Ultrasonographic assessment of nail in psoriatic disease shows a link between onychopathy and distal interphalangeal joint extensor tendon enthesopathy.

We compared ultrasonography (US) with the modified nail psoriasis severity index (mNAPSI) to investigate the nail plate, nail matrix and adjacent tendons in subjects with psoriatic nail disease and to test the hypothesis that nail involvement was specifically linked to extensor tendon enthesopathy. 86 psoriatic patients (169 nails) and 20 healthy controls (HC) (40 nails) were assessed with both the mNAPSI and US. The thickness of the nail plate, nail matrix region and adjacent extensor tendon were assessed and compared with physical examination findings. A good agreement between clinical and sonographic nail findings was noted (kappa value = 0.52, p < 0.0001). Entheseal thickening of the extensor tendon on US was more frequent in patients with clinical nail disease compared to patients without clinical nail disease in both psoriasis and psoriatic arthritis (38 vs. 16%, p = 0.03, and 47 vs. 19%, p = 0.008, respectively). Nail thickness, nail matrix and adjacent skin thickness were higher in psoriatic patients compared to HC. US and clinical findings show good correlation for the assessment of the nail in psoriatic disease. The demonstration of extensor tendon enthesopathy in both psoriasis and psoriatic arthritis supports the importance of enthesopathy in nail disease pathogenesis whether or not clinical arthritis is present.

Aydin SZ ，Castillo-Gallego C ，Ash ZR ，Marzo-Ortega H ，Emery P ，Wakefield RJ ，Wittmann M ，McGonagle D ... -  《-》

Subclinical enthesopathy of extensor digitorum tendon is highly prevalent and associated with clinical and ultrasound alterations of the adjacent fingernails in patients with psoriatic disease.

Nail psoriasis disease is associated with an increased probability of psoriatic arthritis, and its clinical signs may have different correlates with the pathogenesis of adjacent bone destruction and have different prognostic value. Recent publications about psoriasis and nail psoriatic disease describe different ultrasonographic findings but the relationship between these ungueal alterations measured by ultrasonography and the presence of enthesopathy of the extensor digitorum has yet to be discovered. To describe which ultrasonographic characteristics of nail psoriasis are associated with the presence of subclinical enthesopathy in patients with PsO and asymptomatic PsA. Patients with psoriasis and asymptomatic psoriatic arthritis were included in the prospective study. Demographic, clinical data and PASI and NAPSI indexes were recorded of all the patients in the assessment visit. The US assessment included Achilles tendon, extensor digitorum tendon and US scan of the nail plate, nail matrix, nail bed and adjacent skin over nail matrix of the five nails of each hand. Forty-eight patients were included in the study; 33 of them presented ultrasound evidence of extensor digitorum tendon enthesopathy. Nails of the patients with subclinical enthesopathy had a higher NAPSI and skin thickness than the nails of the patients without subclinical enthesopathy (P = 0.047). Patients with asymptomatic enthesopathy had significantly thicker proximal nail folds (1.44 ± 0.312 vs. 1.23 ± 0.27, P = 0.023). Nail beds and matrices were also thicker but the differences were not statistically significant (1.77 ± 0.27 vs. 1.74 ± 0.21, P = 0.66, and 1.79 ± 0.28 vs. 1.67 ± 0.19, P = 0.10, respectively). No statistically significant differences in the trilaminar structure were found between both groups. Patients with and without asymptomatic enthesopathy of extensor digitorum tendons did not statistically differ as regards ultrasonographic alterations of the Achilles tendons (60.6% vs. 46.4%, P 0.368). Enthesopathy abnormalities can be detected by US in patients with psoriasis without musculoskeletal complaints frequently. There is a close relationship between subclinical enthesopathy of the extensor digitorum tendon and the presence of nail alterations. Further studies are required to research what implications have the presence of these ungual alterations measured by US, and how it affects later development of a PsA.

Moya Alvarado P ，Roé Crespo E ，Muñoz-Garza FZ ，López-Ferrer A ，Laiz Alonso A ，Vilarrassa Rull E ，Casademont I Pou J ，Puig Sanz L ... -  《-》

Ultrasound entheseal abnormalities at the distal interphalangeal joints and clinical nail involvement in patients with psoriasis and psoriatic arthritis, supporting the nail-enthesitis theory.

It has been shown that nail involvement in psoriasis is associated with systemic enthesopathy. Our objective was to evaluate the association of nail involvement and enthesopathy at distal interphalangeal joint (DIP) level in psoriasis (PsO) and psoriatic arthritis (PsA) patients. Consecutive patients (54 PsO and 56 PsA) seen at the outpatients clinic in this cross-sectional study were included. All patients underwent both clinical and ultrasound (US) assessment on the same day. US revealed enthesopathy in at least 1 DIP joint in 9 patients with PsO (17%, 95% CI: 8-29%) and in 18 patients with PsA (32%, 95% CI: 20-46%). US extensor tendon enthesopathy was detected in a higher proportion of fingers with clinical nail involvement compared with fingers without clinical nail involvement, both in PsO and PsA patients (61.2% vs 16.8%, p < 0.0001 and 60.1% vs 22%, p < 0.0001, respectively). Among patients with PsO, 20% (95% CI: 7-41%) and 14% (95% CI: 4-32%) of those with and without clinical nail involvement showed enthesopathy on US examination, respectively (p = 0.54). Among PsA patients, the prevalence of enthesopathy was 30% (95% CI: 15-49%) for patients with clinical nail involvement and 35% (95% CI: 17-56%) for those without nail involvement (p = 0.71). Nail disease was associated with DIP US enthesopathy. There was a significant increased prevalence of extensor tendon enthesopathy in fingers with involved nails both in PsO and PsA, although no association was found between nail involvement and extensor tendon enthesopathy at patients' level. These features might support the nail-entheseal pathogenesis theory at DIP level.

Acosta-Felquer ML ，Ruta S ，Rosa J ，Marin J ，Ferreyra-Garrot L ，Galimberti ML ，Galimberti R ，Garcia-Monaco R ，Soriano ER ... -  《-》

Ultrasound nail assessment in patients with psoriasic arthritis: is there an association of findings with clinical scores?

Psoriatic arthritis can involve several domains. Due to its multifaceted nature and its frequent comorbidities such as depression, obesity, osteoarthritis and fibromyalgia, it is difficult to monitor these patients because the clinical scores involve subjective data. High-resolution ultrasound probes allowed the evaluation of more superficial structures, such as the nails and their synovio-entheseal framework, in close relationship with the enthesis of the distal extensor digitorum tendon. Nail ultrasound studies vary in terms of the parameters and fingers studied and in their findings. To describe the most significant sonographic nail changes and the most affected fingers in psoriatic arthritis and to verify the association of nail ultrasound findings with clinical scores (nail psoriasis severity index (NAPSI), ankylosing spondylitis disease activity score with C-reactive protein (ASDAS-CRP), minimal disease activity (MDA), disease activity index for psoriatic arthritis (DAPSA)). This was a cross-sectional study with 52 patients with psoriatic arthritis at the Hospital de Clínicas do Paraná and 50 controls. A total of 1016 nails were analyzed (517 from patients with psoriatic arthritis and 499 from controls). Ultrasonography of the nails of the 10 fingers was performed to assess the trilaminar appearance, measure the distance from the nail bed, identify synovitis of the distal interphalangeal joints and the presence of a power Doppler signal from the nail matrix/nail bed. The captured images were independently evaluated by a rheumatologist with expertise in musculoskeletal ultrasound. Data analysis was performed using IBM SPSS Statistics v.28.0.0 software, and the association of nail plate changes, nail bed distance and power Doppler signal with the NAPSI, DAPSA, MDA and ASDAS-PCR were calculated. Spearman correlation coefficients were estimated to analyze the correlations between pairs of quantitative variables. Student's t test and the Mann‒Whitney U test were used to compare quantitative variables, and Fisher's exact test was used to compare categorical variables between patients and controls. The nonparametric Mann‒Whitney U and Kruskal‒Wallis tests were used to compare groups according to the MDA or DAPSA classification. The Doppler signal of the nail matrix and nail bed was more frequently identified in patients (44.2%) than in controls (6%), and the difference in the mean power Doppler signal between the two groups was significant (p < 0.001). Changes in the nail plate were more common in the right thumb (44.2%), left thumb (36.5%) and second finger on the right hand (32.7%). The number of fingers with nail plate changes, enthesitis, paratendinitis, grayscale synovitis and DIP involvement in the distal interphalangeal joints was higher among patients with psoriatic arthritis (p < 0.001). There were found some correlations between US findings and clinical scores: ultrasound nail involvement and the NAPSI score (p = 0.034), the number of fingers and mean change in the nail plate and the ASDAS-CRP (p = 0.030). DAPSA (remission/low activity versus moderate/high activity) was associated to the mean change in the nail plate (p < 0.013). Nail ultrasound has the potential to assist in the capturing of the actual disease activity status in patients with psoriatic arthritis.

Mehl AC ，Schmidt LM ，Azevedo VF 《Advances in Rheumatology》

Distal interphalangeal joint extensor tendon enthesopathy in patients with nail psoriasis.

Krajewska-Włodarczyk M ，Owczarczyk-Saczonek A ，Placek W ，Wojtkiewicz M ，Wiktorowicz A ，Wojtkiewicz J ... -  《Scientific Reports》