Nail Pitting Psoriatic Arthritis

Nail Pitting Psoriatic Arthritis, Psoriatic arthritis Onychodystrophy is statistically more common in patients with psoriatic arthritis than in patients with psoriasis vulgaris, presenting in 67%  to 83% 1841 to 86.5% 1851 to 88% 1861 of arthritic patients. In one study, psoriasis nail changes were able to predict thc onset of psoriatic arthritis with a risk ratio of 2.24 on multi variant analysis 1871. Zaias and Norton felt that the relationship between nail psoriasis and distal interphalangeal psoriatic joint involvement is unclear.

However, many other investigators disagree. Some reports show an association between the degree of arthritis and the presence of nail dystrophy, but not on the same digit. Baker et al. 1841 noted that clinical nail changes were unrelated to the distribution of the joint involvement. Lavaroni at reported that die more severe the arthritis, the greater the degree of nail involvement. However, there was no relationship found between arthritis of the distal joints and psoriatic nail change in the same digit.

 In a study of 69 patients with psoriatic arthritis. Williamson at  found that the more severe the nail psoriasis. the more unremitting and progressive was the arthritis (P <0.001). Other reports show an association between the arthritis and the nail dystrophy in the same finger. In a study by Jones et at [831 of 100 patients with psoriatic arthritis, there was a significant correlation between disease of the distal interphalangeal joint and disease in the adjacent nail.

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Wright at found nail changes in all patients with distal arthritis and in 88% of patients with deforming arthritis. Support for the association between arthritis and nail disease in the same finger can be found in the concept of psoriatic "nail matrix arthropathy." This concept unites the two conditions by the fact that the nail matrix and the terminal interphalangeal joint share the same blood supply 188, 891.

 Further evidence of a relationship between inflammation in the joint and nail dystrophy can be found in magnetic resonance imaging (MRI) and pathology studies that emphasize the anatomical relationship between the fingernail, the ligament enthesis and the distal interphalangeal joint.

The nail is actually a part of the "enthesis organ" which is composed of nail. ligament, tendon and bone. Other investigators support this theory. The joint collateral ligament enthesis has fibers that merge with the lateral borders of the nail anchoring the nail to the underlying periosteum 192]. Diffuse inflammation envelops the nail root and adjacent bone. These studies suggest that nail findings in psoriatic arthritis are an extension of entheseal inflammatory changes and are a part of arthritis.

Scarpa at  found that subchnical MRI nail involvement was present in almost all patients with psoriatic arthritis studied. including those without clinically evident nail dystrophy. Subclinical entheseal abnormalities were also documented via ultrasound in asymptomatic psoriasis patients 1951.

The tendon dorsal capsular enthesis appears to be the epicenter of the inflammatory reaction 1911 Tan et al 1911 commented that She nail is as much an integral part of the enthesis organ as it is of the skin.' Inflammation of the distal interphalangeal joint extends along enthuses] structures to involve the nail matrix and nail bed.

Proximal nail matrix involvement can lead to pitting; nail bed involvement can lead to onycholysis. If nail changes in psoriasis are an extension of the joint and are therefore a prediction of the development of psoriatic arthritis, this association may have a broader implication in the potential use of systemic medications. particularly systemic biological agents, in controlling psoriatic nail disease and preventing future psoriatic arthritis, a premise that merits further investigation.

Love at  commented that 'this growing body of knowledge suggests that nail changes deserve increased attention in the evaluation of patients with psoriasis and psoriatic arthritis.' Clinical nail changes in patients with psoriatic arthritis vary from mild pitting to gross destruction 1841. Lavaroni et at [85] found great toenail subungual hyperkeratosis to be the most common finding, followed by fingernail pitting.

Love at 1961 found that onycholysis was the nail change most strongly associated with small joint disease in psoriatic arthritis. This study found no association between small joint arthritis and pitting, oil spots or subungual hyperkeratosis. Juvenile psoriatic arthritis is defined through major and minor criteria.

The major criterion is arthritis associated with. but not necessarily coincident with, a typical psoriatic rash. Three of four minor criteria must be satisfied: dactylitis, nail pitting. psoriasis-like rash. and/or a family history of psoriasis. In childhood, there is a strong correlation between distal arthritis and nail dystrophy 1981.

Interestingly, juvenile psoriatic arthritis may have more in common with juvenile rheumatoid arthritis than other seronegative spondylarthropathies with which it is traditionally associated. In 50 children in whom juvenile arthritis was the presenting complaint, 67% had nail pitting as the most common associated feature of psoriasis and IX% went on to develop the cutaneous psoriasis 1241.

 A separate subgroup of juvenile psoriatic arthritis is represented by young females with widespread plaque-type or suberythrodermic psoriasis with a strong family history of psoriasis. a strong family history of autoimmune disease, nail changes and large joint arthropathy.

Source:

Baran and Dawber's Diseases of the Nails and their Management

editat de Robert Baran,David A. R. de Berker,Mark Holzberg,Luc Thomas

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