Jing Zhang, Xue-Yan Chen, Xiao-Yong Man, Min Zheng?

Department of Dermatology, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China.

Abstract

Keywords: nail psoriasis, initial presentation, biologic agents, case report

Introduction

Nail psoriasis can cause substantial physical and psychological impairment,1and affects up to 50% of patients with cutaneous psoriasis,with a lifetime incidence of up to 90%.2However, nail involvement is an often overlooked feature of psoriasis.3There is an urgent need for more attention to be paid to nail psoriatic changes and the administration of appropriate treatment. Herein, we describe the case of a patient with nail changes as the initial sign of psoriasis. Timely recognition and proper treatment enabled the patient to achieve a favorable outcome.

Case report

A 24-year-old male presented with white streaks and deformations on his fingernails,and fingernail losses for 8 months. He was initially diagnosed with onychomycosis and treated with four courses of itraconazole. However,the nails did not improve.He was subsequently diagnosed with nail dystrophy and treated with the vitamin D3 analog calcipotriol ointment Daivonex?for 1 month, but attained no obvious improvement. Fungal microscopic examination and culture were negative. A thorough physical examination revealed salmon patches, distal onycholysis, pitting, splinter hemorrhages, and nail plate crumbling on all ten fingernails (Fig. 1A). Further examination revealed three erythematous scaly patches on the buttock, anus, and scalp, with the presence of the Auspitz sign (Fig. 1B).

Dermoscopy revealed spotty dilated capillaries in the nail folds (Fig. 1C). Skin biopsy from an erythematous plaque on the nail bed demonstrated hyperkeratosis,parakeratosis,acanthosis,and elongated rete ridges of the epidermis (Fig. 1D).

These findings led to a diagnosis of nail psoriasis. Oral acitretin (30mg/day) and topical calcipotriene liniment were administered for 3 months. The fingernails became smoother and more solid, and the number of pits on the nails decreased. The patient decided to stop taking the acitretin, due to his concerns about adverse effects. Four months later,the nail signs returned.The patient was then administered etanercept by subcutaneous injection(50mg once-a-week),and the nail symptoms were well controlled.The patient gave his informed consent for his case publication.

Discussion

Nail psoriasis is usually noticed after the occurrence of skin lesions,but may occur simultaneously with or before skin psoriasis.3-4Occasionally, nail involvement is the only manifestation of psoriasis.4Our patient showed fingernail changes as the primary sign of psoriasis,and the symptoms were localized on the nails, with minor lesions in three other hidden positions.

The clinical signs of nail psoriasis are related to the involvement of the nail matrix or nail bed.4The typical nail abnormalities caused by nail matrix lesions are depressions, including pits scattered on the nail plate. These changes create fragile cornered areas that are worn away by normal friction.4Other manifestations of nail psoriasis include leukonychia, lunular red spots, and nail plate crumbling. When the nail bed is involved, the nail color may change to the brown color of gasoline, which is known as the “oil drop” sign.4Other nail bed lesions reported in patients with psoriasis include onycholysis,subungual hyperkeratosis, and splinter hemorrhages.3-4

Nail lesions are more common in patients with psoriatic arthritis than in the general population,and maybe one of the strongest clinical predictors of psoriatic arthritis.3Furthermore,the dotted vessels of the proximal nail folds seen under dermoscopy are significantly associated with early polyarticular psoriatic arthritis.5Therefore, it is important to identify nail changes in clinical practice,and to recognize the patients with psoriasis. For patients with nail changes resembling nail psoriasis, clinicians should review the medical history and conduct a detailed physical examination.Fungal microscopic examination and culture are often needed to eliminate onychomycosis-induced onychodystrophy,as 50% of all nail disorders are due to onychomycosis,6and dystrophic psoriatic nails can be secondarily infected with fungi.7These measures will help to reduce the incidence of a missed diagnosis of nail psoriasis.

As nail psoriasis has a profound negative influence on quality of life,1management of the disease is important.Topical therapy is rarely sufficiently effective. Systemic treatment plus radiation and light therapies are also administered. Biologic agents should be considered in severe cases.In our case,etanercept produced a favourable response and the patient felt satisfied with the administration of it. Etanercept therapy reportedly achieves sustained improvement of nail symptoms in patients with moderate-to-severe psoriasis.8Other biologic agents,such as adalimumab and ustekinumab, can also be considered as treatment options for nail psoriasis.9