Treatment with intralesional methotrexate injection in a patient with nail psoriasis

Psoriasis vulgaris is an inflammatory skin disease involving the skin, nails, and joints. While nail involvement is observed in 70–80% of patients with psoriasis, the rate of patients with isolated nail involvement is 5–10%. Dystrophies arising in the nails in psoriasis affect the patient’s quality of life, and local and systemic therapies may be used as treatment. Intralesional methotrexate or corticosteroid injection might be an option in the treatment of patients with the involvement of one nail or some nails or without the involvement of the skin and joints, due to the side effects of systemic and biological agents. Herein, we report a female patient with nail psoriasis resistant to a previously applied topical treatment, the efficacy of intralesional methotrexate without the use of a systemic antipsoriatic agent, and no progression of side effects.

Nail disease in psoriatic arthritis. Data from the Russian Psoriatic Arthritis Registry

Objective of the study – to compare, in real clinical practice, according to the data of the Russian Psoriatic Arthritis Registry, characteristics of two groups of psoriatic arthritis (PsA) patients: with and without nail psoriasis.Material and methods. 588 PsA patients (277 males and 311 females) with PsA according to CASPAR criteria were included in the Russian Psoriatic Arthritis Registry. Patients’ age was 48.6±0.5 years, disease duration – 7.0±0.3 years. Patients underwent standard clinical examination of PsA activity. Disease activity measures evaluated in this study included DAPSA (Disease Activity in Psoriatic Arthritis), BASDAI (Bath Ankylosing Spondylitis Disease Activity Index) and ASDAS-СRP (Ankylosing Spondylitis Disease Activity Score). Enthesitis was measured using LEI (Leeds Enthesitis Index) index. Dactylitis was detected, the number of digits with acute dactylitis was defined. Skin lesion severity was evaluated in terms of BSA (Body Surface Area) affected, and PASI (Psoriasis Area Severity Index); PASI was calculated in case BSA > 3%. The criteria of minimal disease activity (MDA) had been used to assess the treatment efficiency. MDA was achieved if a patient met ≥5 of the 7 following categories: tender joint count (TJC) ≤1, swollen joint count (SJC) ≤1, PASI≤1 or BSA≤3%, patient pain VAS ≤15, patient global activity (PGA) VAS ≤20, Health Assessment Questionnaire Disability Index (HAQ) ≤0.5, and tender entheseal points ≤1. Patients were split into two groups: those with nail psoriasis (group 1), and those without nail psoriasis (group 2).Results. 312 (53.1%) patients had nail psoriasis and 276 (46.9%) did not. Patients’ age in group 1 was 45.7±11.9 years, in group 2 – 48.8±13.2 years (р>0.05). PsA duration in groups 1 and 2 did not differ, it was 7.1±6.6 and 7.0±6.2 years respectively (р>0.05). Higher proportions of patients with nail psoriasis were male, disabled from working and chronic smokers compared to patients without nail psoriasis: 51.9% vs 44.1% (р=0.013), 37.20% vs 26.40% (р<0.01) and 18.9% vs 8.7% (р<0.01) respectively. Patients with nail psoriasis had more severe erosive peripheral arthritis compared to patients without nail psoriasis. Median TJC was 8 [4–15] vs 5 [2–12] (р=0.002), SJC – 5 [1–9] vs 2 [0–7] (р=0.003), and erosive radiographic arthritis of feet was found in 45.0% vs 31.2% of patients (р=0.003) respectively. Group 1 patients had higher disease activity measured by DAPSA – 25 [15–39] vs 20 [12–33] (p=0.001) and ASDAS-CRP – 3.1 [2.2–4.0] vs 2.8 [1.8–3.5] (р=0.004), compared to group 2 patients. Patients with nail psoriasis had higher frequency of heel enthesitis and dactylitis; axial disease was diagnosed more often among them, compared to patients without nail psoriasis. Heel enthesitis was detected in 53 (17.0%) vs 28 (10.1%; р=0.016), dactylitis – in 76 (24.4%) vs 46 (16.7%; р=0.022), spondylitis – in 109 (35.0%) vs 73 (26.4%; р=0.025) patients respectively. Patients in group 1 had worse skin psoriasis than in group 2. Patients with nail psoriasis significantly more often had moderate and severe skin psoriasis according to BSA, compared to patients without nail psoriasis (39.9% vs 26.1% and 14.8 vs 1.1% respectively; р<0.01 for both comparisons); group 2 patients significantly more often had limited skin psoriasis compared to group 1 patients – in 72.8% vs 45.3% of cases respectively (р<0.01). Median PASI index in groups 1 and 2 was 6 [2–14] vs 3 [1–6] respectively (р<0.01). Group 1 patients gave worse assessment of their disease than group 2 patients; median PGA was 50 [40–70] mm vs 50 [30–65] mm VAS respectively (р=0.044). Less patients with nail psoriasis compared to patients without nail psoriasis had achieved MDA throughout the whole study. At the first visit MDA was detected in 3% vs 9% (р=0.006) of patients, at the second – in 12% vs 27% (р<0.001), at the third – in 14% vs 28% (р=0.011), at the fourth – in 17% vs 38% (р<0.001) and at the fifth in 27% vs 52% (р=0.004) of patients respectively. Patients with and without nail psoriasis were given equivalent therapy with diseasemodifying antirheumatic drugs (DMARDs) and biological agents (bDMARDs). DMARDs were given to 78.2% and 80.1% of patients respectively (р>0.05), it was mostly methotrexate (MTX); MTX was used in 66.0% and 64.1% of cases respectively (р>0.05). bDMARDs were prescribed to 22.1% and 28.3% (р>0.05) of patients, including tumour necrosis factor (TNF) inhibitors – in 67% and 63% of cases, interleukin (IL) inhibitors – in 33% and 37% of cases (р>0.05 for both comparisons). Taking into account the similar disease duration and equivalent therapy in both groups, it could be concluded that patients with nail psoriasis achieved MDA less frequently due to greater disease severity.Conclusion. Nail involvement is identified in more than half (53%) of PsA patients of the Russian Psoriatic Arthritis Registry. Nail psoriasis is associated with significantly worse disease status as measured by severe peripheral arthritis, enthesitis, dactylitis, spondylitis and skin lesions; higher frequency of erosive arthritis was detected in this category of patients. Patients with nail psoriasis had achieved MDA less frequently compared to patients without nail psoriasis. Nail involvement is associated with worse response to therapy and patients’ disability. These data emphasize the importance of accurate diagnostics of nail psoriasis and optimization of treatment approach, including “targeted” therapy.

A Single Nail Dystrophy as a Unique Manifestation of Sarcoidosis: A Case Report

Sarcoidosis with nail involvement is rare and most commonly affecting plural digits. Nail changes are frequently an indication of systemic disease and underlying bone involvement, thus complete clinical evaluation with bone and thorax radiological examination is a necessity in suspected cases. We report a case of onychodystrophy with osseous involvement of only one finger as unique manifestation of sarcoidosis, which is very rare.

POS1072 ASSOCIATION OF NAIL PSORIASIS WITH WORSE DISEASE OUTCOMES IN PSORIATIC ARTHRITIS PATIENTS. DATA FROM CLINICAL PRACTICE

Background:Limited data are available regarding the burden of nail disease in psoriatic arthritis (PsA). The latest data show that nail involvement in PsA patients (pts) is associated with significantly more severe disease status (1).Objectives:To analyze, in clinical practice, the association of nail psoriasis with disease activity, quality of life, and work productivity in PsA pts.Methods:588 pts (M/F–277 /311) with PsA according to CASPAR criteria were included in the study. Data were collected from 43 rheumatology clinics from different regions of the Russian Federation. Pts’ age 48.6±0.5 years (yrs), disease duration 7.0±0.3 yrs. Pts underwent standard clinical examination of PsA activity. Pts were split into two groups (gr.): those with nail psoriasis – gr.1, and those without it – gr.2. Demographics, disease activity, quality of life, and work productivity were compared between pts with and without nail psoriasis using Pearson’s chi-square test and Mann–Whitney U test.Results:Gr.1 includes 312 (53.1%) cases, gr.2 – 276 (46.9%) cases. More pts in gr.1 were males (51.9% vs 44.1%, р=0.013), disabled at work (37.20% vs 26.40%, р=0.000), chronic smokers (18.9% vs 8.7%, р=0.000) and with axial PsA disease signs according to physician (35.0% vs 26.4%, р=0.025) compared to pts in gr.2. Pts in gr.1 had higher tender and swollen joint counts: 8 [4-15] vs 5 [2-12] (р=0.002) and 5 [1-9] vs 2 [0-7] (р=0.003) respectively. Gr.1 pts had higher disease activity measured by DAPSA 25 [15-39] vs 20 [12-33] (p= 0.001), higher frequency of dactylitis (24.4% vs 16.7% р=0.022) and heel enthesitis (17.0% vs 10.1% р=0.016) respectively, higher frequency of erosive radiographic arthritis of feet (45.0% vs 31.2% р=0.003) compared to gr.2 pts. Pts in gr.1 had worse skin psoriasis measured by Psoriasis Area Severity Index – 6 [2-14] vs 3 [1-6] (р=0.000). Less pts in gr.1 than in gr.2 (27.0% vs 52.0% р=0.004) achieved minimal disease activity (MDA). Pts’ reported outcomes (PRO’s) in gr.1 were worse than in gr.2 in regard to reduced health-related quality of life according to PsAID (4.9±2.3 vs 4.0±2.3, р=0.040) and to EQ-5D (0.56±0.19 vs 0.64 ±0.21, р=0.024) questionnaires, overall work impairment (0.0 [0.0-0.3] vs 0.0 [0.0-0.2], р=0.034) and overall activity impairment (0.4 [0.1-0.7] vs 0.3 [0.0-0.5], р=0.006) according to WPAI.Conclusion:Nail involvement in PsA pts is associated with male gender and axial disease. PsA pts with nail involvement are more often disabled, more often are chronic smokers, have significantly worse disease status as measured by disease activity; they are more likely to have more severe (erosive) peripheral arthritis of feet, higher frequency of heel enthesitis and dactylitis, higher psoriasis disease severity, lower frequency of MDA achievement, and worse quality of life and work productivity according to PRO’s. Detection of nail involvement is critical for choice of treatment approach and better outcomes.References:[1]Mease PJ et al.J Rheumatol, 2020Disclosure of Interests:None declared.

POS1075 PREDICTIVE FACTORS ASSOCIATED WITH DEVELOPMENT OF PSORIATIC ARTHRITIS IN PATIENTS WITH UNDERLYING PSORIASIS

Background:Psoriatic arthritis (PsA) is a chronic inflammatory condition in which a delayed diagnosis will have health impacts including physical and psychological aspects. Thus, identification of risk factors and early diagnosis are crucial in clinical practice. In Malaysia, 13.7% of patients with underlying psoriasis develop PsA 1. However, there are limited data on the risk factors in developing PsA in these patients, not just in Malaysia but also in the Southeast Asia region.Objectives:To analyse sex, clinical features, comorbidities in patients with psoriasis and PsA, and the predictive factors of developing PsA in patients with underlying psoriasis.Methods:A retrospective study was carried out involving patients with a physician-verified diagnosis of psoriasis who were attending the dermatology and/or rheumatology clinics at the University of Malaya Medical Centre, Kuala Lumpur between 2015 to 2020. Data were retrieved from electronic medical records. Data collected included sex, age, body mass index (BMI), duration of psoriasis, socio-demographics, comorbidities, body area affected, severity of skin involvement, presence of nail involvement and systemic therapy used in treating psoriasis. Systemic therapy is defined as methotrexate, sulfasalazine and/or acitretin used before diagnosis of PsA. Patients with psoriasis who developed PsA had information collected on tender joint count, swollen joint count and erythrocyte sedimentation rate (ESR) at their initial visit to the rheumatologist. Logistic regression analyses were performed to identify the possible risk factors of developing PsA.Results:A total of 330 psoriasis patients which included 54.5% male and a mean age of 53 (standard deviation, SD 18.85) years were included. Eighty-three (25.0%) patients were diagnosed with PsA. Among patients with PsA, 39.8% were males with a mean age of 54 (SD 15.79) years. Majority of the PsA patients were ethnic Malay (45.8%), followed by 28.9% Chinese and 25.3% Indian. The median duration of developing PsA was at 36 (IQR 3.5 - 114) months after the diagnosis of psoriasis. 12.3% presented with active polyarthritis at the initial diagnosis of PsA. There was a significant difference in the use of systemic therapy in females, in which there was a higher rate of systemic therapy used in female PsA patients prior to developing PsA as compared to females with psoriasis who did not develop PsA (n=24, 48% vs n=16, 16%; p < 0.001). There was no significant association between ethnicity, education level, comorbidities, BMI, body area affected and family history of psoriasis with development of PsA. The predictive factors in developing PsA are females (OR = 3.14, 95% CI 1.77,5.58), presence of nail involvement (OR = 3.72, 95% CI 1.91,7.26) and the use of systemic therapy (OR = 3.04, 95% CI 1.70,5.43), (all p values <0.001).Conclusion:This study highlighted that female sex, presence of nail involvement and use of systemic therapy prior to PsA diagnosis are predictive risk factors in developing PsA among patients with underlying psoriasis. Further prospective studies with larger cohorts are needed to better delineate these risk factors.References:[1]Mohd Affandi A, Khan I, Ngah Saaya N. Epidemiology and Clinical Features of Adult Patients with Psoriasis in Malaysia: 10-Year Review from the Malaysian Psoriasis Registry (2007-2016). Dermatology research and practice. 2018;2018:4371471.Figure 1.Comorbidities among Patients with underlying Psoriasis and Psoriatic Arthritis (n=330)Chi-square test revealed that there was no significant difference between psoriasis and psoriatic arthritis (p > 0.05)Disclosure of Interests:WAI YANG LOO: None declared, FARIZ YAHYA Speakers bureau: speaker for Novartis, Gilead, AbbVie, Janssen, Eli Lilly, Zuellig-Pharma and Pfizer., Consultant of: consultancy work with Novartis, Gilead, AbbVie, Eli Lilly, Zuellig-Pharma and Pfizer., Grant/research support from: research grants from Novartis, Gilead, AbbVie, Boehringer-Ingelheim and Pfizer., WINN HUI HAN: None declared, NIK AIMEE AZIZAH FAHEM: None declared, SHIN SHEN YONG: None declared, Lydia Say Lee Pok: None declared, Zhenli Kwan Speakers bureau: Novartis, Zuellig, YING CHEW TEE: None declared.