The Impact of Nail Psoriasis and Treatment on Quality of Life: A Systematic Review

Nails in older adults

As the world's population of adults greater than 60 years old continues to increase, it is important to manage nail disorders that may impact their daily lives. Nail disorders may have significant impact on quality of life due to decreased functionality, extreme pain, or social embarrassment. In this review, we discuss nail disorders affecting older patients, including physiologic, traumatic, drug-induced, infectious, environmental, inflammatory, and neoplastic conditions. Diagnosis of these conditions involves a detailed history, physical examination of all 20 nails, and depending on the condition, a nail clipping or biopsy and/or diagnostic imaging. Nails grow even more slowly in older adults compared to younger individuals, and therefore it is important for accurate diagnosis, and avoidance of inappropriate management and delay of treatment. Increased awareness of nail pathologies may help recognition and management of nail conditions in older adults.

Nail psoriasis and nail lichen planus: Updates on diagnosis and management

BACKGROUND

Inflammatory diseases of the nail, including nail psoriasis and nail lichen planus, are associated with significant disease burden and have a negative impact on quality of life. Diagnosis is often delayed, especially when patients present without cutaneous findings. Therefore, recognizing clinical signs and symptoms of inflammatory nail diseases, and initiating timely and appropriate treatment, is of utmost importance.

OBJECTIVE

We review recent studies on diagnostic techniques, discuss severity grading and scoring systems, and describe consensus treatment recommendations for nail psoriasis and nail lichen planus.

METHODS

An updated literature review was performed using the PubMed database on studies assessing diagnostic techniques or treatment modalities for nail psoriasis and nail lichen planus.

RESULTS

Recent studies on diagnostic techniques for inflammatory nail disease have focused on use of dermoscopy, capillaroscopy, and ultrasound modalities. Treatment of these conditions is dichotomized into involvement of few (≤3) or many (>3) nails. Recent psoriatic therapeutics studied for nail outcomes include brodalumab, tildrakizumab, risankizumab, deucravacitinib, and bimekizumab, while emerging treatments for nail lichen planus include JAK inhibitors and intralesional platelet rich plasma injections.

CONCLUSIONS

We emphasize the need for increased awareness and expanded management strategies for inflammatory nail diseases to improve patient outcomes.

Nail psoriasis in China: A prospective multicentre study

BACKGROUND

Data on nail psoriasis (PsO) in China are scarce.

OBJECTIVES

To provide nail PsO-related data regarding epidemiologic characteristics, manifestations, fungal infections, arthritic complaints and treatments that may facilitate improved patient management globally.

METHODS

From August 2021 to August 2022, patients with nail PsO were enrolled in a prospective multicentre observational study at 25 hospitals in China. We collected and analysed data concerning nail PsO demography, clinical signs, fungal detection, arthritic symptoms and treatment.

RESULTS

A total of 817 patients with nail PsO were involved, with a mean body mass index of 24.13 ± 2.93. In addition, 71.41% of the patients were male. The Nail PsO Severity Index score was weakly positively correlated with body surface area. The percentage of nail involvement was 95.29% for fingernails and 57.18% for toenails, with pitting (67.11%) and subungual hyperkeratosis (60.40%) being the most prevalent manifestations, respectively. Toenails showed a significantly higher frequency of nailfold scales, subungual hyperkeratosis and nail plate crumbling and a lower frequency of splinter haemorrhages, pitting and erythema of the lunula. A total of 13.26% of the PsO patients had onychomycosis, and 77.08% were observed in the toenails. Articular symptoms were reported by 12.17% of the patients, with the peripheral type being predominant. Significant associations between articular symptoms and nailfold swelling, subungual hyperkeratosis, nailfold scales, onycholysis and longitudinal ridges were found. Only 2.30% (20 out of 871) of patients with nail PsO received treatment. The most frequently employed therapy for cutaneous PsO with nail involvement was biologic therapy (n = 366).

CONCLUSIONS

PsO showed distinct manifestations in the toenails and fingernails. Additionally, toenail PsO combined with onychomycosis requires special attention. Articular symptoms in psoriatic patients are associated with specific nail changes. It is important to research and advocate for more potent treatments for nail PsO.

Enthesopathy in patients with nail psoriasis - a cross-sectional evaluation of clinical, onychoscopic and ultrasonographic features

Background Nail involvement in psoriasis is common and may be an indicator not only of disease severity, but also of the presence of psoriatic arthritis. However, the relationship of nail psoriasis with enthesitis remains under-explored. Aims This study was conducted to evaluate the clinical, onychoscopic (nail dermatoscopic) and ultrasonographic features in patients with nail psoriasis. Materials and Methods All nails of twenty adult patients with nail psoriasis were examined clinically and onychoscopically. Patients were evaluated for psoriatic arthritis (Classification Criteria for Psoriatic Arthritis), the severity of cutaneous disease (Psoriasis Area Severity Index) and nail disease (Nail Psoriasis Severity Index). Ultrasonography of the clinically involved digits was performed for evidence of distal interphalangeal joint enthesitis. Results Out of 20 patients, 18 patients had cutaneous psoriasis and 2 had isolated nail involvement. Among the 18 patients with skin psoriasis, 4 had associated psoriatic arthritis. The most commonly observed clinical and onychoscopic features were pitting (31.2% and 42.2%), onycholysis (36% and 36.5%) and subungual hyperkeratosis (30.2% and 30.5%), respectively. Ultrasonographic evidence of distal interphalangeal joint enthesitis was seen in 57% (175/307) of the digits with clinical nail involvement. Enthesitis was more common in patients with psoriatic arthritis (77% vs 50.6%). Nail thickening, crumbling and onychorrhexis (all features of nail matrix involvement) were significantly associated with enthesitis (P < 0.005). Limitation The major limitation was the small sample size and lack of controls. Only the clinically involved digits were evaluated for enthesitis. Conclusion Enthesitis was frequently detected on ultrasonography in patients with nail psoriasis, even in clinically asymptomatic individuals. Nail features of thickening, crumbling and onychorrhexis may predict underlying enthesitis and the potential development of arthritis. A comprehensive evaluation could help identify patients with psoriasis at risk for arthritis, helping improve long-term outcomes.

Australian consensus: Treatment goals for moderate to severe psoriasis in the era of targeted therapies - Adult patients

BACKGROUND

Over the last decade, the treatment landscape for moderate-severe psoriasis has rapidly evolved. The Australasian College of Dermatologists sought to review and update previously published treatment goals for moderate-severe psoriasis.

METHODS

A modified Delphi approach was used. Comprehensive literature review and guideline evaluation resulted in the development of statements and other questions to establish current clinical practices. Two rounds of anonymous voting were undertaken, with a collaborative meeting held in between to discuss areas of discordance. Overall, consensus was defined as achievement of ≥75% agreement in the range 7-9 on a 9-point scale (1 strongly disagree; 9 strongly agree).

RESULTS

Consensus was achieved on 26/29 statements in round 1 and a further 20 statements in round 2. There was strong agreement to expanding the classification/definition of psoriasis severity by including a choice of metrics, incorporating quality of life measures, and widening the scope of high-impact sites. Consensus was also reached on revised treatment response criteria, which were then incorporated into a new treatment algorithm. There was discordance with the current requirement to undertake a trial with established systemic agents before accessing targeted therapy.

CONCLUSION

The ability of new targeted treatment options to change the narrative in psoriasis patient care can only be properly realised if challenges to timely and equitable access are addressed. The proposed framework for the assessment, classification and management of moderate-severe psoriasis aligns with international recommendations. Its adoption into Australian clinical practice is hoped to improve treatment outcomes and patients' satisfaction with their care.

Development and Validation of a Patient-Reported Outcome Measure for Fingernail and Toenail Conditions: The NAIL-Q

Background

Patient-reported outcome measures (PROMs) are needed to measure outcomes that matter to people with nail conditions, from their perspective.

Objective

To design a comprehensive new PROM (NAIL-Q) to measure outcomes important in toenail and fingernail conditions.

Methods

A mixed methods iterative approach was used. Phase 1 involved concept elicitation interviews that were audio-recorded, transcribed, and coded line-by-line. Concepts were developed into scales and refined through cognitive debriefing interviews with patients and expert input. Data was then collected from an international sample using a crowdsource platform. Eligible participants were aged ≥18 years with a nail condition for at least 3 months. Rasch Measurement Theory (RMT) analysis was used to examine item and scale performance. Other psychometric tests included test-retest reliability, and convergent and construct validity.

Results

Phase 1 interviews involved 23 patients with 10 nail conditions and input from 11 dermatologists. The analysis led to the development of 84 items for field-testing. In Phase 2, 555 participants completed the survey. Toenail conditions (n = 441) were more common than fingernail conditions (n = 186). The RMT analysis reduced the number of items tested to 45 in 7 scales measuring nail appearance, health-related quality of life concerns, and treatment outcomes. All items had ordered thresholds and nonsignificant chi-square p values. Reliability statistics with and without extremes for the Person Separation Index were ≥0.79 and Cronbach's alpha were ≥0.83, and for intraclass correlation coefficients were ≥0.81. Construct validity was further supported in that most participants agreed that the NAIL-Q was easy to understand, asked relevant and important questions in a respectful way, and that it should be used to inform clinical care.

Conclusion

The NAIL-Q is a rigorously designed and tested PROM that measures nail appearance, health-related quality of life and treatment outcomes. This PROM can be used in clinical practice to inform patient care and to include the patient perspective in research.

Efficacy and Safety of Nail Psoriasis Targeted Therapies: A Systematic Review

INTRODUCTION

Nail changes are frequent clinical findings in patients with cutaneous psoriasis and psoriatic arthritis, often causing significant impairments in quality of life. Numerous targeted therapies have been previously studied for treatment of nail psoriasis, however, newer agents have not been captured in prior systematic reviews. With over 25 new studies published since 2020, the landscape of nail psoriasis systemic treatments is rapidly evolving, warranting analysis of recently approved therapies.

METHODS

An updated systematic review of all PubMed and OVID database studies assessing efficacy and safety of targeted therapies for nail psoriasis was performed, with the goal of incorporating clinical data of recent trials and newer agents, namely brodalumab, risankizumab, and tildrakizumab. Eligibility criteria included clinical human studies reporting at least one of the nail psoriasis clinical appearance outcomes (Nail Psoriasis Severity Index, modified Nail Psoriasis Severity Index).

RESULTS

A total of 68 studies on 15 nail psoriasis targeted therapeutic agents were included. Biological agents and small molecule inhibitors included TNF-alpha inhibitors (adalimumab, infliximab, etanercept, certolizumab, golimumab), IL-17 inhibitors (ixekizumab, brodalumab, secukinumab), IL-12/23 inhibitors (ustekinumab), IL-23 inhibitors (guselkumab, risankizumab, tildrakizumab), PDE-4 inhibitors (apremilast), and JAK inhibitors (tofacitinib). These agents all demonstrated statistically significant improvements in nail outcome scores, compared with placebo or with baseline values, at weeks 10-16 and weeks 20-26, with some studies assessing efficacy up to week 60. Safety data for these agents were acceptable and consistent with known safety profiles within these timepoints, with nasopharyngitis, upper respiratory tract infections, injection site reactions, headache, and diarrhea being the most reported adverse events. Specifically, the newer agents, brodalumab, risankizumab, and tildrakizumab, showed promising outcomes for treatment of nail psoriasis on the basis of current data.

CONCLUSION

Numerous targeted therapies have shown significant efficacy in improving nail findings in patients with psoriasis and psoriatic arthritis. Data from head-to-head trials have shown greater efficacy of ixekizumab over adalimumab and ustekinumab, as well as brodalumab over ustekinumab, while prior meta-analyses have demonstrated superiority of ixekizumab and tofacitinib to other included agents at various assessed timepoints. Further studies on the long-term efficacy and safety of these agents, as well as randomized controlled trials involving comparison with placebo arms, are needed to fully analyze differences in efficacy of newer agents compared with previously established therapies.

Updates in treatment and impact of nail psoriasis

INTRODUCTION

Nail psoriasis is an inflammatory disorder without a potential scarring outcome, but the nail signs, even the milder ones, can cause discomfort to patients and severely affect their quality of life. Nail psoriasis may be associated with psoriatic arthritis and when it starts during infancy, it may be a predictor of a more severe disease course in adulthood. All these issues contribute to the high economic burden of psoriasis.

AREAS COVERED

Nail psoriasis is notoriously difficult to treat, even though new treatments are in continuous development. This paper provides an update on new treatments and address the current gaps in care of nail psoriasis.

EXPERT OPINION

A better understanding of the disease pathogenesis and more 'real-life' studies will definitely be helpful to improve treatment results. A lower level of heterogeneity should be advisable among trials when evaluating nail psoriasis. Moreover, the relationship between nail psoriasis and psoriatic arthritis should be the focus of unbiased studies in order to better define the real risk that nail psoriasis patients have to develop arthritis.

Brodalumab in the Treatment of Plaque Psoriasis Localized in Difficult-to-Treat Areas: A Narrative Review

INTRODUCTION

Psoriasis is a common chronic, immune-mediated, inflammatory skin disease that in certain localization results difficult to treat. Psoriatic lesions in difficult-to-treat areas might be hardly managed as no standardized therapeutic approach and the application of topical treatments might have great limitations. Systemic agents, including biologic therapies, have been proven effective in treating this subgroup of patients. In particular, current evidence has shown beneficial effects with the use of brodalumab, a fully human IgG2 monoclonal antibody antagonizing the IL-17 receptor A subunit (IL-17RA).

OBJECTIVES

The aim of this narrative review was to collect published data about efficacy and safety of brodalumab in the treatment of psoriasis occurring in difficult-to-treat areas.

METHODS

Data on brodalumab effectiveness and safety deriving from both trials and real-world setting that had been published in the last 15 years were collected for this review, together with clinical findings issued during international meetings.

RESULTS

In phase 3 trials, brodalumab demonstrated to be effective in promoting a rapid response in scalp psoriasis as well as in generalized pustular psoriasis and erythrodermic psoriasis. Nail psoriasis demonstrated marked clinical improvement after treatment with brodalumab. Amelioration of palmoplantar psoriasis was also described in brodalumab-treated patients. Various retrospective real-world studies reported a complete clearance of psoriatic lesions in difficult-to-treat areas, including genitalia, through short-term brodalumab treatment.

CONCLUSIONS

Brodalumab, combining rapid and sustained efficacy with a favorable safety profile, may be a valid therapeutic option for severe variants of psoriasis as well as for psoriasis localized in difficult-to-treat areas.

The impact of nail psoriasis on disease activity, quality of life, and clinical variables in patients with psoriatic arthritis: A cross-sectional multicenter study

AIM

Nail involvement is common in psoriatic arthritis. This study assesses clinical characteristics, nail psoriasis prevalence, and impact of nail psoriasis on disease activity in patients with psoriatic arthritis (PsA).

METHOD

This cross-sectional multicenter study was conducted by the Turkish League Against Rheumatism using PsA patients recruited from 25 centers. Demographic and clinical characteristics of PsA patients, such as disease activity measures, quality of life, and nail involvement findings were assessed during routine follow-up examinations. Patients were divided into two groups according to the presence or absence of nail psoriasis and compared using the χ² test or Fisher exact test for categorical variables and the t-test or Mann-Whitney U test for continuous variables.

RESULTS

In 1122 individuals with PsA, 645 (57.5%) displayed nail psoriasis. The most frequent features of fingernails were ridges (38%), followed by pitting (21%) and onycholysis (19%). More females were present in both groups (with and without nail psoriasis; 64% vs 67%, P < 0.282). Patients with nail psoriasis were older, indicated more pain and fatigue, experienced greater swelling, tender joint counts, and skin disease severity, and had a higher disease activity score compared with those without nail psoriasis (all P < 0.05).

CONCLUSION

We demonstrate an increased prevalence of nail psoriasis observed in patients with psoriatic arthritis. Patients with nail involvement experience increased disease activity, lower quality of life, and diminished mental and physical status compared with those without nail involvement.

Safety of current systemic therapies for nail psoriasis

INTRODUCTION

A discussion of safety of systemic treatments for nail psoriasis is lacking, particularly in reference to approval of new therapies assessed for nail outcomes. A review of safety profiles for agents commonly utilized for treatment of nail psoriasis is warranted to help inform treatment choices. The PubMed database was searched on 5 April 20235 April 2023, with articles discussing safety of nail psoriasis systemic therapies identified and reviewed.

AREAS COVERED

Systemic treatments for nail psoriasis include biologic therapies (tumor necrosis factor-alpha inhibitors, interleukin-17 inhibitors, interleukin-23 inhibitors, interleukin-12/23 inhibitors), small molecule inhibitors (apremilast, tofacitinib), and oral systemic immunomodulators (methotrexate, cyclosporine, acitretin), each with unique safety profiles and considerations. Herein, we discuss adverse events, contraindications, drug-drug interactions, screening/monitoring guidelines, as well as utilization for special populations, including pregnant, older, and pediatric patients.

EXPERT OPINION

The advent of targeted therapies, including biologic treatments and small molecule inhibitors, has revolutionized outcomes for nail psoriasis patients, but warrant review and monitoring for potential adverse events. Oral systemic immunomodulators have demonstrated moderate efficacy for nail psoriasis treatment, but are notable for frequent contraindications and drug-drug interactions. Further study of these agents and their use in special populations is needed to elucidate safety profiles for long-term use.

Optimal diagnosis and management of common nail disorders

Nail conditions are not only aesthetic concerns, and nail changes may be a clue to an underlying systemic diseases or infection. Without timely treatment, nail diseases can continue to worsen and significantly impair performance of daily activities and reduce quality of life. Examination of the nails is essential at every medical visit, and may uncover important findings. Brittle nail syndrome, onychomycosis, paronychia, nail psoriasis, longitudinal melanonychia, Beau's lines, onychomadesis and retronychia are common nail disorders seen in clinical practice. These conditions stem from infectious, inflammatory, neoplastic and traumatic aetiologies. Though each nail condition presents with its own distinct characteristics, the clinical findings may overlap between different conditions, resulting in misdiagnosis and treatment delays. Patients can present with nail plate changes (e.g. hyperkeratosis, onycholysis, pitting), discolouration, pain and inflammation. The diagnostic work-up of nail disease should include a detailed history and clinical examination of all 20 nail units. Dermoscopy, diagnostic imaging and histopathologic and mycological analyses may be necessary for diagnosis. Nail findings concerning for malignancy should be promptly referred to a dermatologist for evaluation and biopsy. Nail disease management requires a targeted treatment approach. Treatments include topical and/or systemic medications, discontinuation of offending drugs or surgical intervention, depending on the condition. Patient education on proper nail care and techniques to minimize further damage to the affected nails is also important. This article serves to enhance familiarity of the most common nail disorders seen in clinical practice. It will highlight the key clinical manifestations, systematic approaches to diagnosis and treatment options for each nail condition to improve diagnosis and management of nail diseases, as well as patient outcomes.Key messagesNail disease is not only a cosmetic issue, as nail changes can indicate the presence of a serious underlying systemic disease, infection or malignancy.Nail pain and changes associated with NP are physically and emotionally distressing and may contribute to functional impairment and diminished quality of life.LM is a hallmark sign of subungual melanoma and this finding warrants further investigation to rule out malignancy.

A mask R-CNN based automatic assessment system for nail psoriasis severity

Nail psoriasis significantly impacts the quality of life in patients with psoriasis, which affects approximately 2-3% of the population worldwide. Disease severity measures are essential in guiding treatment and evaluation of therapeutic efficacy. However, due to subsidy, convenience and low costs of health care in Taiwan, doctor usually needs to manage nearly hundreds of patients in single outpatient clinic, leading to difficulty in performing complex assessment tools. For instance, Nail Psoriasis Severity index (NAPSI) is used by dermatologists to measure the severity of nail psoriasis in clinical trials, but its calculation is quite time-consuming, which hampers its application in daily clinical practice. Therefore, we developed a simple, fast and automatic system for the assessment of nail psoriasis severity by constructing a standard photography capturing system combined with utilizing one of the deep learning architectures, mask R-CNN. This system not only assist doctors in capturing signs of disease and normal skin, but also able to extract features without pre-processing of image data. Expectantly, the system could help dermatologists make accurate diagnosis, assessment as well as provide precise treatment decision more efficiently.

Comparison of the Objective Severity and the Esthetic Perception of Nail Symptoms in Psoriasis

Introduction

Nail changes are frequent in psoriasis, and the negative impact of nail psoriasis on patients' quality of life is well known. No data are available however about the association of the objective severity of nail psoriasis and the subjective perception of these symptoms. The purpose of this study was to determine the correlation between the severity of psoriatic nail changes (as determined by the Nail Psoriasis Severity Index [NAPSI]) and the esthetic assessment of nail psoriasis.

Methods

Participants (general population and psoriasis patients) were asked to rate 19 nail images (including psoriatic and healthy nails) on a 0–10 scale, based on how disturbing they considered them esthetically. Objective severity (NAPSI) scores of nails were compared to the subjective evaluation values.

Results

Nail symptom severity correlated well with the subjective scores. However, while nails with low (0) and high (6–8) NAPSI values received consistent subjective scores, the esthetic perception of nails with moderate NAPSI scores was rather heterogeneous. The age of the respondents showed robust positive correlation with the subjective assessment of nail symptoms both within the psoriatic and the general population.

Discussion

Gender, the presence of psoriasis, or medical education had no significant influence on the esthetic assessment of psoriatic nail changes.

Ultrasound Evaluation of the Effectiveness of the Use of Acitretin in the Treatment of Nail Psoriasis

The study aimed to evaluate the effect of retinoid treatment on the morphological changes in the nail apparatus in patients with nail psoriasis. Material and methods: 41 patients aged 32 to 64 with nail psoriasis, without clinical signs of psoriatic arthritis, started on acitretin 0.6 to 0.8 mg kg b.w./d, for six months and 28 people in the control group were included in the study. Both groups had ultrasound examination of fingernails and digital extensor tendon in the distal interphalangeal joints. In psoriatic patients, US examination was conducted before starting the treatment and after six months. A total of 685 nails were examined. Results: After six months of treatment, there was a reduction in the thickness of the nail bed and nail matrix (p = 0.046 and p = 0.031, respectively). The thickness of the nail plates decreased, although it was statistically insignificant (p = 0.059) and it was higher than in the control group (p = 0.034). The reduced severity of clinical nail changes after six months of retinoid treatment did not correlate with the reduction in extensor tendon thickness in any group of patients. Conclusions: In patients with nail psoriasis, acitretin treatment resulted in a rapid decrease in the thickness of the nail bed and matrix, but it did not affect the thickness of the nail plate after six months. There was no effect of acitretin on the digital extensor tendon thickness or the increased blood supply to the tendon area. The results of the study may indicate the usefulness of ultrasound nail examinations in patients with nail psoriasis not only to assess the advancement of morphological changes and response to treatment, but also to choose the potential treatment.