Severe Nail Fold Psoriasis Extending from Nail Psoriasis Resolved with Ustekinumab: Suggestion of a Cytokine Overflow Theory in the Nail Unit

Because nail psoriasis is difficult to treat, therapy with many biological drugs has been attempted. Ustekinumab is approved for chronic plaque psoriasis and psoriatic arthritis (PsA), with some trials reporting nail improvement using this agent. A 51-year-old man with severe chronic plaque psoriasis had severe involvement of all fingernails and toenails, with accompanying nail fold psoriasis. He also had PsA of the small joints of the fingers. Despite multiple conventional therapies, the nail lesions did not improve, and his nail psoriasis severity index score was 97. After a fourth ustekinumab injection, most of the fingernail psoriasis was resolved, and only hyperkeratosis remained on both large toenails. Because the nail plate, nail fold, and small joints of the fingers are closely apposed structures within a small area, cytokines produced from the nail units overflow to the nail fold and small joints and can induce nail fold psoriasis and PsA.     

Nail Psoriasis: The Journey So Far

Nail involvement is an extremely common feature of psoriasis and affects approximately 10-78% of psoriasis patients with 5-10% of patients having isolated nail psoriasis. However, it is often an overlooked feature in the management of nail psoriasis, despite the significant burden it places on the patients as a result of functional impairment of manual dexterity, pain, and psychological stress. Affected nail plates often thicken and crumble, and because they are very visible, patients tend to avoid normal day-to-day activities and social interactions. Importantly, 70-80% of patients with psoriatic arthritis have nail psoriasis. In this overview, we review the clinical manifestations of psoriasis affecting the nails, the common differential diagnosis of nail psoriasis, Nail Psoriasis Severity Index and the various diagnostic aids for diagnosing nail psoriasis especially, the cases with isolated nail involvement. We have also discussed the available treatment options, including the topical, physical, systemic, and biological modalities, in great detail in order to equip the present day dermatologist in dealing with a big clinical challenge, that is, management of nail psoriasis.     

Nail Psoriasis: Combined Therapy with Systemic Cyclosporin and Topical Calcipotriol

Background Nail psoriasis is a common problem in psoriatic patients and often it is difficult to cure. Several treatments have been proposed in the last decade using new molecules like vitamin-D analog and/or immunosoppressive drugs both systemically and locally.Objective Our goal was to evaluate a combination of cyclosporin and topical calcipotriol cream versus cyclosporin alone in a matched group of patients treated with cyclosporin alone.Méthod Fifty-four patients affected by severe psoriasis and nail involvement were selected and matched for severity of nail involvement, sex, age, and cyclosporin dosage. Group A included 21 patients treated with cyclosporin alone (3.5 mg/kg/day) for three months. Group B included 33 patients treated with the same cyclosporin dosage plus, for the same time, topical application of calcipotriol cream twice a day. Evaluation for clinical improvement was the personal feeling of the patient after three months, while clinical appearance of the lesions was evaluated by the same dermatologist using digital pictures and who was blind as to the treatment of the patient. A score ranging from + to +++ was used in order to evaluate the improvement, and data were statistically evaluated with the Wilcoxon test.Results Both cyclosporin alone and a combination of cyclosporin with topical calcipotriol twice a day were useful for treating nail psoriasis after three months of therapy although the combined therapy showed a better overall result in both mild and severe nail psoriasis. Improvement of the clinical appearance of the nail lesions was seen in about 79% of patients in group B (p 0.0004) versus about 47% of patients in group A (p 0.15).Conclusions In patients with severe involvement of nail psoriasis we suggest the use of a combination of topical calcipotriol twice a day with systemic treatment such as cyclosporine.

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SommaireAntécédents Le psoriasis unguéal est une affection fréquente et souvent difficile à guérir qui se présente chez les patients souffrant de psoriasis. Plusieurs traitements ont été proposés durant la dernière décennie qui impliquent Iusage systémique ou local de nouvelles molécules telles que lanalogue de la vitamine D ou des médicaments immunosuppresseurs.Objectif Notre objectif était de comparer leffet dun traitement combiné de la cyclosporine et du calcipotriol topique en crème avec leffet de la cyclosporine utilisée seule, dans un groupe apparetllé de patients traités à la cyclosporine.Method 54 patients souffrant de psoriasis aigu impliquant longle ont été choisis et appareillés selon la gravité de latteinte, le sexe, 1âge et le dosage de cyclosporine. Le groupe A comprenait 21 patients traités à la cyclosporine seule (3,5 mg/kg/jour) pendant trois (3) mois; le groupe B comptait 33 patients traités à la même dose de cyclosporine mais recevant en plus, et pendant la même durée, une application topique de calcipotriol en crème deux fois par jour. Lamélioration clinique était évaluée selon le sens de soulagement personnel des patients après 3 mois. Lapparence clinique des lésions était évaluée au moyen de photos numériques prises par un dermatologue ne connaissant pas la nature du traitement des patients. Un score variant entre + et +++ a été utilisé en vue dévaluer lamélioration; lévaluation statistique des données a été faite au moyen du test de Wilcoxon.Résultats Le traitement systémique utilisant la cyclosporine seule ou une combinaison de cyclosporine et de calcipotriol topique deux fois par jour ont été efficaces dans le traitement du psoriasis unguéal après trois mois de thérapie. Cependant, le traitement combiné a donné de meilleurs résultats généraux dans les cas de psoriasis unguéal moyen et grave. Une amélioration de lapparence clinique des lésions de longle a été remarquée chez 79% des patients du groupe B (p 0.0004) comparativement à environ 47% chez les patients du groupe A, soil le groupe traité à la cyclosporine seule (p 0.15).Conclusion Chez les patients atteints dun psoriasis unguéal grave, nous recommandons un traitement combinant le calcipotriol topique, deux fois par jour, à un traitement systémique, la cyclosporine par exemple.

     

Active Tuberculosis in Patients with Psoriasis Receiving Biologic Therapy: A Systematic Review

American Journal of Clinical Dermatology - Biologic therapies pose a risk for opportunistic infections, especially for reactivating latent tuberculosis infection (LTBI). The aim was to describe the...     

Nail Changes as the Initial Sign of Psoriasis: A Case Report

Introduction: Nail psoriasis has a profound negative influence on quality of life and has a more closely relationship with psoriatic arthritis. However, patients with nail changes only were often overlooked with the diagnosis of psoriasis. It is necessary to pay more attention to nail psoriatic changes.Case presentation: The nails presented with white streaks, deformations, and had been missed for 8 months. Physical examination further revealed one erythematous scaly plaque on the buttock, anusa...     

Nail Disorders in Children

Nail disorders in children can be divided into seven categories. The first is physiologic alterations, which every physician should be aware of in order to reassure parents. These usually disappear with age and do not require any treatment. Among congenital and inherited conditions, the nail-patella syndrome, with its pathognomonic triangular lunula, should not be missed as recognition of the disease allows early diagnosis of associated pathologies. The most common infection is the periungual wart, whose treatment is delicate. Herpetic whitlow should be distinguished from bacterial whitlow as their therapeutic approaches differ. Dermatologic diseases encompass eczema, psoriasis, lichen planus, lichen striatus, trachyonychia, and parakeratosis pustulosa. Lichen planus, when it presents as in adults, is important to recognize because, if not treated, it may lead to permanent nail loss. Systemic or iatrogenic nail alterations may be severe but are usually not the first clue to the diagnosis. Beau lines on several fingernails are very common in children after temperature crest. Tumors are rare in children. Radiographic examination allows confirmation of the diagnosis of subungual exostosis. Other cases should undergo biopsy. Single-digit longitudinal melanonychia in children is mostly due to nevi. Its management should be tailored on a case-by-case basis. Acute trauma should never be underestimated in children and hand surgeons should be involved if necessary. Onychophagia and onychotillomania are responsible for chronic trauma.     

Finger Nail Pitting in Psoriasis and its Relation with Different Variables

Incidence of pitting, vary considerably in different types of psoriasis. In clinical practice, toe nail examination is inconvenient. There are inadequate studies which show relation of nail pitting with duration and severity of the disease. The objective was to examine the incidence of finger nail pitting in all types of cutaneous psoriasis and its relation with different variables. This is a clinico-epidemiological study. A careful clinical examination of finger nails was done in day time. Severity of disease was calculated by psoriasis area severity index (PASI). Statistical analysis was done using Microcomputer statistics software (MSTAT). In study group, 621 patients and in control group 350 people were taken. Finger nail pitting was present in 37% (total number was < 20 in 17%; 20-60 in 8% and > 60 in 12%) in study group. In control group, it was present in 10% (in all cases total number was < 20). In < 1 year duration group, pitting was present in 32% of cases, while in > 1 year duration group it was 40.5%. In mild psoriasis, pitting was present in 34.2%, while in severe cases it was 47.6%. Finger nail pitting is an important nail finding in psoriasis and its incidence increases with duration and severity of disease.     

Body Image in Children with Morphea: A Systematic Review

This systematic review was conducted to evaluate the present state of body image research in children with morphea and the extent of body image distress in this population. Only five studies met inclusion criteria. Disease‐related skin changes in children with morphea typically were associated with, at most, mild levels of body image distress.     

Association of Metabolic Comorbidities with Pediatric Psoriasis: A Systematic Review and Meta-Analysis

BackgroundAn evident relationship has been shown between psoriasis and metabolic comorbidities. However, the results in pediatric psoriasis vary from study to study, and no meta-analysis exists on the association of metabolic comorbidities with pediatric psoriasis.ObjectiveTo evaluate the association between psoriasis and metabolic comorbidities in pediatric patients.MethodsWe searched articles published in PubMed, EMBASE, and Cochrane Library databases from inception to April 30, 2019. All observational studies reporting the prevalence of obesity or metabolic comorbidities in pediatric patients with psoriasis were included.ResultsThe meta-analysis included 16 unique studies meeting the inclusion criteria. The pooled odds ratios in pediatric patients with psoriasis was 2.40 (95% confidence interval [CI], 1.60~3.59) for obesity (13 studies), 2.73 (95% CI, 1.79~4.17) for hypertension (8 studies), 2.01 (95% CI, 1.09~3.73) for diabetes mellitus (8 studies), 1.67 (95% CI, 1.42~1.97) for dyslipidemia (7 studies), and 7.49 (95% CI, 1.86~30.07) for metabolic syndrome (4 studies).ConclusionPediatric patients with psoriasis showed a significantly higher prevalence of obesity, hypertension, diabetes, dyslipidemia, and metabolic syndrome. Adequate monitoring and timely management of metabolic comorbidities should be considered in these patients.     

Nail Psoriasis: Treatment Options and Management Strategies in Special Patient Populations

Nail involvement is common in psoriasis and is considered a risk factor for and a predictor of the development of psoriatic arthritis. The treatment of nail psoriasis is challenging because of the unique anatomical structure of nails and the absence of standardized treatment protocols. Herein, we provide an up-to-date overview of the treatment options for nail psoriasis, including topical drugs and penetration enhancement strategies, traditional and novel oral drugs, and biologic agents. In addi...     

Risk of Parkinson's Disease Among Patients with Psoriasis: A Systematic Review and Meta-analysis

Background:Patients with psoriasis might be at a higher risk of developing Parkinson''s disease (PD) as a result of the detrimental effect of chronic inflammation on the neuronal tissue. This meta-analysis aimed to investigate this risk by comprehensively reviewing all available data.Methods:We conducted a systematic review and meta-analysis of cohort and case–control studies that reported relative risk, hazard ratio, odds ratio, or standardized incidence ratio comparing the risk of PD in patients with psoriasis versus subjects without psoriasis. Pooled risk ratio and 95% confidence interval (CI) were calculated using random-effect, generic inverse variance methods of DerSimonian and Laird.Results:Three retrospective studies and one case–control study met our eligibility criteria and were included in this meta-analysis. The pooled risk ratio of PD in patients with psoriasis versus participants without psoriasis was 1.38 (95% CI, 1.15–1.66). The statistical heterogeneity was low with an I² of 35%.Conclusions:Our meta-analysis demonstrated a statistically significant increased risk of PD among patients with psoriasis.     

雷公藤治疗银屑病的系统评价

目的评价雷公藤治疗银屑病的疗效。方法按文内纳入标准和排除标准计算机检索Medline、Pubmed(1966-2004)、Ovid、The Cochrane library2004.4th、中国生物医学文献数据库(1978-2004)、Vip全文数据库(1994-2004)、解放军医学图书馆、国家科技图书文献中心的数据库,手工检索国内的期刊杂志和药厂提供的资料。应用RevMan4.2版软件进行统计分析。结果9个雷公藤治疗银屑病的有效率研究按亚组分类后,组间有异质性(χ2=22.84,P=0.004,I2=65.0%),用随机效应模型进行合并,结果显示应用雷公藤治疗银屑病的有效率与对照组差异有统计学意义[OR4.38,95%CI(2.45,7.81)]。结论由于目前缺乏高质量的研究,故尚不能据此证实雷公藤治疗银屑病是有效的,随着高质量的报告出现,今后可以不断地完善本评价。     

Association of Multiple Sclerosis with Psoriasis: A Systematic Review and Meta-Analysis of Observational Studies

American Journal of Clinical Dermatology - Previous studies have reported the occurrence of psoriasis together with multiple sclerosis (MS). Although similar predisposing genes and pathomechanisms...