures, suggesting that different dysbiosis is associated with the pathogenesis of OM in psoriatic and nonpsoriatic patients.

Challenge of Nail Psoriasis: An Update Review

Nail psoriasis is a refractory disease that affects 50-79% skin psoriasis patients and up to 80% of patients with psoriatic arthritis (PsA). The pathogenesis of nail psoriasis is still not fully illuminated, although some peculiar inflammatory cytokines and chemokines seems to be the same as described in psoriatic skin lesions. Psoriatic nail involving matrix can cause pitting, leukonychia, red spots in lunula, and nail plate crumbling, while nail bed involvement can result in onycholysis, oil-drop discoloration, nail bed hyperkeratosis, and splinter hemorrhages. The common assessment methods of evaluating nail psoriasis includes Nail Psoriasis Severity Index (NAPSI), Nail Assessment in Psoriasis and Psoriatic Arthritis (NAPPA), Nail Psoriasis Quality of life 10 (NPQ10), and so on. Treatment of nail psoriasis should be individualized according to the number of involving nail, the affected site of nail and presence of skin and/or joint involvement. Generally, topical therapies are used for mild nail psoriasis, while biologic agents such as etanercept are considered for severe nail disease and refractory nail psoriasis. Even though the current literature has shown some support for the pathogenesis, clinical presentation, or therapies of nail psoriasis, systemic review of this multifaceted disease is still rare to date. We elaborate recent developments in nail psoriasis epidemiology, pathogenesis, anatomy, clinical manifestation, diagnosis, differential diagnosis, and therapies to raise better awareness of the complexity of nail psoriasis and the need for early diagnosis or intervention.

Pulsed-dye Laser Versus Intralesional Steroid in the Management of Nail Psoriasis: A Randomized, Intra-patient, Comparative, Controlled Study

BACKGROUND

Intralesional injection of corticosteroid (ILIS) and pulsed-dye laser (PDL) have been used in nail psoriasis treatment with variable outcomes.

OBJECTIVE

We sought to compare the efficacy of ILIS to PDL for the treatment of psoriatic fingernails using a dermoscope in the assessment and follow-up.

METHODS

This study included 30 patients with bilateral nail psoriasis. The fingernails of one hand were treated with PDL, whereas ILIS was used to treat the fingernails of the other hand. One psoriatic nail was left alone as a control. Every patient received four treatment sessions once every month. Efficacy was recorded clinically using the Nail Psoriasis Severity Index (NAPSI) and by a dermoscope before treatment (baseline) and at eight, 24, and 36 weeks after treatment.

RESULTS

The assessment by NAPSI revealed improvements of 22.24% and 24.11% occurred in the laser group and the intralesional steroid group, respectively. Also, the dermoscopic assessments revealed an improvement of 18.33% in the laser group versus that of 21.69% in the ILES. No significant difference was found between the two groups.

CONCLUSION

Both PDL and ILIS are considered safe treatments for nail psoriasis, yielding nearly equal results. The dermoscope is a reliable tool for the diagnosis and follow-up of nail psoriasis treatment.

Dermoscopic features of nail psoriasis: Positive correlation with the severity of psoriasis

Dermoscopy is an efficient and non-invasive technique which has been widely used in the diagnosis of nail disorders including nail psoriasis (NP). Many nail dermoscopic features are considered as clues to NP. The aim of this study was to investigate specific dermoscopic features of fingernail psoriasis and the correlation between the severity of nail lesions or systemic inflammation, and psoriasis severity of skin and nail. This observational study recruited 135 patients with fingernail psoriasis (1186 fingernails) and 30 patients with onychomycosis (80 fingernails). All of the involved fingernails were examined with a handheld dermatoscope. The Nail Psoriasis Severity Index score (NAPSI) score, Psoriasis Area and Severity Index (PASI) score, body surface area (BSA), and detailed history of patients with psoriasis were recorded. Mann-Whitney U-test, χ² -test, Spearman's correlation, and Kruskal-Wallis H-test were used for statistical analysis, and the significance threshold was p < 0.05. The trial registration number was 2020-SR-045. We identified onycholysis as the most common feature (93.3%) of fingernail psoriasis. Red lunula, longitudinal fissures, transverse grooves, nail plate crumbling, trachyonychia, oil-dropping sign, erythematous border of an onycholytic area, subungual hyperkeratosis, and dilated streaky capillaries were relevant to NP severity (p < 0.05). Red lunula, transverse grooves, nail plate crumbling, trachyonychia, oil-dropping sign, erythematous border of an onycholytic area, splinter hemorrhages, and dilated streaky capillaries were relevant to systemic inflammation severity (p < 0.05). The total NAPSI score was positively associated with the PASI score and BSA (p < 0.0001). The thumb had a higher NAPSI score than the other fingers (p < 0.05). In conclusion, dermoscopic features can improve the accuracy of diagnosis of nail psoriasis, and have correlations with psoriasis severity.

Nail Psoriasis: Diagnosis, Assessment, Treatment Options, and Unmet Clinical Needs

OBJECTIVE

An estimated 40-50% of patients with psoriasis (PsO) have psoriatic nail disease, which is associated with and directly contributes to a greater clinical burden and worse quality of life in these patients. In this review, we examine how recent advances in the use of new diagnostic techniques have led to improved understanding of the link between nail and musculoskeletal manifestations of psoriatic disease (PsD; e.g., enthesitis, arthritis) and we review targeted therapies for nail PsO (NP).

METHODS

We performed a literature search to identify which systemic therapies approved for the treatment of PsO and/or psoriatic arthritis (PsA) have been evaluated for the treatment of NP, either as a primary or secondary outcome. A total of 1546 articles were identified on February18, 2019, and evaluated for relevance.

RESULTS

We included findings from 66 articles on systemic therapies for the treatment of NP in PsD. With several scoring systems available for the evaluation of psoriatic nail disease, including varied subtypes and application of the Nail Psoriasis Area Severity Index, there was a high level of methodological heterogeneity across studies.

CONCLUSION

NP is an important predictor of enthesitis, which is associated with the early stages of PsA; therefore, it is important for rheumatologists and dermatologists to accurately diagnose and treat NP to prevent nail damage and potentially delay the onset and progression of joint disease. Further research is needed to address the lack of both standardized NP scoring systems and well-defined treatment guidelines to improve management of PsD.

Dermoscopy of Onycholysis Due to Nail Psoriasis, Onychomycosis and Trauma: A Cross Sectional Study in Skin of Color

Background:

Clinical differentiation of onycholysis due to various etiologies is difficult task that compels to do invasive investigations to arrive at accurate diagnosis. Wrong diagnosis often leads to treatment failure and physicians and patient's anxiety. Dermoscopic patterns in nail psoriasis, onychomycosis are well established. Here, authors attempted to describe dermoscopic patterns in onycholysis due to psoriasis, onychomycosis and trauma in skin of color.

Methodology:

Study was conducted in a tertiary hospital in Southern India. Ethical clearance and informed consent from patients was obtained. Sixty consecutive patients who attended dermatology outpatient department with onycholysis were included in the study. Nail potassium hydroxide (KOH) study was done in all the cases. Onychoscopy was done with DermLite 3 with ultrasound gel as interface medium.

Results:

Totally 60 patients (42 males; 18 females) with onycholysis were included. Mean age was 37 years (range; 6-68 years). KOH was positive in 22 (36.6%) cases. Onychoscopy showed proximal erythematous rim, red dots, splinter hemorrhages in 23(65.71), 26 (74.28) and 21(60) in nail psoriasis respectively. Spiked and jagged-edges, aurora borealis and ruins pattern (65%) suggestive of onychomycosis were seen in 18(90%), 17 (85%) and 13 (65%) patients respectively. Plain edges without erythema or spikes were noted in 5 (8.33%) in traumatic onycholysis group.

Conclusion:

Onychoscopy is a non- invasive modality to diagnose psoriasis, onychomycosis and traumatic involvement of nail apparatus by demonstrating characteristic patterns. Hence, it also plays an important role in effective management of such cases.

Uncovering subtle nail involvement in lichen planus with dermoscopy: a prospective, controlled study

Introduction

There are very few studies investigating the dermoscopic aspect of nail involvement in lichen planus and these studies described dermoscopic features of only clinically visible nail involvement in lichen planus.

Aim

To reveal subtle dermoscopic nail findings in patients with lichen planus.

Material and methods

The study included 40 patients with lichen planus and 40 healthy volunteers. All fingernails of the patients and healthy volunteers were examined by a handheld dermoscope and the findings detected were recorded. The patients were grouped by age, gender, disease duration and extent of the disease. The statistical analysis was performed using Chi square test.

Results

82.5% of the patients and 17.5% of the healthy volunteers showed at least one dermoscopic nail finding. The frequency of multiple splinter haemorrhage (p < 0.05), multiple leukonychia (p < 0.05), longitudinal erythronychia (p < 0.05), prominent hyponychial vascular structures (p < 0.05) and onycholysis (p < 0.05) observed in the patients group was statistically significant. The other findings included distal short longitudinal lines, onychorrhexis, solitary splinter haemorrhage and solitary punctate leukonychia and showed no statistically significant differences between the two groups.

Conclusions

To the best of our knowledge, this is the first study focusing on uncovering subtle nail involvement in lichen planus. The presence of dilated hyponychial vascular structures in lichen planus was first described in the present study. It can be concluded that the frequency of nail involvement in lichen planus is more than known. Dermoscopic imaging of the nails of all patients with lichen planus may help establish early diagnosis and treatment to avoid permanent nail damage.

Inflammatory nail conditions. Part 1: nail changes in psoriasis

Nail changes are visible in a variety of inflammatory dermatoses. The commonest dermatological condition with nail manifestations is chronic plaque psoriasis. This two-part article reviews the nail signs in psoriasis in Part 1, and the nail changes in cutaneous lichen planus and alopecia areata in Part 2. It provides a brief summary of the salient points in the clinical features, management and prognosis of these entities, with practical recommendations that may be beneficial to all dermatologists.

Dermoscopic Features of Nail Psoriasis: An Observational, Analytical Study

Introduction

Nail involvement in psoriasis occurs in up to 30-50% of patients, and 5-10% may have isolated nail disease. Onychoscopy, a noninvasive tool, might obviate the need for nail biopsy, which is a diagnostic gold standard.

Objective

The aim of this study was to evaluate onychoscopic features of nail unit in patients with nail psoriasis.

Methods

Fifty-five patients with clinically diagnosed and histologically documented nail psoriasis were recruited. Onychoscopy was performed for each nail (excluding the 5th toenail). Clinically, 443/550 fingernails and 101/440 toenails were involved. The frequency distributions of various onychoscopic features was assessed and compared using the χ² test (p value <0.05 was considered significant).

Results

With onychoscopy, additional 52 fingernails and 64 toenails showed psoriatic involvement. Pitting was the commonest finding in fingernails (60.5%) followed by subungual hyperkeratosis (SUH) (52.8%), onycholysis (40.8%), and dotted capillaries in hyponychium, proximal, and lateral nail folds (38.6 vs. 35.8 vs. 35.8%). In toenails, we observed SUH (85.1%), nail plate thickening (82.1%), onycholysis (77.2%), and dotted capillaries in hyponychium and nail folds (59.4 vs. 53.4 vs. 45.5%). Fuzzy lunula was a novel onychoscopic finding noted in 33.6% fingernails and 4.95% toenails (p < 0.00001).

Limitations

Small sample size.

Conclusions

Onychoscopy may aid in diagnosing nail lesions even before the clinical signs are apparent.

Comparative Study of Clinical and Dermoscopic Features in Nail Psoriasis

BACKGROUND AIMS AND OBJECTIVES

Nail changes have been reported in approximately 40% of psoriasis patients. Occasionally nail psoriasis may be the sole finding or the first presentation of the disease. Assessment of the nail changes associated with psoriasis can be done clinically, ultrasonographically, and most recently using a dermoscope. The aim of this study is to assess the dermoscopic features in nails of psoriasis as well as to compare the dermoscopic with the clinical findings. This study has also assessed the correlation between disease duration and the severity of skin and nail involvement.

MATERIALS AND METHODS

A total of 50 patients with psoriatic nail changes were recruited in the study. The psoriasis area severity index (PASI) was used to assess the severity of the disease. The nail psoriasis severity index (NAPSI) was used to determine the severity of nail involvement. The patient's nails were examined both clinically and dermoscopically.

RESULTS

Pitting was the commonest feature (84%) noted both clinically and dermoscopically. A statistically significant higher NAPSI score (P < 0.05) was obtained by a dermoscope than by clinical examination. Salmon patch and splinter hemorrhage were better visualized using a dermoscope than by clinical evaluation (P < 0.05). The duration of the disease had a strong positive correlation (R = 0.901) with the duration of nail involvement whereas there was a weak correlation between the duration of the disease and the clinical NAPSI (R = 0.23) and dermoscopic NAPSI (R = 0.28). A weak positive correlation (R = 0.3) was noted between the PASI and NAPSI scores.

CONCLUSION

Dermoscopy of nails proved to be an efficient, supportive, easy, noninvasive method that provides a better insight into the subtle nail changes in psoriatic patients, which may have been missed clinically.

Efficacy of long-pulsed Nd-YAG laser in the treatment of nail psoriasis: a clinical and dermoscopic evaluation

BACKGROUND

Nail psoriasis (NP) is frequently seen in psoriatic patients. It is difficult to treat and shows unsatisfactory response to topical preparations. Recently, different types of Lasers have been shown to be effective in some nail disorders.

AIM

The aim was to evaluate the efficacy and safety of long-pulsed Nd: YAG laser 1,064 nm as a method for NP treatment.

METHODS

A prospective intra-patient left-to-right, randomized, placebo-controlled study conducted on 22 patients with bilateral fingernail psoriasis, randomly assigned into right or left-side therapy with either four sessions of long-pulsed Nd:YAG laser once monthly or daily topical placebo for 4 months, followed by 3 months follow-up. Evaluation was done using NP severity index at baseline, second month, fourth month and after follow-up period. Clinical and dermoscopic photographs were taken both at baseline and at 4th month.

RESULTS

There was a statistically significant improvement in both NP severity index and dermoscopic features in laser side, along with significant difference between laser and placebo side. Nail bed showed obvious improvement than nail matrix.

CONCLUSION

Nd:YAG laser represents an effective and safe modality for NP treatment and dermoscopy is a useful tool for treatment efficacy assessment.

Comparing the Efficacy of Triamcinolone Acetonide Iontophoresis versus Topical Calcipotriol/Betamethasone Dipropionate in Treating Nail Psoriasis: A Bilateral Controlled Clinical Trial

Background and Objective

Psoriasis is a common chronic inflammatory skin disorder affecting any age and gender. The clinical presentation of the nail disease depends on the location of the pathology: nail bed or nail matrix. We aimed to compare the therapeutic effects of triamcinolone acetonide iontophoresis (TI) and topical calcipotriol/betamethasone dipropionate in the nail bed and nail matrix involvements of psoriasis using Nail Psoriasis Severity Index (NAPSI).

Materials and Methods

In the present bilateral comparison clinical trial, sixteen patients with clinical diagnosis of nail psoriasis were enrolled and randomized to receive six monthly TI treatment sessions either on their right or on the left hand target nails and daily application of topical calcipotriol/betamethasone dipropionate for six months on their other hand. Clinical efficacy was evaluated according to target nails NAPSI before and after the treatment. Wilcoxon sign-rank test and repeated measures ANOVA were used to compare the efficacy of the treatments.

Results

The results did not show any difference between the therapeutic effects of TI and topical calcipotriol/betamethasone dipropionate regarding the nail bed score (P value =  .356), matrix score (P value =  .137), and total NAPSI (P-value =  .098).

Conclusion

Monthly TI has an equal efficacy compared to daily topical calcipotriol/betamethasone dipropionate. It can be used as a safe, easy, and compliant treatment for nail psoriasis. This study is registered under IRCT2017050233778N1.

Alternative uses of dermoscopy in daily clinical practice: An update

Dermoscopy is a noninvasive diagnostic tool that is currently being used for neoplastic skin lesions, several inflammatory and infectious diseases, and skin appendage disorders. As the clinical applications of dermoscopy beyond pigmented lesions are constantly increasing, the aim of this article is to provide an update on this topic. This comprehensive review substantiates how several diseases may show peculiar dermoscopy features so as to enhance the diagnosis and avoid (in selected cases) unnecessary histologic confirmation. In other cases, dermoscopy features may be shared with other conditions, with the advantage of narrowing down the differential diagnosis by ruling out those dermatoses with similar clinical aspect but different dermoscopic presentation.

Dermoscopy as a first step in the diagnosis of onychomycosis

Introduction

Over the years, clinical studies have provided new knowledge about the dermoscopic features of the diseases of cutaneous annexes. It seems that dermoscopy has opened a new morphological dimension in the diagnosis and management of hair disorders and onychopathies.

Aim

To identify and describe dermoscopic features of onychomycosis.

Material and methods

A total of 81 consecutive patients with onychomycosis (55 men and 26 women) were prospectively enrolled in the present study. For each patient, all fingernails and toenails were evaluated in clinical and dermoscopic examinations. Mycological tests were performed by potassium hydroxide (KOH) preparation. Mann-Whitney U and χ² tests were used for the statistical analysis, with a significance threshold of p < 0.05.

Results

Dermoscopic examination of the patients' nails revealed the following: jagged proximal edge with spikes of the onycholytic area (51.9%), longitudinal streaks and patches (44.4%), subungual hyperkeratosis (27.2%), brown-black pigmentation (9.9%) and leukonychia (1.2%). Jagged proximal edge, subungual hyperkeratosis and leukonychia were positively associated with the onychomycosis type.

Conclusions

Onychomycosis accounts for up to 50% of all consultations for onychopathies. Fast and effective diagnostic approaches are needed in everyday clinical practice. Dermoscopy can provide immediate and accurate information in the diagnosis of onychomycosis. We suggest that dermoscopy should be taken as a first step toward the diagnosis of onychomycosis.