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

Objective An estimated 40%–50% of patients with psoriasis 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 (eg, enthesitis, arthritis) and we review targeted therapies for nail psoriasis. Methods We performed a literature search to identify which systemic therapies approved for the treatment of psoriasis and/or psoriatic arthritis (PsA) have been evaluated for the treatment of nail psoriasis, either as a primary or secondary outcome. A total of 1546 articles were identified on February 18, 2019 and evaluated for relevance. Results We included findings from 66 articles on systemic therapies for the treatment of nail psoriasis in psoriatic disease. With several scoring systems available for the evaluation of psoriatic nail disease, including varied subtypes and application of the Nail Psoriasis Severity Index, there was a high level of methodological heterogeneity across studies. Conclusion Nail psoriasis 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 nail psoriasis 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 nail psoriasis scoring systems and well-defined treatment guidelines to improve management of psoriatic disease.

The relationship between the nail and systemic enthesitis in psoriatic arthritis

Objective Psoriatic nail disease is more common in PsA than in isolated skin psoriasis (PsO). The nail is closely integrated to the DIP joint entheses. US data have shown that those patients with nail disease in PsO are more likely to have systemic enthesitis. We examined whether there was a relationship between nail disease, DIP enthesitis and systemic enthesitis in established PsA. Methods Forty-six PsA participants with nail disease underwent US scanning of the nail unit and the DIP entheses along with peripheral entheseal sites according to the Madrid sonographic enthesitis index (MASEI). Results At the finger level, there was a mild to moderate correlation between nail US changes and both clinical nail disease and DIP enthesis changes (DIP US) [Spearman correlation (rS) = 0.30, P < 0.001 and rS = 0.16, P < 0.001, respectively]. At the patient level, there was a moderate correlation between the nail US score and nail psoriasis severity index score and DIP US (rS = 0.33, P = 0.024 and rS = 0.43, P = 0.003, respectively). At the patient level, there was also a positive correlation between a higher nail US score and the active peripheral enthesitis score (MASEI-active) (rS = 0.35, P = 0.018). When power Doppler was part of nail US score, similar results were demonstrated at both the finger and patient levels. Conclusion This study has demonstrated the utility of nail US imaging and the close relationship, on scanning, between the DIP entheses and the nail unit. In PsA, we have seen a correlation between active US changes at the nail and peripheral enthesitis, which requires further analysis. Trial registration ClinicalTrials.gov, https://clinicaltrials.gov, NCT03955861.

P265 Burden of psoriatic nail disease and response to biologic therapy in a PsA cohort

Background Psoriatic nail disease is one of the six disease manifestations of psoriatic arthritis (PsA) in addition to peripheral arthritis, psoriasis, enthesitis, dactylitis and axial disease. Nail pitting is associated with an increased risk of developing PsA and onycholysis is associated with radiographic damage at the distal interphalangeal joints. Quantitative assessment of psoriatic nail disease is rarely performed in clinical practice therefore little is known about the burden of nail disease and effect of treatment in observational cohorts. We set out to quantify the burden of nail disease and response to b/tsDMARD treatment in a secondary care cohort. Methods Data were taken from the Bath PsA cohort. Patients fulfil CASPAR criteria and have clinical and patient reported outcomes at routine clinic follow-up visits. Patients commencing a b/tsDMARD with at least one follow up visit were included for analysis. Nail involvement was assessed using the Bath Nail score; pitting (0-10), onycholysis (0-10), hyperkeratosis (0-10) and severe deformity (0-10). Results 157 of 485 (32%) of the cohort commencing b/tsDMARDS had nail disease at baseline and were included in the analysis. At baseline nail pitting (65%) and onycholysis (57%) were the most frequent nail manifestations followed by hyperkeratosis (14%) and severe nail deformity (7%) (Table 1). At the first follow-up visit (mean duration 20 weeks), 39% of patients achieved clear nails. At the final follow-up visit (mean duration 59 weeks) 56% had clear nails and 44% of patients had residual nail disease with a median (IQR) nail score of 0 (0.0-2.0). Earliest improvements were seen in nail bed manifestations (onycholysis/ hyperkeratosis) whilst improvement in nail matrix features (pitting) occurred later (Table 1) (p < 0.001). Conclusion Psoriatic nail disease affects one third of those commencing b/tsDMARDs in this cohort. Earliest treatment responses are seen in features of psoriatic nail dystrophy that affect the nail distally. At 20 weeks 39% of those with nail disease at baseline achieve clear nails. At one year, 44% of patients have ongoing nail manifestations, but few patients have persistently high nail scores. Disclosures P. Nair None. A. Anthony None. C. Lovell None. E. Korendowych None. C. Cavill None. N. McHugh None. W. Tillett None.

The microvascular and morphostructural changes of nails in psoriatic patients with nail disease; a link between ultrasound and videocapillaroscopy findings in the nailfold

Objective: The objective of this study is to evaluate the link between nail fold vessel resistive index (NVRI) measured by ultrasound (US) and capillary loops diameters measured using nailfold videocapillarascopy (NVC), and to assess the morphological appearance of the nail bed in patients with psoriatic nail disease (PND) as compared with healthy controls (HCs).Material and methods: This study was conducted in patients with PND and HCs. General demographic data were collected and clinical assessments were performed for all subjects. The nail plate thickness (NPT) was measured on gray scale using US. The NVRI was measured using color Doppler (CD) US. The measurements of the apical, arterial, venous limb diameters and morpho-structural changes (tortuous, cross-linked capillaries) were assessed using NVC.Results: Thirty-four patients with PND and 15 HCs were enrolled in this study. The two groups were matched for age and body mass index (BMI). Patients with PND had higher NPT and NVRI in comparison with HCs [(20 (17-23) vs 14 (14-15), p<0.001), (0.55 (0.51-0.61) vs 0.43 (0.38-0.49), p<0.001), respectively]. A higher proportion of patients with PND had tortuous capillaries than HCs (62% and 20% respectively, p=0.005). The mean NVRI was higher in patients with PND who had tortuous capillaries than patients who did not have tortuous capillaries (0.58 (0.7) and 0.52 (0.09), respectively p=0.033).Conclusion: Microvascular changes can be detected easily using non-invasive methods such as US and NVC. These methods can provide an objective data to better assess PND.

Nail manifestations in Hong Kong Chinese patients with psoriatic arthropathy (PsA)

Background Nail psoriasis is accepted as a common feature in psoriatic arthropathy (PsA) and is one of the diagnostic criteria for PsA. Several nail characteristics are allegedly associated with joint damage, however, information concerning their prevalence and features is extremely lacking, particularly in Hong Kong. Objective The primary objective of the study was to investigate the frequency of psoriatic nail disease and to understand their patterns. The secondary objective was to explore the associated factor for nail dystrophy among them. Methods This study was a cross-sectional observation study. The eligible PsA patients were recruited from Rheumatology Clinic of Tseung Kwan O Hospital. Their demographics and clinical characteristics were collected, their respective nail psoriasis were scored and the nail features were recorded. By comparing the clinical variables between PsA patients, with and without nail involvement, the associated factor was explored. Results A total of 106 PsA patients were recruited and 61.3% (65/106) of them had nail psoriasis. Among all the patients with nail involvement, 72.3% of them had pitting, 50.8% had onycholysis, 15.7 had crumbling, 6.9% had leukonychia and 3.9% suffered from nail-bed hyperkeratosis, with mean modified Nail Psoriasis Severity Index of 9.5 +/-15.3. Nail involvement was more common in those with severe skin extent, but neither related to psoriatic disease duration, arthritis subclasses, nor inflammatory markers. Conclusion A significant proportion of PsA patients had nail involvement and there were various nail features noted. The occurrence of psoriatic nail disease was found to be associated with severe skin problem. This common manifestation of PsA should not be overlooked in the rheumatologists’ daily practice, in view of its common prevalence.