Original Research Article http://doi.org/10.18231/j.ijced.2019.

026

Utility of dermoscopy in nail psoriasis: Its correlation with the Nail Psoriasis Severity
Index (NAPSI) and psoriatic arthritis
Akbar Ali Shanavaz1, Amina Asfiya2*, Manjunath Shenoy3, Vishal B4
1
Post Graduate, 2Senior Resident, 3HOD, 4Professor, 1-4Dept. of Dermatology, 1-4Yenepoya Medical College Hospital, Derlakatte,
Mangalore Karnataka, India

*Corresponding Author: Amina Asfiya

Email: dr.akbaralishanavaz87@gmail.com

Abstract
Introduction: Nail changes are present in 25-50% of patients with psoriasis with higher frequency in arthritis. Dermoscopy can be a useful
tool for better visualization and quantifying the nail defects.
Aim of the Study: To evaluate the dermoscopic findings in nail psoriasis.
Settings and Design: Hospital based cross sectional descriptive study.
Materials and Methods: 110 clinically diagnosed psoriatic fingernails were included in the study. The Nail Psoriasis Severity Index
(NAPSI) scores were recorded. Dermoscopic evaluation was conducted and the features were recorded. Comparison of features was done
with mild, moderate and high NAPSI groups and arthritic and non-arthritic patients. Statistical analysis included percentages, frequency,
chi square test and Fischer’s exact test.
Results: The most common dermoscopic findings included subungual hyperkeratosis (90.9%), onycholysis (64.5%) and pitting (62.7%).
Pitting, nail plate thickening, transverse grooves, trachyonychia, and onycholysis were associated with higher NAPSI scores (p<0.05).
Nails of arthritis patients had significantly higher NAPSI scores (p=0.004). Corresponding dermoscopic evaluation revealed subungual
hyperkeratosis, transverse grooves, pitting, onycholysis and trachyonychia to be more frequent in higher NAPSI groups and transverse
grooves, nail plate thickening and trachyonychia in arthritic patients.
Conclusion: Dermoscopy coupled with NAPSI scoring in nail psoriasis can serve as a useful guide to assess the nail, cutaneous and
arthritic psoriasis.

Keywords: Dermoscopy, Nail psoriasis, NAPSI.

Key Messages: Various specific and non specific dermoscopic features of nail psoriasis can help in early diagnosis and assessment of the
disease severity.

Introduction interpret with clinical and dermoscopic evaluation. All the

Psoriasis is a common immune mediated dermatosis which participants gave written informed consent. Patients in
is chronic and seen globally. It has a bimodal age remission following the systemic treatment of psoriasis and
distribution with no sexual predilection.1 Clinically, it those who had other associated dermatological and systemic
manifests as well demarcated plaques with silvery white diseases that are likely to cause nail changes were excluded
scales, with a predilection for the extensor surfaces of the from the study. Relevant demographic and clinical data such
body such as elbows, knees, lower back and scalp.1,2 Nail as patient’s age, sex, duration of disease, joint symptoms,
changes are seen in 50% of cases, and maybe considered as cutaneous and nail changes were noted. Nails were
a reason for significant morbidity due to the pain and examined clinically; specific and non-specific findings of
aesthetic appearance.3-5 In addition to this, nail psoriasis is psoriatic nail were recorded. Nail Psoriasis Severity Index
connected to psoriatic arthritis. It is estimated that 87% of (NAPSI) scores were calculated and graded as mild (0-2),
patients with psoriatic arthritis show nail involvement.3 moderate (3-5) and severe (6-8). Only fingernails with a
Dermoscopy is a useful and feasible diagnostic technique NAPSI score of >1 were included for the dermoscopic
which helps in in vivo evaluation of pigmentary skin study. Dermoscopic examination was carried out using
lesions.6Recently, dermoscopy has been considered a useful Heine Delta 20 plus dermatoscope with a magnification of
modality for the clinical assessment of nail disease.7 The 10X and the findings were noted (table 1). Polarised light
aim of the present study was to evaluate the dermatoscopic and ultrasound gel as interface medium were used to
findings in nail psoriasis. visualize the nail bed features. The collected data was
summarized by frequency and percentages. Association of
Materials and Methods dermoscopic features of nail psoriasis with NAPSI score
A total of 110 finger nails were studied from patients in all was assessed. Comparison of NAPSI and dermoscopic
age groups and both sexes with clinical diagnosis of nail findings was also performed. Statistical analysis of the
psoriasis recruited over a period of 2 months. It was a findings by chi square test, Fischer’s exact test and Mann-
hospital based cross sectional descriptive study. Only the Whitney test was done. Analysis was performed using SPSS
clinically visible psoriatic fingernails were selected; toe -17 software; p value of < 0.05 was considered statistically
nails were excluded because of anticipated gross nail significant.
dystrophies due to trauma and other causes that could
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Results finding followed by salmon patch, pitting and subungual

These 110 nails included a total of 19 patients, 12 patients hyperkeratosis. Higher NAPSI scores (6-8) were seen in
were male (63.2%) and 7 were females (36.8%), and they patients have dermoscopic findings of nail plate thickening,
were aged between 26-70 years (mean age 44.2 years). The transverse grooves and trachyonychia. Among these
duration of psoriasis ranged from 2 months to 20 years findings association of splinter hemorrhage with mild and
(mean duration 51.8 months). Joint disease (Psoriatic moderate NAPSI, and transverse groove and nail plate
arthritis) was detected in 3(15.78%) out of the 19 patients; thickening with high NAPSI were highly significant. Nail
among them 2(10.5%) showed involvement of all 10 plate thickening, Transverse grooves and trachyonychia
fingernails. The mean NAPSI score was 4 (Range 1 - 8). were seen at higher frequency with high NAPSI group and
The dermoscopic features observed have been shown in Pitting and onycholysis were seen at higher frequency with
the table 2.The most common dermoscopic findings of nail moderate and high NAPSI groups. These findings were
psoriasis in our study included subungual hyperkeratosis statistically significant. Splinter hemorrhages were seen at
(90.9%), onycholysis (64.5%) and pitting (62.7%). The higher frequency in the mild and moderate NAPSI groups
other features included nail plate thickening (26.4%), but these findings were statistically not significant.
transverse grooves (25.5%), Leukonychia (23.6%), Salmon We compared the NAPSI scores of patients with and
patch (21.8%), splinter hemorrhages (8.2%) and without arthritis. We found a mean NAPSI of 5.39 for the
trachyonychia (7.3%). arthritis patients as compared to 3.63 for the non-arthritis
We attempted to correlate the nail findings with the patients. The difference in the scores was statistically
severity of nail disease by categorizing them in to 3 NAPSI significant (Mann-Whitney test p value of 0.004). Nail plate
groups which has been summarized in table 3. Mild NAPSI thickening, transverse grooves and trachyonychia were
scores (1-2) were found to be commonly associated with found at higher frequency with arthritis group and the
splinter hemorrhages, followed by subungual hyperkeratosis finding was statistically significant.
and onycholysis. With respect to moderate NAPSI scores
(3-5) we found that Leukonychia was the commonest

Table 1: Dermoscopic description of the nail findings

Feature Dermoscopic Appearance
Pitting Irregular depressions with sharp margins
Leukonychia Irregular opaque chalky white irregular spots
Onycholysis Uniform whitish area with longitudinal striations with reddish - orange halo
Salmon patches Irregular homogenous yellow to orange spots
Splinter hemorrhages Longitudinal black, purple or brown marks

Table 2: Individual dermoscopic features observed in the study (n=110)

Dermoscopic features Present
Number %
Subungual hyperkeratosis 100 90.9%
Onycholysis 71 64.5%
Pitting 69 62.7%
Nail plate thickening 29 26.4%
Transverse grooves 28 25.5%
Leukonychia 26 23.6%
Salmon patches 24 21.8%
Splinter Hemorrhages 9 8.2%
Trachyonychia 8 7.3%
Dilated hyponychial capillaries 0 0%
Pseudo fiber sign 0 0%
Lunular red spots 0 0%

Table 3: Correlation of dermoscopic features with grades of NAPSI

Dermoscopic Features Mild NAPSI Moderate NAPSI High NAPSI P value
Number % Number % Number %
Subungual Absent 4 40.0% 3 30.0% 3 30.0% 0.708
hyperkeratosis Present 30 30.0% 43 43.0% 27 27.0%
Onycholysis Absent 20 51.3% 16 41.0% 3 7.7% 0.000
Present 14 19.7% 30 42.3% 27 38.0%
Pitting Absent 24 58.5% 15 36.6% 2 4.9% 0.000
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Akbar Ali Shanavaz et al. Utility of dermoscopy in nail psoriasis: Its correlation with the Nail…

Present 10 14.5% 31 44.9% 28 40.6%

Nail plate Absent 33 40.7% 39 48.1% 9 11.1% 0.000
thickening Present 1 3.4% 7 24.1% 21 72.4%
Transverse Absent 34 41.5% 39 47.6% 9 11.0% 0.000
grooves Present 0 .0% 7 25.0% 21 75.0%
Leukonychia Absent 30 35.7% 32 38.1% 22 26.2% 0.136
Present 4 15.4% 14 53.8% 8 30.8%
Salmon patches Absent 31 36.0% 34 39.5% 21 24.4% 0.081
Present 3 12.5% 12 50.0% 9 37.5%
Splinter Absent 30 29.7% 42 41.6% 29 28.7% 0.464
Hemmorhages Present 4 44.4% 4 44.4% 1 11.1%
Trachyonychia Absent 34 33.3% 43 42.2% 25 24.5% 0.036
Present 0 .0% 3 37.5% 5 62.5%

Table 4: Difference between the NAPSI in the arthritic and non-arthritic patients
Psoriatic arthritis Total Nails Mean NAPSI Mann-Whitney test p value
Absent 87 3.63 0.004
Present 23 5.39
Total 110 4.00

Table 5: Comparison of dermoscopic features of arthritis and non-arthritis patients

Psoriatic Arthritis
Dermoscopic Features Absent Present Total
Number % Number % Number % P value
Subungual Absent 9 10.3% 1 4.3% 10 9.1% 0.374
hyperkaratosis Present 78 89.7% 22 95.7% 100 90.9%
Onycholysis Absent 33 37.9% 6 26.1% 39 35.5% 0.291
Present 54 62.1% 17 73.9% 71 64.5%
Pitting Absent 34 39.1% 7 30.4% 41 37.3% 0.446
Present 53 60.9% 16 69.6% 69 62.7%
Nail plate Absent 71 81.6% 10 43.5% 81 73.6% 0.000
thickening Present 16 18.4% 13 56.5% 29 26.4%
Transverse Absent 73 83.9% 9 39.1% 82 74.5% 0.000
grooves Present 14 16.1% 14 60.9% 28 25.5%
Leukonychia Absent 65 74.7% 19 82.6% 84 76.4% 0.428
Present 22 25.3% 4 17.4% 26 23.6%
Salmon patches Absent 65 74.7% 21 91.3% 86 78.2% 0.087
Present 22 25.3% 2 8.7% 24 21.8%
Splinter Absent 81 93.1% 20 87.0% 101 91.8% 0.339
hemorrhage Present 6 6.9% 3 13.0% 9 8.2%
Trachyonychia Absent 84 96.6% 18 78.3% 102 92.7% 0.003
Present 3 3.4% 5 21.7% 8 7.3%

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Akbar Ali Shanavaz et al. Utility of dermoscopy in nail psoriasis: Its correlation with the Nail…

Fig. 1: Leukonychia (a, b) and splinter hemorrhages (c, d) Fig. 4: Nail plate thickening (a), Transverse grooves (b, c)
and Salmon patch (d)

Discussion
Nail psoriasis can impact the quality of life of the afflicted
patients.8,9 Such changes may be more frequent and severe
in patients with arthritis.10 Several scoring systems have
been adopted for the nail psoriasis assessment such as Nail
Psoriasis Severity Index (NAPSI), modified NAPSI, target
NAPSI, Psoriasis Nail Severity Score etc.11 NAPSI was
chosen ahead of other scoring systems because it has been
widely quoted in scientific literature. Nail involvement
includes that of nail bed and nail matrix changes. Nail bed
changes include onycholysis, oil drop (salmon patch) sign,
splinter hemorrhages, and subungual hyperkeratosis. Nail
matrix changes are pitting, Leukonychia, red spots in the
Fig. 2: Nail pitting (a, b)
lunula and crumbling. NAPSI score evaluates the presence
of any of these 8 clinical signs in each quadrant of a
fingernail. Nail bed and the matrix change will get 1 score
each per quadrant thus totaling to a maximum of 8 score per
nail.12
Dermoscopy is a user friendly, non-invasive optical tool
that has found great utility in the dermatological practice in
the recent times. Initially its usage was limited to the
pigmented lesions but currently it has been used in variety
of disorders like inflammatory, infective, hair and nail
disorders.13 Nail findings in various diseases such as nail
pigmentation, onychomycosis and nail psoriasis also utilizes
dermoscopy as a tool of assessment.14
There is dearth of literature and few studies are
available on the dermoscopic features of nail psoriasis.7,15,16
A study conducted by Yorulmaz, found that splinter
hemorrhages (73.1%), pitting (58.2%), distal onycholysis
(55.2%) and salmon patches (22.4%) as the most common
dermoscopy features in nail psoriasis.7 These findings are
Fig. 3: Onycholysis with subungual hyperkeratosis (a, b, c, similar to our study except for splinter hemorrhages, and we
d) observed subungual hyperkeratosis (90.9%), onycholysis
(64.5%), pitting (62.7%) followed by Salmon patch (21.8%)
as the most common finding. We did not find the pseudo
fiber sign, dilated hyponychial capillaries or lunular red
spots as mentioned in this study; these findings may be
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Akbar Ali Shanavaz et al. Utility of dermoscopy in nail psoriasis: Its correlation with the Nail…

visible only on higher magnification of the video Conflict of Interest: None.

dermoscope used in their study.7 A study by Yadav et al
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