Psoriatic onychodystrophy

Symptoms

Psoriatic nails are characterized by a translucent discolouration in the nail bed that resembles a drop of oil beneath the nail plate. 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.

Diagnosis

The Nail Psoriasis Severity Index (NAPSI) is a numeric, reproducible, objective, simple tool for evaluation of nail psoriasis. 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". 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.

A 2008 study found that Cannavo's qualitative system correlated with NAPSI (p

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. Treatments include topical, intralesional, radiation, systemic, and combination therapies.

• Tacalcitol ointment obtains a significant improvement in all nail parameters, both of the matrix and of the bed.
• Clobetasol nail lacquer and tacalcitol ointment
• 5-fluorouracil. A reported side-effect is yellow nails
• Calcipotriol
• Calcipotriol plus betamethasone dipropionate ointment.
• Efalizumab
• Infliximab
• Golimumab
• Low dose methotrexate
• Intralesional corticosteroid injection

Relative effectiveness of treatments

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

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

• Infliximab appears to be the most effective treatment for nail psoriasis to date.
• 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.

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

Research

Active clinical trials investigating nail psoriasis:

Phase IV

• Effects of Etanercept.
• Effects of Golimumab.

Phase II

• Dose response and safety of topical Methotrexate.

References

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. (1983). "The "oil drop" sign of psoriatic nails. A clinical finding specific for psoriasis". The American Journal of Dermatopathology.
3. (Nov 2007). "Do fungi play a role in psoriatic nails?". Mycoses.
4. (2003). "Nail Psoriasis Severity Index: A useful tool for evaluation of nail psoriasis". Journal of the American Academy of Dermatology.
5. Parrish, CA. (October 2005). "Modification of the Nail Psoriasis Severity Index". Journal of the American Academy of Dermatology.
6. (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.
7. (2003). "Treatment of Psoriatic Nails with Topical Cyclosporin: A Prospective, Randomized Placebo-Controlled Study". Dermatology.
8. (2007). "The comparison of Nail Psoriasis Severity Index with a less time-consuming qualitative system". Journal of the European Academy of Dermatology and Venereology.
9. (2007). "Psoriasis of the nail: Anatomy, pathology, clinical presentation, and a review of the literature on therapy". Journal of the American Academy of Dermatology.
10. (2009). "Tacalcitol ointment for the treatment of nail psoriasis". Journal of Dermatological Treatment.
11. (2008). "Nail psoriasis: A combined treatment with 8 clobetasol nail lacquer and tacalcitol ointment". Journal of the European Academy of Dermatology and Venereology.
12. (2009). "Yellow nails as an adverse reaction to the topical use of 5-fluorouracil for the treatment of nail psoriasis". Journal of Dermatological Treatment.
13. (2008). "Calcipotriol used as monotherapy or combination therapy with betamethasone dipropionate in the treatment of nail psoriasis". Acta Dermato-Venereologica.
14. (2009). "Treatment of Nail Psoriasis with a Two-Compound Formulation of Calcipotriol plus Betamethasone Dipropionate Ointment". Dermatology.
15. (2008). "Treatment of nail psoriasis with efalizumab: A preliminary study". Cutis; Cutaneous Medicine for the Practitioner.
16. (2008). "Evaluation of the efficacy and safety of infliximab on psoriatic nails: An unblinded, nonrandomized, open-label study". British Journal of Dermatology.
17. {{ClinicalTrialsGov. NCT00265096. A Study of the Safety and Efficacy of Golimumab in Patients With Active Psoriatic Arthritis (GO-REVEAL)
18. (November 2009). "Severe 20-nail psoriasis successfully treated by low dose methotrexate". Dermatology Online Journal.
19. (2008). "Treatment of nail psoriasis with a modified regimen of steroid injections". Journal of the College of Physicians and Surgeons Pakistan.
20. (2009). "Interventions for nail psoriasis". Protocols.
21. (2009). "Nail psoriasis and biologics". [[Journal of Cutaneous Medicine and Surgery]].
22. (2013-01-31). "Interventions for nail psoriasis". Cochrane Database of Systematic Reviews.
23. [http://clinicaltrials.gov/ct/search?term=nail+psoriasis&submit=Search clinicaltrials.gov]
24. {{ClinicalTrialsGov. NCT00581100. Effects of Etanercept on Nail Psoriasis and Plaque Psoriasis
25. {{ClinicalTrialsGov. NCT00666354. Dose Response and Safety Study of Topical Methotrexate for the Treatment of Fingernail Psoriasis