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ORIGINAL ARTICLE
Year : 2022  |  Volume : 67  |  Issue : 5  |  Page : 488-494
Study of clinical and dermoscopic features in nails of papulosquamous disorders and their correlation with disease severity: A cross-sectional study


Department of Skin & VD, SCB Medical College and Hospital, Cuttack, Odisha, India

Date of Web Publication29-Dec-2022

Correspondence Address:
Dinesh R Panda
Department of Skin and VD, SCB Medical College, Cuttack, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijd.ijd_519_22

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   Abstract 


Background: As face is the index of the mind, so is the nail the index to health, as the nail is capable of mounting only a limited number of reaction patterns to the large number of disorders affecting it. Dermoscopy is thus a valuable aid not only in enhancing visible nail features but also in revealing cryptic features of diagnostic value. Aims: To study the clinical and dermoscopic features in nails of papulosquamous disorders and correlate it with disease severity. Methods and Material: This was a cross-sectional study with convenient sampling. After obtaining ethical clearance, according to inclusion and exclusion criteria, papulosquamous disorders were enrolled in the study. Finger nails and toe nails were numbered 1–10. Detailed clinical examination was done. Wet and dry dermoscopic examination was made in both polarised and non-polarised mode using ultrasound (USG) gel. Psoriasis area and severity index (PASI) and body surface area (BSA) were compared with nail changes. Statistical analysis of data was performed using the Statistical Package for the Social Sciences (SPSS) version 26. Results: Out of 203 patients, 117 were male. Psoriasis was the most common disease (55.6%). A total of 65.51% of patients had nail changes. Pitting was the most common finding in psoriasis, both dermoscopically and clinically. Splinter haemorrhage, oil drop, dilated capillaries, and pseudofibre sign were detected better on dermoscopy (P < 0.05). Positive correlation was found between PASI and nail psoriasis severity index (NAPSI). A strong correlation was also found between clinical (cNAPSI) and dermoscopic (dNAPSI). Thinning was the most common in lichen planus. No relation between BSA and nail changes was observed. Conclusions: Dermoscopy is thus a valuable aid not only in enhancing visible nail features but also in revealing cryptic features of diagnostic value and reducing the requirement for invasive procedures like nail biopsies, early diagnosis, directing management.


Keywords: Dermoscopy, nail changes, NAPSI, papulosquamous disease


How to cite this article:
Subudhi A, Jena S, Mohanty P, Panda DR. Study of clinical and dermoscopic features in nails of papulosquamous disorders and their correlation with disease severity: A cross-sectional study. Indian J Dermatol 2022;67:488-94

How to cite this URL:
Subudhi A, Jena S, Mohanty P, Panda DR. Study of clinical and dermoscopic features in nails of papulosquamous disorders and their correlation with disease severity: A cross-sectional study. Indian J Dermatol [serial online] 2022 [cited 2023 Feb 5];67:488-94. Available from: https://www.e-ijd.org/text.asp?2022/67/5/488/366134





   Introduction Top


The nail is an index to health. Nail disorders comprise of 10% of all dermatological disorders, the main contributors being papulosquamous disorders. Dermoscopy is a valuable interface between macroscopic dermatology (i.e. clinical features) and microscopic dermatology (i.e. histopathological features). Onychoscopy allows rapid, real-time, high-resolution viewing at higher magnifications, together with the ability to capture and store the projected images with ease. So here we are observing both clinical and dermoscopic findings in the same patient and also comparing it with severity of disease in the form of body surface area (BSA) and psoriasis area severity index (PASI). As the nail is capable of mounting only a limited number of reaction patterns to the large number of disorders affecting it, many conditions may not be diagnosed reliably only by visual inspection. Even a nail biopsy may not be confirmatory every time. Dermoscopy is thus a valuable aid not only in enhancing visible nail features but also in revealing cryptic features of diagnostic value and reducing the requirement for invasive procedures like nail biopsies, early diagnosis, directing management, and improve the follow-up of the patient with respect to his/her response to treatment.

The study aims at finding the clinical and dermoscopic features in nails of papulosquamous disorders and correlate it with disease severity.

Objectives

  1. To find the prevalence of nail changes in papulosquamous disorders.
  2. To study the pattern and frequency of clinical and dermoscopy findings in nails.
  3. To compare the prevalence of clinical and dermoscopic nail changes.
  4. To correlate nail findings with disease severity assessed by BSA and PASI.



   Subjects and Methods Top


This study was done from May 2020 to November 2021. It was a cross sectional study done on all age group patients. Convenient sampling method was used with 203 samples.

Inclusion criteria were patients with papulosquamous disorders defined as per ICD 10 and presented to the skin and Veneral Disease outpatient department (OPD).

Exclusion criteria

  1. Pregnant and lactating females.
  2. Patients who did not give consent and had history of using artificial nails at any time of their lives.
  3. Patients having congenital nail changes and any nail changes prior to the development of papulosquamous disorders.


Data collection techniques

After obtaining ethical clearance patients with papulosquamous disorders diagnosed on the basis of clinical and dermoscopic findings was enrolled in the study. A detailed history and physical examination was done. In case of any dilemma in diagnosis, biopsy was done. Demographic data was collected. The toe nails were numbered 1 to 10 from the left to the right toe. Similar numbering was given to the fingers. Detailed nail examination was carried out regarding the number of nail involvement and the different types of nail changes. Dermoscopic examination was performed using DermLite DL4 (TIMPAC) with 10× magnification. For optimum evaluation of vasculature, the hand was at the level of the heart. The nail plate was thoroughly cleaned with acetone/spirit. The initial examination was a dry examination (without any interface medium) though later a wet examination (using an interface medium) was done using ultrasound gel to see nail bed changes. Examination was done in both polarised and non-polarised mode. Photographs were taken after obtaining informed consent. In psoriasis patients, nail psoriasis severity index (NAPSI) was correlated with psoriasis area severity index (PASI). In other disorders, nail changes were correlated with body surface area (BSA).

Statistical analysis

Data entry was done in Microsoft Excel spreadsheet and all the statistical analysis was performed on the Statistical Package for the Social Sciences (SPSS) version 26. For quantitative data, mean ± standard deviation (SD) was used to define the data, whereas for qualitative data number and percentage (%) were used. Paired t-test was used to assess the statistical significance between various scores. McNemar's test was used to analyse the statistical significance between the various individual parameters observed clinically and dermoscopically. A P value of <0.05 was taken as significant for all the statistical tests. Strength of association between the various quantitative data was determined by the Pearson correlation coefficient test.


   Results Top


The total number of patients included in the study were 203. Of these, the male-to-female ratio was 1.3:1. The maximum number of patients were in the age group of 31–45 years (28.0%). Psoriasis (113 cases) was the most common papulosquamous disorder followed by lichen planus (42 cases) [Table 1]. Among the papulosquamous disorders, nail changes were present in 133 (65.5%) patients. Out of the 113 patients with nail changes, 69.9% of patients were male and 30.08% were female [Figure 1]. Pitting was overall the most common finding in both clinical and dermoscopic examinations [Table 2]. In 21 (10.3%) cases, biopsy was done to confirm the diagnosis. Out of 203 cases, psoriasis was reported in 113 (56%) patients. Out of the 113 patients, 70 (62%) were male and 43 (38%) were female. The majority of the patients with psoriasis were in the age group 31–45 years. Most of the patients had a disease duration between 6 and 10 yrs. Chronic plaque psoriasis was the most common presentation among psoriatic patients. Disease type has a significant relation with nail involvement (P < 0.05). Among 133 patients, 18 patients (15.9%) had joint involvement. 14 patients (77%) had nail involvement. Disease type had no significant relation with joint involvement. Mean PASI was 13.23 ± 5.55. Most of them had their PASI in the range of 11–15. Duration of disease had a significant correlation with PASI. The most common pattern of nail change observed was pitting (79%) [Figure 2] followed by onycholysis (49.5), both clinically and dermoscopically. Finger nail was more frequently involved than toe nail [Table 3] and [Figure 3]. Oil drop, splinter haemorrhage [Figure 5], pseudofibre sign [Figure 6], dilated capillaries [Figure 7] and hyponychial capillaries were detected better by dermoscopy than clinical examination (P < 0.05). Mean clinical NAPSI (cNAPSI) was 22.02 ± 18.89. Mean dermoscopic NAPSI (dNAPSI) was 25.49 ± 20.24. The paired t test for comparison between the clinical and dermoscopic NAPSIs showed that the dNAPSI score was significantly higher (P < 0.05) than the cNAPSI score. A positive correlation was also noted between the PASI score and the clinical and dermoscopic NAPSI scores [Table 4]. A strong correlation was observed between the duration of psoriasis and the clinical and dermoscopic NAPSI scores. In our study, the total number of patients with lichen planus was 42, out of which 19 were male and 23 were female. The maximum number of patients were in the 31–45 years age group in both male and female categories. Mean age was 32.71 ± 11.56 years. Mean duration of disease was 3.65 ± 3.19 years. Nail changes were present in 26% of cases. Thinning was the most common pattern and was seen in 8 patients followed by longitudinal striation in the finger nail. Longitudinal striation is most commonly seen in toe nails. Prevalence of all the nail changes was same in both clinical and dermoscopic observations [Table 5] and [Figure 4]. In pityriasis rosea, the male-to-female ratio was 1.18:1. Most of the patients were in the 16–20 age group. Only 8% had nail changes that was in the form of beau's line. Both patients having nail changes had a longer duration and recurrent episodes. A total of 8 cases of lichen nitidus were seen. Leukonychia was the only finding in 3 cases. The most common nail changes were seen in middle finger of left hand (F3). In lichen striatus, all the patients were children with age ranging from 3 to 12 years. Leukonychia was the only finding in one patient. In pityriasis lichenoides chronica, beau's line was the only nail change in a single patient out of 5 cases. Out of 3 parapsoriasis cases, one patient had beau's line on F5 nail. In pityriasis rubra pilaris nail plate thickening was the commonest finding. No difference between clinical and dermoscopic findings [Table 6]. Most common nail involved-T5, T6.
Figure 1: Age and sex distribution according to nail involvement

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Figure 2: Clinical (left) and dermoscopic (right) images showing coarse and irregular pitting

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Figure 3: Clinical (left) and dermoscopic (right) images showing subungual hyperkeratosis

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Figure 4: Clinical (left) and dermoscopic (right) images showing pterygium

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Figure 5: Dermoscopic image showing splinter haemorrhage

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Figure 6: Dermoscopic image showing pseudofibre sign

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Figure 7: Dermoscopic image showing dilated capillaries

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Table 1: Frequency of various papulosquamous disorders

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Table 2: Distribution of nail changes in papulosquamous disorders

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Table 3: Clinical and dermoscopic correlation of nail changes in psoriasis

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Table 4: Correlation between PASI and NAPSI

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Table 5: Comparative nail changes between clinical and dermoscopic examination

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Table 6: Clinical and dermoscopic correlation

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   Discussion Top


Totally 203 cases of papulosquamous disorders were enrolled in the study, in contrast to studies by David et al.[1] and Wali and Prasad,[2] who had included 50 patients in their study. In our study, 56% were psoriasis which was comparable with their study. Male-to-female ratio in our study was 1.3:1, whereas their study was a male predominant study.[1],[2]

Psoriasis

The male-to-female ratio was 1.6:1, consistent with Rajsekhar et al.,[3] whereas Chauhan et al.,[4] Wanniang et al.,[5] and Yadav and Khopkar[6] had a ratio of 2.66:1, 3.1:1, and 2.83:1, respectively. Age group was compatible with Rajsekhar et al.[3] Eighty percent had nail involvement which was compatible with Salomon et al.[7] Mean age in our study was similar to the study by Polat and Kapicioglu[8] (34.05 ± 15.9) and Daulatabad et al.[9] (36.3 ± 14.7). Mean duration of disease was comparable to Chauhan et al.[4] (5.29 ± 4.39), Rajsekhar et al.[3] (7.321 ± 6.371). Most common type of psoriasis was chronic plaque psoriasis in our study, which was compatible with Wanniang et al.'s[5] findings. Disease type had a significant relation with nail involvement (P < 0.05), whereas in the study by Kyriakou et al.[10] it had no relation.

In our study, pitting was the most common clinical and dermoscopic finding, whereas the most common clinical and dermoscopic findings were pitting (92.5%) and leukonychia (92.5%) in a study by Polat and Kapicioglu.[8] In Daulatabad et al.[9] pitting was the common finding (97.4%).

Most frequently observed dermoscopic features were splinter haemorrhage (73.1%) in Yorulmaz and Artuz,[11] whereas oil drop was present in 79.6% of patients with nail psoriasis in Kyriakou et al.[10]

Oil drop, splinter haemorrhage, dilated capillaries, pseudofibre sign, and hyponychial capillaries were detected better by dermoscopy than clinical examination (P < 0.05), whereas in the study by Wanniang et al.[5] splinter haemorrhage and salmon patch had significant difference.

The most common finger nail involved in our study was the thumb and index finger of the right hand, in contrast to Brazzelli et al.[12] who reported the fourth fingernail as the most affected in both hands.

Mean PASI was compatible with Daulatabad et al.[9] (14.4) and more compared to Chauhan et al.[4] (7.67), Polat and Kapicioglu[8] (10.61), and less compared to Wanniang et al. (19.80).[5]

Mean cNAPSI and mean dNAPSI was comparable with the study by Polat and Kapicioglu.[8]

The mean cNAPSI score was 23.82 ± 16.128, whereas the mean dNAPSI score was 26.68 ± 16.073 in Wanniang et al.[5] and the mean cNAPSI in Rajsekhar et al.[3] was 30.1 ± 29.19. Mean NAPSI was much higher in Daulatabad et al. (83.16).[9]

PASI and both clinical and dermoscopic NAPSIs had positive correlation which was comparable with Wanniang et al.[5] and Yorulmuz and Artuz.[11] The dNAPSI score was significantly higher (P < 0.05) than the cNAPSI score, comparable to Wanniang et al.[5]

A positive correlation was found between duration of disease and cNAPSI (R = 0.683), dNAPSI (R = 0.675), and PASI (R = 0.626), whereas weak correlation was observed between the duration of psoriasis and the dNAPSI score in the study by Wanniang et al.

The incidence of psoriatic arthritis in our study was 15.92% which was similar to van der Velden et al. (18.4%).[13]

Lichen planus

In this study, there was female predominance which was similar to the study by Żychowska and Żychowska,[14] and Sharma et al.[15] The age group most commonly affected was 31–45 years, which was comparable to studies by Kanvar et al.[16] Mean age was 32.71 ± 11.56 years which was less compared to that in the study by Zychowska and Zychowska[14] (53.27 ± 15.75 years), Wechsuruk et al.,[17] and Sharma et al.[15] Type of lichen planus and gender had significant relation with nail changes (P < 0.05). Age, duration of disease, and BSA had no relation with nail changes. In a study by Zychowska and Zychowska,[14] they found that nail involvement was independent of age, gender, presence of pruritus, the affected skin area, or the duration of CLP.

Out of 42 cases, 11 (26%) patients had nail changes which was compatible with the study by Zychowska and Zychowska (28%). Most of the patients (92%) had BSA <20% with mean BSA as 11.36 ± 7.68, comparable with the study by Zychowska and Zychowska.

Most common nail change was thinning (19.04%) whereas it was longitudinal ridging in the study by Zychowska and Zychowska[14] and Sharma et al.,[15] and melanonychia in Wechsuruk et al.[17]

Most common nail change observed in finger nail was thinning of nail plate, whereas it was longitudinal riding in the study by Zyschowska and Zychowska.[14]

The most common nail change in toe nail was longitudinal striation, whereas it was hyperkeratosis (82.7%) with yellowish discoloration (69.3%) in the study by Zychowska and Zychowska. No statistically significant difference between clinical and dermoscopic findings was observed.

In a study by Sharma et al.,[15] the difference in observations made clinically and dermoscopically was significant for both splinter haemorrhage and longitudinal melanonychia in LP.

In case of other papulosquamous diseases like PR and PRP ,beau's line and thickening of nail plate was the most common finding respectively which was compatible with previous studies.[18],[19] In lichen nitidus and lichen striatus, observations were similar to that in studies by Natarajan and Dick[20] and Vozza et al.,[21] respectively.


   Conclusion Top


From this study, we conclude that nail examination using dermoscopy aids in the diagnosis of the subtle changes in the nails of psoriasis patients, with significant difference between clinical and dermoscopic NAPSI. In other papulosquamous diseases, no difference was found between clinical and dermoscopic NAPSI. As PASI is significantly correlated with NAPSI.So nail changes were a comorbidity of psoriasis, not a isolated expression.you can put one comma after psoriasis. But in other diseases, BSA was not related with nail changes.

The NAPSI score would be helpful in following patient progress during treatment and would allow for the comparison between different treatment modalities. But NAPSI does not quantify the existing lesions and might not have the sensitivity to detect small changes: it must be used in conjunction with a tool that also assesses quality of life.

Leukonychia is a frequent finding in individuals without any nail disease. Therefore, it should be reconsidered whether inflammatory process of psoriasis leads to leukonychia or it is a more common finding and whether it should play a role in NAPSI score. In contrast, longitudinal ridges and beau's lines are common findings in fingernail psoriasis but are not included in the NAPSI.

Detection of irregularity and size of pitting was better in dermoscopic examination. Better visualisation of splinter haemorrhage and salmon patch were done using a dermoscope. Additional findings such as dilated capillaries, hyponychial capillaries and pseudofibre sign were also observed with the help of a dermoscope. Whether these features are specific to psoriasis or a coincidental finding needs to be further evaluated.

Dermoscopy is thus a valuable aid not only in enhancing visible nail features but also in revealing cryptic features of diagnostic value and reducing the requirement for invasive procedures like nail biopsies, early diagnosis, directing management, and improve the follow-up of the patient with respect to their response to treatment.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Key messages

To correlate clinical and dermoscopic findings in nail of papulosquamous disorders and to detect the changes in nail early and in a better way and to avoid the need for biopsy.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Chauhan A, Singal A, Grover C, Sharma S. Dermoscopic features of nail psoriasis: An observational, analytical study. Skin Appendage Disord 2020;6:207-15.  Back to cited text no. 4
    
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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