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Scalp and nail involvement

form of psoriasis, and this will affect how the disease is managed.

Nail involvement was significantly associated with PsA in the meta-analysis2 (odds ratio (OR) 2.92; 95% CI 2.34– 3.64), particularly onycholysis (OR 2.38; 95% CI 1.74–3.26). Moreover, nail psoriasis was also associated with distal interphalangeal joint arthritis. The extent of psoriasis appeared to be associated with PsA in one cohort study14

(≥3 sites:

HR 2.24; 95% CI 1.23-4.08), one case-control study15

(body surface area

>75%: OR 2.52; 95% CI 1.33–4.75) and three cross-sectional studies.2


meta-analysis suggested a trend for an association between high PASI and PsA risk (mean difference 3.39; 95% CI 0.94–5.83). Therefore, psoriasis patients with such clinical features may require a particular attention for early and close detection of PsA during the course of the cutaneous disease.

Evaluating the impact

The cosmetic handicap in nail psoriasis is sometimes so extensive that patients tend to hide their hands and/or feet or shy away from social and business interactions.16

Nail psoriasis engenders both a physical and psychological handicap, leading to significant negative repercussions in QoL.10

The burden of nail

in 1728 patients, which showed that nail psoriasis caused significant cosmetic handicap in 93% of patients, restriction of daily housekeeping and professional activities in 60% of patients, and 52% of patients described pain as a symptom. In 2009, Ortonne et al,17 devised the Nail Psoriasis Quality of Life Scale (NPQ10) to evaluate the impact of nail psoriasis on QoL. The scale correlated well with the Dermatology Life Quality Index (DLQI). A valid and reliable questionnaire consisting of ten questions was prepared with all the questions specifically targeting the impact of nail psoriasis on QoL. The questionnaire was completed by 1309 patients and showed that 86% of patients considered nail psoriasis as bothersome, 87% as unsightly, and 59% as painful. Such an impact of nail psoriasis definitely warrants an insight into its clinical manifestations and treatment options by a present day dermatologist. In contrast to scalp psoriasis, some recent studies have been performed about the impairment of QoL in patients

psoriasis on its sufferers can be seen from the results of a study carried out de Jong et al,16

suffering from nail psoriasis. A cross- sectional observational study using validated questionnaires concerning QoL (SF-36, modified onychomycosis questionnaire) was performed in 49 patients with fingernail psoriasis.18


mean SF-36 scores for fingernail psoriasis patients were comparable to the mean scores of the Dutch reference population. However, mean scores on the modified onychomycosis QoL questionnaire for all domains were reduced. Localisation, gender and duration of nail psoriasis influenced the impact of nail psoriasis on patients’ QoL. In another study,19

a self-administered

questionnaire was distributed to all members (n=5400) of the Dutch Psoriasis Association. The DLQI and the NPQ10 score were included as QoL measures. Severity of cutaneous lesions was determined using the self- administered psoriasis area and severity index (SAPASI). Patients with nail psoriasis scored significantly higher mean scores on the DLQI (4.9 versus 3.7; p≤0.001) and showed more severe psoriasis (SAPASI, 6.6 versus 5.3; p≤0.001). Patients with coexistence of nail bed and nail matrix features showed higher DLQI scores compared with patients with involvement of one of the two localisations exclusively (5.3 versus 4.2 versus 4.3; p=0.003). Patients with only nail bed alterations scored significant higher NPQ10 scores compared with patients with only nail matrix features. Patients with PsA and nail psoriasis experience more impairments compared with nail psoriasis patients without PsA (DLQI 5.5 versus 4.3; NPQ10 13.3 versus 7.0). Females scored higher mean scores on all QoL scores. Hence, fingernail psoriasis can interfere with patients’ social, mental and physical wellbeing but there is a need for questionnaires specific for the burden of nail disease to measure it. l


The involvement of scalp and nails by psoriasis deeply alters the quality of life and is predictive of a PsA.

References 1. De Korte J et al. Quality of life in patients with psoriasis: A systematic literature review. J Investig Dermatol Symp Proc 2004;9:140–7.

2. Rouzaud M et al. Is there a psoriasis skin phenotype associated with psoriatic arthritis? Systematic literature review. J Eur Acad Dermatol

Venereol 2014;28 (suppl.5):17–26.

3. Wilson FC et al. Incidence and clinical predictors of psoriatic arthritis in patients with psoriasis: a population-based study. Arthritis Rheum 2009;61:233–9.

4. Yang Q et al. Prevalence and characteristics of psoriatic arthritis in Chinese patients with psoriasis. J Eur Acad Dermatol Venereol 2011;25:1409–14.

5. Zanolli MD, Wikle JS. Joint complaints in psoriasis patients. Int J Dermatol 1992;31:488–91.

6. Chen SC, Yeung J, Chren MM. Scalpdex: a quality-of-life instrument for scalp dermatitis. Arch Dermatol 2002;138:803–7.

7. Oostven AM et al. Reliability, responsiveness and validity of Scalpdex in children with scalp psoriasis: the Dutch study. Acta Derm Venereol 2014;94:198–202.

8. Lebwohl MG et al. Patient perspectives in the management of psoriasis: results from the population-based Multinational Assessment of Psoriasis and Psoriatic Arthritis Survey. J Am Acad Dermatol 2014;70 871–81.

9. Reich A, Szepietowski JC. Clinical aspects of itch: Psoriasis. In: Carstens E, Akiyama T (eds). Itch: Mechanisms and Treatment. Boca Raton (FL): CRC Press;2014.

10. Dogra A, Arora AK. Nail psoriasis: the journey so far. Indian J Dermatol 2014;59:319–33.

11. Rich P, Scher RK. Nail psoriasis severity index: A useful tool for evaluation of nail psoriasis. J Am Acad Dermatol 2003;49:206–12.

12. Scarpa R et al. Nail and distal interphalangeal joint in psoriatic arthritis. J Rheumatol 2006;33:1315–19.

13. Tan AL et al. The relationship between the extensor tendon enthesis and the nail in distal interphalangeal joint disease in psoriatic arthritis: A high-resolution MRI and histological study. Rheumatology (Oxford) 2007;46:253–6.

14. Wilson FC et al. Incidence and clinical predictors of psoriatic arthritis in patients with psoriasis: a population-based study. Arthritis Rheum 2009;61:233–9.

15. Thumboo J et al. Risk factors for the development of psoriatic arthritis: a population based nested case control study. J Rheumatol 2002;29:757–62.

16. de Jong EM et al. Psoriasis of the nails associated with disability in a large number of patients: Results of a recent interview with 1728 patients. Dermatology 1996;193:300–3.

17. Ortonne JP et al. Development and validation of nail psoriasis quality of life scale (NPQ10). J Eur Acad Dermatol Venereol. 2010;24:22–7.

18. Van der Velden HM et al. The impact of fingernail psoriasis on patients’ health-related and disease-specific quality of life. Dermatology 2014; Aug 27 [Epub ahead of print].

19. Klaassen KM, van de Kerkhof PC, Pasch MC. Nail psoriasis, the unknown burden of disease. J Eur Acad Dermatol Venereol 2014; Jan 15 [Epub ahead of print].


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