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Scalp and nail involvement


is an objective and a reproducible tool for estimating the severity of psoriatic nail involvement. However, NAPSI is mainly used to measure the efficacy of various therapeutic interventions because its use is long and tedious.


(NAPSI), initially described by Rich and Scher,11


Treatment


“Nail psoriasis is considered a precursor of an inflammatory joint disorder, and there is a positive association between nail psoriasis and the severity of joint involvement”


effects of treatments of scalp psoriasis show an improvement of QoL, that is evaluated by general scales or scales dedicated to dermatology. Nonetheless, a specific scale has been designed: Scalpdex.6


This 23-item instrument


explores symptoms, functioning and emotions. It has good reliability, responsiveness, and validity and was shown to be more discriminant than Skindex. A specific scale for children is derived from Scalpdex. This 22-item questionnaire, Children’s Scalpdex in Psoriasis (CSP), demonstrated similar qualities in 6–18-year-old patients.7 A recent study on 3426 patients with


showed that these patients indicated that their most bothersome signs or symptoms were itching (43%), scales (23%), and flaking (20%). The impairment of scalp psoriasis on QoL is easily understandable, with daily visible scaling, sometimes visible lesions, itching and other unpleasant sensations, possible hair loss and the use of topical treatments for decades. The mean severity of itch in patients with scalp psoriasis is around 5/10 and itch is declared by 64–97% of these patients.9


psoriasis8 Consequences are 16 frequently impaired emotional www.hospitalpharmacyeurope.com


functioning, a negative body and self-image, limitations in daily activities, social contacts and work.


Nail psoriasis


Nail involvement is an extremely common feature of psoriasis and affects approximately 10–80% of psoriasis patients, with 5–10% of patients having isolated nail psoriasis.10


The high


variability of the measurement of incidences is due to the high variability of clinical manifestations. Pitting is the most common manifestation of nail psoriasis but is not so specific of psoriasis. Other clinical manifestations are transverse grooves, nail plate thickening and crumbling, leukonychia, oil spot or salmon patches, onycholysis (separation of nail plate from nail bed), subungual hyperkeratosis and splinter haemorrhages. More rarely, acropustulosis, subacute or chronic paronychia and psoriatic


onychopachydermoperiostitis can be observed. Pain is frequently reported but it is difficult to ascribe it to the nail involvement or to the underlying (clinical or infra-clinical) enthesis involvement. The Nail Psoriasis Severity Index


The topical treatment of nail psoriasis is tedious and poorly effective, mainly because of a poor drug delivery and the slow rate of nail growth. General measures can be: protection of nails from all traumatic factors, good hygiene, use of cosmetic camouflage and avoiding aggressive manicure. Topical therapy can be used against the nail matrix involvement: intralesional steroids; tazarotene; or topical potent steroids. In cases of involvement of the nail bed, the combination of calcipotriol and steroids, as well as tazarotene or cyclosporin, can be used. As penetration of UVB is rather superficial, targeted UVB therapy may not be an appropriate option for


palmoplantar lesions or nail psoriasis, but photochemotherapy (PUVA: psoralens + UVA) appears to be successful in the treatment of psoriasis arising in the nail bed. There is a need of systemic treatment when many nails are affected by the disease or in case of an associated moderate to severe generalised psoriasis or PsA. Hence, the prescription of systemic methotrexate, cyclosporin or retinoids is frequent and biotherapies are increasingly proposed.


Associated PsA


The nail involvement in psoriasis is frequently associated with an underlying enthesitis, therefore a PsA. Nail psoriasis is considered a precursor of a severe inflammatory joint disorder.10


There is a


positive association between nail psoriasis and the severity of joint involvement.11


Nail psoriasis is also


correlated with enthesitis, polyarticular disease, and unremitting progressive arthritis.12,13


High-resolution magnetic


resonance imaging studies have found that PsA-related distal interphalangeal joint inflammatory reaction is very extensive, and frequently involves the nail matrix and often extends to involve the nail bed.13


This is mainly due to the


attachment of fibres of ligaments and tendons of distal interphalangeal joints close to the matrix.14


The presence of joint or nail symptoms may indicate a severe


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