Nail involvement in adult patients with plaque-type psoriasis: prevalence and clinical features *

Transcription

1 314 INVESTIGATION Nil involvement in dult ptients with plque-type psorisis: prevlene nd linil fetures * Kren Regin Rosso Shons 1 André Avelino Cost Beer 2 Mristel de Oliveir Bek 2 Odirlei André Montiielo 3 DOI: Astrt: B ACKGROUND: Psorisis is disese of worldwide distriution with prevlene of 1 to 3%. Nil psorisis is estimted in 50% of ptients with psorisis, nd in the presene of joint involvement, it n reh 80%. OBJECTIVE: To study the nil hnges - nd their linil implitions - presented y ptients with psorisis vulgris under surveillne in university hospitl from the south of Brzil. METHODS: This ross-setionl study evluted 65 dult ptients from Jnury 2012 to Mrh Cutneous severity ws ssessed ording to the Psorisis Are nd Severity Index (PASI). The Nil Psorisis Severity Index (NAPSI) ws used to evlute ptient s nils. The dignosis of psoriti rthritis ws estlished ording to the Clssifition Criteri for Psoriti Arthritis (CASPAR). RESULTS: The prevlene of NP ws 46.1%. These ptients hd medin [interqurtili rnge (IQR)] NAPSI of 1 (0-15). A totl of 63.3% of ptients reported estheti disomfort or funtionl impirment relted to their nils. Onyholysis ws the most ommon feture (80%). When ompred with ptients without nil involvement, ptients with NP hd lower men ge t psorisis onset [21 (18-41) vs. 43 (30-56) yers, p=0,001]; longer disese durtion [15.5 (10-24) vs. 6 (2-12) yers, p=0.001]; higher PASI [9.2 (5-17) vs. 3.7 (2-10), p=0.044], higher frequeny of psoriti rthritis (43.3 vs. 3.7, p = 0.002) nd more often reported fmily history of psorisis (40% vs. 7.4%, p = 0.011). CONCLUSION: Onyholysis ws the most frequent finding nd most ptients feel unomfortle with the psoriti nil hnges tht they experiene. Keywords: Dermtology; Nils; Psorisis INTRODUCTION Psorisis is hroni inflmmtory disese of multiftoril pthogenesis involving immunologil, geneti nd environmentl uses. 1 Although psorisis n present t ny ge, onset efore the ge of 30 is more ommon, so tht most ptients re ffeted t the most produtive stge of their lives. 2 The nils re onsidered modified speiliztion of the skin nd re ommonly ffeted y the disese, presenting in up to 80% of the ptients. 3-5 The linil signs of nil involvement in psorisis re heterogeneous nd relted to the effets of the disese in either the mthrix, the nil ed or the periunguel tissue, whih results in distint injury ptterns. 6 In psorisis, nil involvement implies importnt psyhologil stress, pin nd deresed funtionlity. It my represent more severe forms of utneous psorisis nd e preditor of joint inflmmtion In Brzil, epidemiologil dt on psorisis re sre, nd so re the dt out the nil disese. The im of this study ws to evlute nil involvement in ptients with plque-type psorisis, nd determine it s prevlene, linil fetures nd possile ssoitions. PATIENTS AND METHODS This ross-setionl study ws onduted from Jnury 2012 to Mrh During this period, ll ptients with plque-type psorisis over the ge of 18 yers who ttended the Dermtology Deprtment of the University Hospitl of Snt Mri, loted in Snt Mri, Rio Grnde do Sul stte, were invited to prtiipte in the study. Smpling ws done y onveniene. All ptients who met the eligiility riteri were invited to join the study nd responded ording to their vilility. All dt olletion ws performed y the sme reserher. Reeived on Approved y the Advisory Bord nd epted for pulition on * Study onduted t the University Hospitl of Snt Mri (HUSM- UFSM) Snt Mri (RS), Brzil. Finnil Support: None. Conflit of Interest: None. 1 Universidde de Psso Fundo (UPF) Psso Fundo (RS), Brzil. 2 Universidde Federl de Snt Mri (UFSM) Snt Mri (RS), Brzil. 3 Universidde Federl do Rio Grnde do Sul (UFRGS) Porto Alegre (RS), Brzil y Anis Brsileiros de Dermtologi

2 Nil involvement in dult ptients with plque-type psorisis: prevlene nd The reserh ws onduted ording to the rules of Resolution 196/96 of the Ntionl Helth Counil, whih regultes reserh with humn sujets in Brzil. The study projet ws pproved y the Ethis Committee of the Federl University of Snt Mri. All ptients reeived nd provided written onsent to prtiipte in the study. Ptients nswered speifi questionnire out the following demogrphi vriles: gender, ge, ouption, skin phototype, disese durtion, ge t disese onset, fmily history of psorisis, urrent meditions nd omoridities. Ptients with nil psorisis (NP) were lso questioned: do you experiene ny sort of estheti or funtionl disomfort in your dily life due to the nil prolem? Psorisis skin severity t the time of the physil exmintion ws ssessed y using the Psorisis Are nd Severity Index (PASI). 12,13 All ptients hd their nils exmined for nil disorders relted to psorisis. If onyhomyosis ws suspeted, sed on nil fetures suh s onyhorrhexis, hyperkertosis, thikening or rumling, diret mirosopy exmintion nd myologil ulture were performed. 14 Ptients with onyhomyosis, even though they ould present other fetures relted to NP, were exluded from this group. Ptients with NP were then evluted ording to the NAPSI Nil Psorisis Severity Index (NAPSI). 15,16 The olleted dt were sumitted to sttistil tests in the softwre SPSS 17.0 (SPSS In., IBM Corportion, Armonk, New York). Cthegoril vriles were represented y perentges nd nlyzed y Chi squre test or Fisher s ext test. Vriles hd their normlity verified y Kolmogorov-Smirnov test. Continuous vriles with norml distriution were tested y T student test nd the results were presented s men±stndrd devition. For ontinuous vriles with n norml distriution, the Mnn Whitney test ws performed. The entrl tendeny mesure used ws medin nd its orresponding interqurtile rnge. Sttistil signifine ws onsidered t level of 5% (p<0.05) for ll tests. RESULTS A totl of 65 ptients with plque-type psorisis were inluded in this study. Their min linil nd demogrphi hrteristis re summrized in tle 1. The smple onsisted mostly of women (64.6%) nd the men ge ws 49±14.6 yers. The min ouption reported ws frming nd the mjority of ptients hd skin olor phototype III (61.5%), ording to Fitzptrik. 17 The men disese durtion ws 14±10.5 yers nd the men ge of disese onset ws 34.8±16.4 yers, with minority of ptients reporting onset fter the ge of 60 (7.7%, n = 5). Most ptients (69.2%) hd skin severity lssified s mild (PASI 10). 18,19 The smple onsisted mostly of ptients who were under tretment for psorisis (84.6%). Of these, 56.9% were using topil ortiosteroids, 64.6% were using emollient rems nd 44.6% were tking systemi drugs. No ptients were under topil tretment for the nils or periungul tissues or eing treted with phototherpy or immunoiologil therpy. A totl of 70.7% of ptients hd some type of medil omoridity. Among these, hypertension ws the most prevlent omoridity (38.5%), followed y dietes mellitus (20%) nd smoking (15.4%). Other less frequently reported omoridities were ishemi hert disese (n=3), renl filure (n=2) nd ulertive TABLE 1: Chrteristis of ptients with plque-type psorisis (n=65)* Chrteristi Sttistis Femle gender 42 (64.6) Age, yers 49±14.7 Men 45±14.1 Women 51.8±15.5 Ouption Frmers 22 (33.8) Housekeepers 11 (16.9) sellers 7 (10.7) Others 25(38.4) Fitzptrik s phototype III 40 (61.5) PASI 8.3± (69.2) >10 20(30.8) Psorisis onset, yers 34.9±16.4 <20 15 (23.1) (69.2) 60 5 (7.7) Disese durtion, yers 14±10.5 Fmily history of psorisis 16 (24.6) Current tretment 55 (84.6) Systemi 29 (44.6) Topil 49(75.3) Oniomyhosis 8 (12.3) Nil psorisis 30 (46.1) Comoridities 46 (70.7) ASH 25 (38.4) DM 13 (20) Smoking 10 (15.4) Others 16(24.6) Psoriti Arthritis 16 (24.6) PASI, Psorisis Are nd Severity Index. DM, Diete Mellitus. ASH, Artheril Sistemi Hypertension *All dt re presented s the numer of individuls = n (%), unless otherwise desried Dt expressed in medin±stndrd devition Other ouptions: housemid (n=6); driver, mniure, student (n=3); teher (n=2); ook, ountnt, oler, mson, dministrtor, pinter, eletriin nd uther (n=1) Other omoridities: ishemi hert disese (n=3); renl filure, ulertive olitis (n=2); hypothyroidism, tumors of the entrl nervous system, depression, prostte ner, sthm, llergi rhinitis, utoimmune heptitis nd polyrteritis nodos (n=1)

3 316 Shons KRR, Beer AAC, Bek MO, Montiielo OA olitis (n=2). Hypothyroidism, entrl nervous system tumor, depression, prostte ner, sthm, llergi rhinitis, utoimmune heptitis nd polyrteritis nodos were oserved in only one ptient eh. Of the 65 ptients who prtiipted in the study, 8 were dignosed with onyhomyosis (12.3%). Even though these ptients lso presented findings omptile with NP, they did not reeive this dignosis. NP ws then dignosed in 16 women nd 14 men, whih ounted for prevlene of 46.1% (n=30). The medin [interqurtile rnge (IIQ)] NAPSI overll sore otined ws 1 (0-15). Most ptients with NP hd involvement of oth hnds nd feet (70%, n=21), while exlusive involvement of the feet oured in 10% (n=3) of ses nd exlusive involvement of the hnds ws oserved in 20% (n=6) of ses. Both hnds were frequently involved: the left hnd ws ffeted in 80% of ses nd the righ hnd ws ffeted in 73.3% of ptients. The left foot ws involved in 76.7% of ses nd the left foot in 73.3%. When nil hnges were oserved, more thn one pttern ws often found [2 ( )], nd these hnges were oserved in the sme nil or in different nils. The medin numer of ffeted nils ws 1 (IIQ 0-8, n=243 nils). Onyholysis ws the most frequent pttern, seen in 24 ptients (80%), followed y suungul hyperkertosis (66.7%, n=20) nd y oil stins (43.3%, n=13). No signifint differenes relted to these findings were found etween genders. Detils on the morphologil types of nil hnges found in ptients with NP re desried in tle 2. The omprison etween groups where nil psorisis ws present or sent is desried in tle 3. When oth groups were ompred y ge, gender nd presene of omoridities, no sttistilly signifint differenes were found. When ompred with ptients TABLE 2: Morphology of nil ptterns in ptients with psorisis (n=30)* Finding Prevlene Women Men p** (n) (n=16) (n=14) Oniholysis 24 (80) 12 (75) 12 (85.7) Suunguel 20 (66.7) 9 (56.3) 11 (78.6) hyperkertosis Oil drops 13 (43.3) 7 (43.8) 6 (42.9) Pitting 10 (33.3) 6 (37.5) 4 (28.6) Splinter 8 (26.7) 2 (12.5) 6 (42.9) hemorrhges Leukonyhi 8 (26.7) 4 (25) 4 (28.6) >0.999 Crumling 4 (13.3) 2 (12.5) 2 (14.3) >0.999 Red spots 1 (3.3) 1 (6.5) 0 (0) >0.999 *All dt re presented s the numer of individuls = n (%), unless otherwise desried**p vlue ws lulted y Fisher ext test without nil involvement, ptients with NP showed lower medin ge of psorisis onset [21 (18-41) vs. 43 (30-56) yers, p=0.001] nd longer skin disese durtion [15.5 (10-24) vs. 6 (2-12), p=0.001]. This group lso showed higher frequeny of psoriti rthritis (43.3% vs. 3.7%, p=0.002) nd higher medin PASI [9.2 (5-17) vs. 3.7 (2-10), p=0.044]. Fmily history of psorisis ws negtive in most ptients in oth groups, ut when NP ws present, positive fmily history ws more often reported (40% vs. 7.41%, p=0.011). The prevlene of psoriti rthritis ws 24.6%: 10 ptients were women nd 6 ptients were men. The omprison etween groups of ptients with nd without psoriti rthritis is desried in tle 4. We found no sttistilly signifint differenes with regrd to gender, ge nd PASI sore. Yers of disese presenttion nd positive fmily history of psorisis hd orderline sttistil signifine (p=0.052). The men ge of psorisis onset ws lower in ptients with psoriti rthritis (261±13.6 yers vs. 37.7±16.4 yers, p=0.002) nd the NAPSI sore ws signifintly higher in these ptients [14 (4-28) vs 0 (0-13), p=0.001] Ptients were sked if they experiened ny kind of funtionl or estheti disomfort s result of their nil hnges, nd totl of 63.3% of ptients nswered ffirmtively to this question (Tle 5). Most TABLE 3: Chrteristis of ptients with nd without nil involvement (n=57)* Chrteristi With nil Without nil p** hnges hnges (n=30) (n= 27) Femle gender 16 (53.3) 19 (70.4) Age, yers 51.8± ± Disese onset, 27.6± ± yers <20 12 (40) 2 (7.4) (56.6) 21 (77.7) (3.3) 4 (14.8) Disese durtion, 17.5± ± yers PASI 11.1± ± (53.3) 22 (81.5) >10 14 (46.7) 5 (18.5) Fmily history 12 (40) 2 (7.4) of psorisis Comoridities 19 (63.3) 20 (70.1) Psoriti rthritis 13 (43.3) 1 (3.7) PASI: psorisis re nd severity index. * The dt re presented s numer of individuls = n (%), unless otherwise desried. ** p vlues were lulted y Fisher s ext test, unless otherwise desried. Sttistil signifine ws estlished y the Chi squre test. Dt re expressed s men ± stndrd devition. Sttistil signifine ws estlished y the t Student test. d Dt express the medin nd interqurtile rnge vlues (P25-P75). e Sttistil signifine ws estlished y the Mnn Whitney test.

4 Nil involvement in dult ptients with plque-type psorisis: prevlene nd TABLE 4: Chrteristis of ptients whith nd whithout psoriti rthritis Chrteristi With Without p** psoriti psoriti rthritis rthtritis (n=16) (n=49) Femle gender 10 (62.5) 32 (65.3) >0,999 Age, yers 45.9± ± Disese onset, yers 26.1± ± Disese durtion, 19.5 (1-40) 10 (1-41) yers Fmily history of 7 (43.8) 9 (18.4) psorisis NAPSI 18.3± ± PASI 11.3± ± d NAPSI, Nil Psorisis Severity Index; PASI, Psorisis Are nd Severity Index. * Dt express the medin nd interqurtile rnge vlues (p25-p75). ** The p vlues were lulted y Mnn Whitney test, unless otherwise desried. All dt re presented s numer of individuls = n (%). Sttistil signifine ws estlished y the Chi squre test. Dt re expressed s men ± stndrd devition. d p vlue ws lulted y t Student test. e p vlue ws lulted y Fisher s ext test. TABLE 5: Aestheti disomfort nd funtionl impirment relted to nil psorisis (n=30)* Chrteristi With Without p** disomfort disomfort or funtionl or funtionl impirment impirment n=19 n=11 Femle gender 11 (57.9) 5 (45.5) Age, yers 46.7± ± NAPSI 21.2 ±13 8.2± PASI 12.4± ± Numer of 9.7± ± ffeted nils Under psoriti 16 (84.2) 9 (81.8) >0.999 tretment NAPSI, Nil Psorisis Severity Index. PASI, Psorisis Are nd Severity Index. *All dt re presented s men ± stndrd devition, unless otherwise desried. **p vlue ws lulted y Mnn-Whitney test, exept when otherwise desried Dt expressed s n = numer of individuls (%) p vlue ws lulted using Chi squre test. p vlue ws lulted using Student s t test. d p vlue ws lulted using Fisher s ext test. ptients who reported feeling disomfort were urrently under some sort of tretment for psorisis vulgris (84.2%). They lso more often hd higher NAPSI sores nd greter numer of nils ffeted. There were no signifint differenes etween genders, ge groups, PASI nd the presene of tretment. DISCUSSION Although nil mnifesttions re ommon in ptients with psorisis, they re only reently eing the trget of stndrdized quntifition nd detiled hrteriztion. In Brzil, there re only few studies on nil psorisis, espeilly when onsidering epidemiologil nd morphologil ptterns of NP in our popultion. The min urrent knowledge on NP omes from Europen studies. Compred to them, the prevlene of NP otined in this smple of Brzilin ptients ws similr to tht found in Spnish (47.7%) nd Germn ptients (40.9%). 10,11 Brzzelli nd ollegues report prevlene of NP of 76.9% in smple of 137 Itlin ptients. 20 Similr results were found in study with 106 Polish ptients (78.3%). 21 In the Brzilin study y Rieiro nd ollegues, whih foused on the periunguel pillrosopy of psoriti ptients, 37% (n=46) of ptients hd nil disese, defined y pitting or onyhodystrophy. 22 The differenes in the prevlene of NP in the different popultions reflet the diffiulty in estlishing n ext vlue of NP prevlene in ptients with utneous psorisis or its vriility. Most ptients hd mild skin ondition, whih my hve een influened y the ft tht most ptients were lredy under some type of tretment with fous on utneous psorisis. This ftor my even hve interfered with the NAPSI sores nd the prevlene of nil psorisis. However, this shows tht physiins need to py ttention to nil findings nd to omplints relted to the nils, euse even ptients who were under tretment reported some type of funtionl or estheti disomfort. Still, this smple ws not omposed of ptients who were under immunoiologil therpy - whih hs proven to e effetive in the tretment of nil psorisis. 4,23,24 The exlusion of ll ses of onyhomyosis from the nlysis relted to nil psorisis ws mde in order to minimize potentil is. Tht is euse onyhomyosis my present with linil fetures tht re similr to nil psorisis. 25 Diret exmintion nd ulture were used for this purpose; however, we point out the sene of nil iopsy proedures s study limittion. This ould hve helped to hieve higher ury for the dignosis of onyhomyosis. Furthermore, it is estimted tht the presene of onyhomyosis is oserved in out 4.6 to 30% of ptients with PU, whih points out to possile exlusion of ses with this ssoition, underestimting the dt otined on prevlene. 25 NP ws ssoited with erlier onset of psorisis nd ses of longer disese presenttion, in ordne to previous studies from other uthors. 10,26,27 The highest ourrene of nil normlities relted to older ges, whih ws oserved in this study, n e

5 318 Shons KRR, Beer AAC, Bek MO, Montiielo OA ssoited with the higher frequeny of nil prolems tht is oserved in dvned ge due to defiits in peripherl irultion, neuropthy nd repetitive lol trum. 21 NP ws lso ssoited with more extensive utneous disese nd presene of joint involvement. Suh oservtions hve een desried y severl uthors. 6,8,11,28 The lose mirontomil reltionship etween the nil unit nd the musuloskeletl system is plusile reson for the ssoition etween the unguel nd joint findings. Through this link, the extension of the lol inflmmtion - relted to n enthesitis t the terminl phlnx - ould use the hnges found in the nils. 29 Therefore, it is estimted tht n verge of 80% of ptients with PA will present nil involvement t some point of their lives. 6,20,29,30 The greter extent of skin involvement ssoited with the presene of nil psorisis n e eluidted through the following eqution: for eh one-point inrese in the severity of skin involvement, 10-point inrese in the severity of nil involvement is expeted. This eqution ws proposed y Hllji nd ollegues in study tht evluted 100 ptients, nd orrelted the PASI nd the NAPSI. 28 For some uthors, the most ommon sign of NP is the pitting, 31,32 while for others the min finding is suunguel hyperkertosis. 21 Attempting to disriminte nd ompre the unguel findings identified y the NAPSI in ptients with psorisis nd in ontrol group of helthy ptients, Duth study identified onyholysis nd splinter hemorrhges s the most frequent signls ssoited with psorisis. 33 Similr to tht, onyholysis ws the most ommon finding in our study nd in the study y Brzzelli nd ollegues. 20 We find importnt to emphsize tht the NAPSI sore used in the present study onstitutes n exellent vlidted tool to nlyze the ptterns nd quntify the unguel involvement. However, it only tkes into ount six fetures relted to nil psorisis (onyholysis, suungul hyperkertosis, oil stin, pitting, splinter hemorrhges, leukonyhi, rumling, nd red spots in the lunul), nd does not onsider ny other fetures whih re lso known to e relted to psorisis, suh s Beu s lines, for exmple. 1 Moreover, the NAPSI sore only tkes into ount the ojetive impression of the exminer nd is therefore unle to predit the impt of these sores on the qulity of life of ptients with PU. Studies mesuring qulity of life impirment in these ptients showed tht 51.8% omplined of pin in the nils, 58.9% reported restritions in their dily life, 7 nd 90% onsidered the osmeti pperne of their nils to e disturing. 6 In this ontext, in order to inlude sujetive vrile dedited to the ptient into our study, we questioned the ptients whether they experiened ny estheti or funtionl disomfort in their dily tivities. Suh questioning my e onsidered too simple when ompred with the NPQ10 (Nil Psorisis Qulity of Life Sle), designed to ssess the qulity of life in ptients with nil psorisis. 34 However, the ltter ws not used euse vlidted trnsltion into Portuguese is not yet ville. CONCLUSION As fr s we know, this study is the first study in Brzil on the prevlene of n il hnges in ptients with plque-type psorisis. It foused on the morphologil hrteristis of the unguel presenttion, nd showed similr results to tht previously pulished interntionlly. The frequeny of nil findings in the studied popultion, whih onsisted mostly of ptients who were lredy using systemi drugs nd who hd utneous severity lssified s mild, suggests tht nil involvement my e underestimted y dotors. In this ontext, it is essentil tht the dermtologil evlution of psoriti ptients tke in onsidertion the nil prolem, in order to optimize tretment nd improve ptients stisftion.

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Am J Clin Dermtol. 2012;13: vn der Velden HM, Klssen KM, vn de Kerkhof PC, Psh MC. Fingernil psorisis reonsidered: A se-ontrol study. J Am Ad Dermtol. 2013;69: Ortonne JP, Brn R, Corvest M, Shmitt C, Voisrd JJ, Tie C. Development nd vlidtion of nil psorisis qulity of life sle (NPQ10). J Eur Ad Dermtol Venereol. 2010;24:22-7. MAILING ADDRESS: Kren Regin Rosso Shons BR 285, São José Psso Fundo - RS Brzil. E-mil: [email protected] How to ite this rtile: Shons KRR, Beer AAC, Bek MO, Montiielo OA. Nil involvement in dult ptients with plque-type psorisis: prevlene nd linil fetures.