British Journal of Dermatology 2004; 150: 568569.

CONCISE COMMUNICATION

A nail psoriasis severity index

R.L.BARAN
Nail Disease Centre, 42 rue des Serbes, 06400 Cannes, France

Accepted for publication 1 August 2003

Summary

Background The Psoriasis Area and Severity Index does not take the severity of nail involvement
into account.
Objectives To devise a system of scoring for nail psoriasis.
Methods A system of scoring for nail psoriasis was devised that takes into account the site of the
pathology, i.e. (i) the matrix, (ii) the subungual tissues distal to the lunula, or (iii) the whole nail
unit.
Results The proposed scoring system evaluates several signs of nail psoriasis separately, each on a
13 scale: pitting, Beaus lines, subungual hyperkeratosis and onycholysis.
Conclusions Using this classification it will be possible to assess and grade nail pathology simply and
accurately.
Key words: index of severity, nail psoriasis, scoring

The Psoriasis Area and Severity Index scale is almost

universally accepted as the criterion for assessment of
psoriasis of the skin. However, it does not specifically
consider the severity of nail involvement. Evaluation of
treatment for nail psoriasis must take into account the
severity of the disease and whether it is limited to the nail
or extends to the skin, locally or generally. A scale for the
assessment of nail psoriasis is therefore necessary.
To achieve its effect, a drug must be able to reach the
site of pathology. Therefore nail penetration is a major
therapeutic problem. With the exception of clobetasol
nail lacquer1 and ciclosporin,2 attempts to apply
medication to the affected area include deposition of
the drug around the nail, e.g. for 5-fluorouracil,3 or by
rubbing with cream, ointment4 (calcipotriol) or foam5
(clobetasol).

Materials and methods

A system of scoring for nail psoriasis was devised that
takes into account the site of the pathology, i.e. (i)
matrix involvement; (ii) involvement of the subungual
tissues distal to the lunula; or (iii) involvement of the
Correspondence: Robert Baran.
E-mail: baran.r@club-internet.fr

568

whole nail unit. Nail matrix involvement may be

subdivided further: involvement of the proximal matrix
produces pitting, Beaus lines, onychomadesis which
leads to nail loss, and trachyonychia, whereas involvement of the intermediate matrix is responsible for
leuconychia. Involvement of the subungual tissues
distal to the lunula results in subungual hyperkeratosis, onycholysis, splinter haemorrhages or oily spots. In
total involvement, the whole nail unit may be affected,
i.e. the matrix, nail bed and hyponychium, and
proximal nail fold.

Results
It is too imprecise to establish the scoring as: 1,
slight; 2, moderate; 3, extensive. Instead, the proposed scoring system evaluates several signs of nail
psoriasis.
For nail surface involvement such as pitting, the
number of pits should be counted and scored as: 1,
slight, fewer than 10 pits; 2, moderate, between 10 and
20 pits; 3, severe, more than 20 pits.
Beaus lines, which are composed of contiguous pits,
may be scored in the same way as pitting: 1, one
transverse groove; 2, two or three grooves; 3, more
than three grooves.
2004 British Association of Dermatologists

NAIL PSORIASIS SEVERITY INDEX

569

calculation to record the area of nail involvement as: 1,

slight, less than 25%; 2, moderate, 2550%; 3, severe,
more than 50%.
Trachyonychia, leuconychia and oily spots may also
benefit from this type of calculation. However, splinter
haemorrhages, which are often of traumatic origin,
should not be taken into account, nor should onychomadesis or nail loss. These should be just noted, and
nail regrowth awaited in order to check the features of
the affected nail(s).
The assessment of psoriasis nail involvement should
be recorded for each digit, i.e. fingers as well as toes.

Discussion
Using this classification it will be possible to assess and
grade nail pathology simply and accurately. Matrix
pathology may be identified if the nail surface is
affected, with or without leuconychia. It is not more
difficult to localize the pathology when the subungual
tissues distal to the lunula present with abnormalities.
It seems logical to evaluate both the scoring of each
sign and a global score, that is the overall summation
of the severity of each sign.

References
Figure 1. (A) Calliper used for evaluating subungual hyperkeratosis.
(B) Scheme allowing assessment of onycholysis and trachyonychia.

Subungual hyperkeratosis may be evaluated with a

calliper (Fig. 1A) as follows: 1, slight, less than 2 mm;
2, moderate, 23 mm; 3, severe, more than 3 mm.
To score onycholysis, the area involved should be
calculated by dividing the nail into eight portions as
shown in Figure 1B, where three horizontal lines divide
the nail into four segments each of 25% and a vertical
line divides each segment into two portions, leaving
small segments of 125%. It is easy using this method of

1 Baran RL, Tosti A. Topical treatment of nail psoriasis with a new

corticoid-containing nail lacquer formulation. J Dermatol Treat
1999; 10: 2014.
2 Cannavo SP, Guarneri F, Vaccaro M et al. Treatment of psoriatic
nails with topical cyclosporin: a prospective, randomized placebocontrolled study. Dermatology 2003; 206: 1536.
3 Fritz K. Erfolgreiche Lokalbehandlung der Nagelpsoriasis mit
5-Fluorouracil. Z Hautkr 1989; 64: 10838.
4 Kokelj F, Lavaroni G, Piraccini BM, Tosti A. Nail psoriasis treated
with calcipotriol: an open study. J Dermatol Treat 1994; 5: 149
50.
5 Spuls P, Lebwohl M. Treatment of nail psoriasis. Workshop 7. In:
Abstracts from the 9th International Psoriasis Symposium, New
York, NY, USA, 1722 June 2003; 128.

2004 British Association of Dermatologists, British Journal of Dermatology, 150, 568569