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Clin Rheumatol (2007) 26:12451247

DOI 10.1007/s10067-006-0476-y

ORIGINAL ARTICLE

The relationship between nail- and distal phalangeal bone


involvement severity in patients with psoriasis
Gamze Serarslan & Hayal Gler & Sinem Karazincir

Received: 29 September 2006 / Revised: 18 October 2006 / Accepted: 19 October 2006 / Published online: 22 November 2006
# Clinical Rheumatology 2006

Abstract We aimed to investigate the relationship between


nail involvement and joint manifestations and whether there
was a correlation between nail psoriasis severity and bone
manifestations in psoriatic patients without symptomatic
psoriatic arthritis in plaque type psoriasis. Thirty-one
patients with nail involvement (16 men, 15 women, mean
age 45.2918.73) and 39 patients without nail involvement
(16 men, 23 women, mean age 38.4117.33) were enrolled
in the study. X-ray of the hands and feet with magnification
were performed. The distal interphalangeal (DIP) joint and
bone (tuft of terminal phalanx) were evaluated. A scoring
method was performed on the patients with nail involvement. There was no difference in DIP joint involvement in
patients with or without finger- and toenail involvement
(p=0.085 and p=0.062, respectively). However, the prevalence of bone involvement was higher in patients with
finger- and toenail involvement than without finger- and
toenail involvement (p=0.039 and p=0.021, respectively). A
G. Serarslan
Department of Dermatology, Faculty of Medicine,
Mustafa Kemal University,
Antakya, Turkey
H. Gler
Department of Physical Medicine and Rehabilitation,
Faculty of Medicine, Mustafa Kemal University,
Antakya, Turkey
S. Karazincir
Department of Radiology, Faculty of Medicine,
Mustafa Kemal University,
Antakya, Turkey
G. Serarslan (*)
Akevler Mah. 6/1 Sok. Melis Apt., C Bl. 5/12,
31100 Antakya/Hatay, Turkey
e-mail: gserarslan@hotmail.com

positive correlation was also determined between fingerand toenail psoriasis severity and bone involvement
severity (r=0.379, p=0.001 and r=0.288, p=0.015).
Keywords Bone . Distal interphalangeal . Erosions . Nail .
Psoriasis . Psoriatic arthritis

Introduction
Psoriatic nail involvement is a common finding of psoriasis,
and in many patients, both the matrix and nail involvement
is present. At least 70% of patients with psoriatic arthritis
(PsA) have nail changes [1]. In previous studies, association between nail involvement and joint manifestations
have been studied. Distal interphalangeal (DIP) joint
involvement associated with nail dystrophy in PsA has
been shown by Jones et al. [2]. Patients with more severe
nail disease have worse skin disease and higher rates of
unremitting and progressive arthritis with associated functional impairment [3].
However, the relationship between joint, bone and nail
psoriasis in patients without PsA has not been reported
previously. We aimed to investigate the relationship
between the nail involvement and bone and joint manifestations and whether there was a correlation between nail
psoriasis severity and bone involvement severity in psoriatic patients without PsA.

Materials and methods


Seventy patients with plaque type psoriasis and without
signs and symptoms of joint swelling, pain and tenderness
were included in the study. Full demographic details and

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Clin Rheumatol (2007) 26:12451247

history of the disease was recorded for each patient.


Psoriasis severity was graded according to the Psoriasis
Area Severity Index (PASI). Patients with PsA or other
joint diseases such as systemic lupus erythematosus and
rheumatoid arthritis were excluded from the study. The
mean duration of the disease with and without nail
involvement was 6.227.64 years and 6.427.48 years,
respectively. Erythrocyte sedimentation rate and C-reactive
protein were within normal limits in all patients. Romatoid
factor titres of the patients were negative. A consent form
was obtained from the patients.
Diagnosis of the psoriatic nail involvement was made
clinically. Onychomycosis was excluded by KOH examination and cultures. Pustular psoriasis of the nails was not
included in the study. The severity of nail disease was
scored by using the method described by Rich et al. [4].
The nail plate was assessed for nail matrix psoriasis by the
presence of nail pitting, leukonychia, red spots in the lunula
and crumbling. Nail bed psoriasis was assessed by the
presence of onycholysis, oil drop dyschromia, splinter
hemorrhages and hyperkeratosis. If only finger- or toenail
involvement was present, a target nail was selected. If both
finger- and toenail involvement was present in a patient,
two target nails were selected from both finger- and toenail
and evaluated separately. According to the scoring method,
lower than 4 was accepted as mild, between 5 and 7 was
accepted as moderate, and more than 8 was accepted as
severe nail psoriasis [4].
X-ray of the hands and feet with magnification were
performed in patients with and without nail involvement. The
presence of erosion was accepted as DIP involvement. Tuftal
involvement was evaluated and graded from 0 to 4. Zero
indicated no lesion, 1 indicated tuftal minimal erosion, 2
indicated tuftal bone resorption, 3 indicated tuftal periostal
osteitis, and 4 indicated overlap of erosion and osteitis [5].
Fishers exact test, chi-square test, Pearson chi-square,
MannWhitney U test and correlations were used for
statistical analysis. Values are given as meanstandard
deviation.

Results
Thirty-one psoriasis patients with nail involvement (16 men
and 15 women, mean age 45.2918.73; group I) and 39

Table 2 Tuftal changes in patients with and without finger- and


toenail involvement

Fingernail
Toenail

Involved
Not involved
Involved
Not involved

Tuft (+)

Tuft ()

p value

17
19
10
10

8
26
11
39

0.039
0.021

psoriasis patients without nail involvement (16 men and 23


women, mean age 38.4117.33; group II) were enrolled in
the study. The mean duration of the disease was 6.22
7.64 years and 6.427.48 years, respectively. The mean
PASI was 5.93.2 in group I and 6.53.0 in group II.
There was no statistical significance between the two
groups of gender, mean age, duration of the disease and
PASI score (p>0.05). Nail psoriasis severity was scored as
mild in 18 fingernails and 20 toenails, moderate in 4
fingernails and 1 toenail and severe in 3 fingernails
(Table 1).
There was no difference in DIP involvement in patients
with and without finger- and toenail involvement (p=0.089
and p=0.578, respectively). However, bone involvement
was higher in patients with finger- and toenail involvement
than without finger- and toenail involvement (p=0.039 and
p=0.021, respectively; Tables 2 and 3).
We determined that there was a positive correlation
between finger- and toenail psoriasis severity and bone
involvement severity (r=0.379, p=0.001 and r=0.288, p=
0.015).

Discussion
In this study, we determined that (1) DIP involvement was
present in the two groups regardless of nail involvement,
(2) bone involvement was higher in patients with nail
involvement than patients without nail involvement, and (3)
there was a correlation between nail psoriasis severity and
bone involvement severity.
The inflammatory process of PsA in the peripheral joints
can induce bone damage without clinical signs of arthritis
or a very recent onset of the symptomatic disease [6]. DIP
Table 3 DIP involvement in patients with and without finger- and
toenail involvement

Table 1 Nail psoriasis severity


Fingernail (n)

Toenail (n)

18
4
3

20
1

Fingernail
Mild
Moderate
Severe

Toenail

Involved
Not involved
Involved
Not involved

DIP (+)

DIP ()

p value

5
2
2
2

20
43
19
47

0.089
0.578

Clin Rheumatol (2007) 26:12451247

joint involvement and nail dystrophy are distinctive clinical


features of PsA. With regard to nail involvement in PsA, it
has been suggested that nail lesions are the only clinical
features that identify patients with psoriasis who are destined
to develop arthritis [7]. A relationship has been shown
previously between joint involvement and nail involvement
in PsA in several studies. Elkayam et al. [8] found an
association between nail involvement and deformed joints.
Kane et al. [9] also reported that DIP involvement was
associated with enthesopathy and nail dystrophy and
hypothesized that it may be due to the close anatomical
proximity of the nail bed and the ligamentous capsule of
DIP joint. Williamson et al. [3] suggested that nail
involvement may provide a mechanistic link between skin
and joint disease in PsA. In our study, we showed that nail
psoriasis severity was correlated with bone involvement
severity but not DIP involvement in patients without PsA.
In one study, fingernails of patients with psoriatic
onychopathy and patients with PsA without onychopathy
have been evaluated. They have found no statistical
difference in the distribution of DIP involvement in patients
with or without onychopathy [5]. In our study, we also did
not find a difference in the DIP involvement between
patients with and without nail involvement of finger and
toe. The authors also showed that irrespective of the
presence of DIP involvement, patients with onychopathy
showed a more marked bone involvement than patients
with PsA without nail involvement [5]. Our results also
confirmed these findings.
In conclusion, DIP involvement was present in the two
groups regardless of nail involvement; however, bone
involvement was higher in patients with nail involvement
than patients without nail involvement, and a correlation

1247

was detected between nail and bone involvement severity in


patients without PsA. Therefore, whether the psoriatic
patients with nail involvement are prone to develop PsA
remains to be determined by further prospective studies.

References
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Dermatology, second completely revised edition. Springer, Berlin
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NJ (1994) Psoriatic arthritis: outcome of disease subsets and
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Wordsworth BP (2004) Extended report: nail disease in psoriatic
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