**7. Quality of life**

Nail psoriasis has been shown to severely impair quality of life (see Scoring of nail psoriasis). Pain, cosmetic embarrassment, impaired function, loss of dexterity are just some of the complaints brought forward by the patients (De Jong et al, 1996). More than 90% of the patients consider their nail psoriasis to be a significant social problem affecting their professional work, and more than half of them experienced pain (de Berker, 2009, Gupta and Cooper, 2009).

#### **7.1 Scoring of nail psoriasis**

To score the extent and severity of nail psoriasis the **nail psoriasis severity index** (NAPSI) was developed (Rich and Scher, 2003). Each nail is divided into 4 quadrants by a horizontal

Nail Psoriasis 161

without hesitation' or 'very painful'. Item 2 and 6 are specific for toe and finger nail psoriasis, respectively. Item 7 relates only to patients driving a car. Scores are transferred into percentages in order to be able to compare them always resulting in a maximum of 100. A test-retest questionnaire was sent out to a few patients yielding a very good reproducibility. NPQ10 scores are significantly higher in patients having both finger and toe nail psoriasis, in female psoriatics, and in patients with a shorter history of psoriasis (Ortonne et al, 2010). The NPQ10 score shows good correlation with the dermatology life

quality index (DLQI) (Finlay and Khan, 1994).

house:

or tights):

tempered with people:

2011).

State the location of your psoriasis of the nails 1. Fingernails 2. Toenails 3. Both

1. Would you say that your psoriasis of the nails is mostly:

1. Always 2. Sometimes 3. Never

1. Always 2. Sometimes 3. Never

1. Always 2. Sometimes 3. Never

1. Always 2. Sometimes 3. Never

1. Always 2. Sometimes 3. Never

1. Always 2. Sometimes 3. Never

1. Always 2. Sometimes 3. Never

1. Always 2. Sometimes 3. Never

1. Always 2. Sometimes 3. Never

Table 1. Questionnaire of the NPQ10 (Ortonne et al, 2010)

1. Very painful 2. Not very painful 3. Not painful

2. Because of my psoriasis of the nails, I have difficulty putting my shoes on:

4. Because of my psoriasis of the nails, I get dressed more slowly than usual:

6. Because of my psoriasis of the nails, I have trouble turning my door key:

7. Because of my psoriasis of the nails, I have trouble driving my car:

8. Because of my psoriasis of the nails, someone helps me to get dressed:

9. Because of my psoriasis of the nails, I avoid doing big jobs around the house:

10. Because of my psoriasis of the nails, I am more irritable than usual, and bad-

The **psoriasis weighted extent and severity index** (PWESI) evaluates the skin disease on a scale from 0 (none) to 4 (extensive) and severity of skin disease on a scale of 0 to 4 (intensely inflamed). Ten areas are assessed, among them hands/fingers/fingernails (Wittkowski et al,

The **extended 10-area linear psoriasis area and severity index (XL-PASI)** combines the PASI and PWESI scoring methods (Feldman and Krueger, 2005) and includes the assessment of surface area involved as well as dimension for scaling, erythema, thickness and joint involvement for specific areas of psoriatic involvement. As with the PASI, severity

3. Because of my psoriasis of the nails, I don't do any of the jobs I usually do around the

5. Because of my psoriasis of the nails, I have trouble putting on my socks (or stockings

and a vertical line. Nail matrix and nail bed are scored independently. Any of the matrix signs – pitting, leukonychia, red lunula spots and crumbling – as well as the nail bed signs – onycholysis, salmon or oil spots, subungual hyperkeratosis, splinter hemorrhage – are counted. Absence is given 0, presence in one quadrant 1, presence in two quadrants 2 etc up to 4 quadrants receiving 4. Matrix and nail bed signs are added resulting in a maximum score of 8 per nail. All finger nails can have a maximum NAPSI score of 80, finger and toenails of 160. All of the 8 individual features of matrix and nail bed psoriasis are just given one score independent from their number per quadrant. For a target nail, the same technique can be used to evaluate all 8 parameters (pitting, leukonychia, red spots in lunula, crumbling, oil drop, onycholysis, hyperkeratosis, and splinter hemorrhages) in each quadrant of the nail, giving that one nail a score of 0-32. The NAPSI is a useful tool for nail evaluation in the course of therapeutic studies, both for the effect on all nails as well as for the judgment of a target nail (Rich and Scher, 2003). Interobserver reliability for the total NAPSI score is good whereas the nail score only shows moderate agreement (Aktan et al, 2006).

The NAPSI has some limitations. It does not consider the number of pits or red spots of the lunula per quadrant nor the size of an oil spot or the thickness of subungual hyperkeratosis. This limits its use to assess improvement in the course of a treatment (Parrish et al, 2004). Therefore, an additional gradation was proposed for each sign from absent (= 0), mild (= 1), moderate (= 2) and severe (=3) as a qualitative scale similar to that used in the Psoriasis Area and Severity Index (PASI). Nail crumbling is given the same score like a pit, but is considerably more severe. Pustular psoriasis and psoriatic arthritis are not included in the NAPSI.

A **modified NAPSI** was developed for patients with psoriatic arthritis (Maejima et al, 2010). This modified NAPSI is higher in patients with psoriasis of the proximal nail fold, distal interphalangeal (DIP) joint arthritis whereas there was no correlation with the modified NAPSI and other systemic signs. Nail psoriasis was assumed to be related to the Koebner phenomenon and local inflammatory DIP joint arthritis in PsA patients, and nail involvement in PsA was suggested to be among the disorders indicative of distal phalanx enthesitis (Tan et al, 2007, Elder et al,2010).

Nail psoriasis has both a physical and psychological impact on the patients negatively influencing their quality of life (QoL). A **nail psoriasis quality of life index** (NPQ10) was developed to measure life quality impairment due to nail psoriasis and its modification in the course of treatment (Ortonne et al, 2010). Again, psoriatic arthritis patients are not included in the NPQ10. Of the 17000 members of the French Association pour la lutte contre le psoriasis, 4000 were asked to fill in a questionnaire regarding the physical aspects of nail psoriasis. Roughly one third responded and 795 of them had nail psoriasis. The items were elaborated by physicians and patients alike. The patients rated their nail psoriasis as bothersome in 86%, as unsightly in 87%, and as painful in 59%. The number of nails involved significantly affected the pain, aesthetic and functional impairment. Whereas 86% received therapy, 72% were dissatisfied with their treatment. From these facts, 10 questions were created, only one of which concerned pain, the other 9 were related to functional handicaps in daily life. Answers are scored from 0 to 2 with 0 being 'no without hesitation' (absent) or 'not painful', 1 not for 'yes sometimes' or 'not very painful', and 2 for 'yes

and a vertical line. Nail matrix and nail bed are scored independently. Any of the matrix signs – pitting, leukonychia, red lunula spots and crumbling – as well as the nail bed signs – onycholysis, salmon or oil spots, subungual hyperkeratosis, splinter hemorrhage – are counted. Absence is given 0, presence in one quadrant 1, presence in two quadrants 2 etc up to 4 quadrants receiving 4. Matrix and nail bed signs are added resulting in a maximum score of 8 per nail. All finger nails can have a maximum NAPSI score of 80, finger and toenails of 160. All of the 8 individual features of matrix and nail bed psoriasis are just given one score independent from their number per quadrant. For a target nail, the same technique can be used to evaluate all 8 parameters (pitting, leukonychia, red spots in lunula, crumbling, oil drop, onycholysis, hyperkeratosis, and splinter hemorrhages) in each quadrant of the nail, giving that one nail a score of 0-32. The NAPSI is a useful tool for nail evaluation in the course of therapeutic studies, both for the effect on all nails as well as for the judgment of a target nail (Rich and Scher, 2003). Interobserver reliability for the total NAPSI score is good whereas the nail score only

The NAPSI has some limitations. It does not consider the number of pits or red spots of the lunula per quadrant nor the size of an oil spot or the thickness of subungual hyperkeratosis. This limits its use to assess improvement in the course of a treatment (Parrish et al, 2004). Therefore, an additional gradation was proposed for each sign from absent (= 0), mild (= 1), moderate (= 2) and severe (=3) as a qualitative scale similar to that used in the Psoriasis Area and Severity Index (PASI). Nail crumbling is given the same score like a pit, but is considerably more severe. Pustular psoriasis and psoriatic arthritis

A **modified NAPSI** was developed for patients with psoriatic arthritis (Maejima et al, 2010). This modified NAPSI is higher in patients with psoriasis of the proximal nail fold, distal interphalangeal (DIP) joint arthritis whereas there was no correlation with the modified NAPSI and other systemic signs. Nail psoriasis was assumed to be related to the Koebner phenomenon and local inflammatory DIP joint arthritis in PsA patients, and nail involvement in PsA was suggested to be among the disorders indicative of distal phalanx

Nail psoriasis has both a physical and psychological impact on the patients negatively influencing their quality of life (QoL). A **nail psoriasis quality of life index** (NPQ10) was developed to measure life quality impairment due to nail psoriasis and its modification in the course of treatment (Ortonne et al, 2010). Again, psoriatic arthritis patients are not included in the NPQ10. Of the 17000 members of the French Association pour la lutte contre le psoriasis, 4000 were asked to fill in a questionnaire regarding the physical aspects of nail psoriasis. Roughly one third responded and 795 of them had nail psoriasis. The items were elaborated by physicians and patients alike. The patients rated their nail psoriasis as bothersome in 86%, as unsightly in 87%, and as painful in 59%. The number of nails involved significantly affected the pain, aesthetic and functional impairment. Whereas 86% received therapy, 72% were dissatisfied with their treatment. From these facts, 10 questions were created, only one of which concerned pain, the other 9 were related to functional handicaps in daily life. Answers are scored from 0 to 2 with 0 being 'no without hesitation' (absent) or 'not painful', 1 not for 'yes sometimes' or 'not very painful', and 2 for 'yes

shows moderate agreement (Aktan et al, 2006).

are not included in the NAPSI.

enthesitis (Tan et al, 2007, Elder et al,2010).

without hesitation' or 'very painful'. Item 2 and 6 are specific for toe and finger nail psoriasis, respectively. Item 7 relates only to patients driving a car. Scores are transferred into percentages in order to be able to compare them always resulting in a maximum of 100. A test-retest questionnaire was sent out to a few patients yielding a very good reproducibility. NPQ10 scores are significantly higher in patients having both finger and toe nail psoriasis, in female psoriatics, and in patients with a shorter history of psoriasis (Ortonne et al, 2010). The NPQ10 score shows good correlation with the dermatology life quality index (DLQI) (Finlay and Khan, 1994).


Table 1. Questionnaire of the NPQ10 (Ortonne et al, 2010)

The **psoriasis weighted extent and severity index** (PWESI) evaluates the skin disease on a scale from 0 (none) to 4 (extensive) and severity of skin disease on a scale of 0 to 4 (intensely inflamed). Ten areas are assessed, among them hands/fingers/fingernails (Wittkowski et al, 2011).

The **extended 10-area linear psoriasis area and severity index (XL-PASI)** combines the PASI and PWESI scoring methods (Feldman and Krueger, 2005) and includes the assessment of surface area involved as well as dimension for scaling, erythema, thickness and joint involvement for specific areas of psoriatic involvement. As with the PASI, severity

Nail Psoriasis 163

b) Fig. 21. Psoriatic onycholysis demonstrates a livid-red proximal margin (A), which is not

There are also many histopathological signs in common of onychomycosis and nail psoriasis (Table 3). This may render the differential diagnosis between these two frequent nail conditions very difficult if not impossible. Furthermore, it is possible that both onychomycosis and psoriasis are present in the same subject in different digits as well as in the same nail (Fig.22). It is therefore self-evident that a specimen sent for histopathological diagnosis of nail psoriasis is also stained with periodic acid-Schiff (PAS) or another fungal

seen in mycotic onycholysis (B).

stain like silver-methene amine (Grocott).

a)

is graded from 0 to 4 and body surface is divided into ten areas and each is quantified. The XL-PASI scale ranges from 0 to 148 (Wittkowski et al, 2011).
