Original papers Med Ultrason 2018, Vol. 20, no.

2, 177-184
DOI: 10.11152/mu-1327

Ultrasonography of the nail unit reveals quantitative and qualitative

alterations in patients with psoriasis and psoriatic arthritis
Luca Idolazzi1, Paolo Gisondi2, Angelo Fassio1, Ombretta Viapiana1, Alessandro Giollo1,
Maurizio Rossini1, Giampiero Girolomoni2, Davide Gatti1

1Rheumatology Unit, 2Dermatology Clinic , Department of Medicine, University of Verona, Verona, Italy

Abstract
Aims: The nail unit is a matter of interest both for dermatologist and rheumatologist. The nail is considered one of the
possible targets of assessment, especially when ultrasonography is performed.
The aim of the study is to highlight peculiar features and alterations of the nail unit in patients affected by psoriasis and
psoriatic arthritis versus healthy controls using ultrasonography. Materials and methods: The study sample included 82 pa-
tients affected by psoriasis and/or psoriatic arthritis and 50 healthy controls. The patients were consecutively enrolled during
their routine visit in the outpatient clinic and they performed clinical and ultrasonographic evaluation of the nail. The evalu-
ation of disease activity was done using Disease Activity in Psoriatic Arthritis (DAPSA), Psoriasis Activity Severity Index
(PASI), and Nail Psoriasi Severity Index (NAPSI). Results: Multivariate analysis of variance was performed between groups.
Post hoc analysis underlined the differences between healthy and affected regarding nail plate thickness (0.063±0.011 cm for
patients with psoriasis, 0.065±0.014 cm for patients with psoriatic arthritis and 0.051±0.006 cm for healthy controls, p<0.05).
Elementary lesions of nail plate and nail bed were compared using Pearson’s chi square test between patients in psoriasis and
psoriatic arthritis groups, with no differences except for a trend for onycholisis and crumbling (p=0.07 and 0.06, respectively)
in the psoriatic arthritis group. ROC curves were calculated (AUC = 0.68) obtaining also quantitative cut offs for nail plate and
nail bed thickness in the affected vs healthy patients. Conclusions: Our study shows that ultrasonography may be a potential
advantage in clinical practice. Our results strengthen the information already available in the literature and add quantitative
parameters for ultrasonography of the nail.
Keywords: nail; psoriatic arthritis; psoriasis; ultrasonography

Introduction the strong association between Ps and psoriatic arthritis

(PsA) is well known [5]. The prevalence of PsA in pa-
Psoriatic onicopathy (PsO) is one of the hallmarks of tients affected by PsO ranges from 6% to 40% depend-
psoriasis (Ps) and it is very common, especially in as- ing on the study design [6]. Ps is closely associated with
sociation with plaque psoriasis. It is esteemed that up to the development of PsA, correlating to specific subsets of
70-80% of patients with plaque Ps have nail involvement skin manifestations such as scalp and palmoplantar pso-
[1–3]. Although Ps alone is quite uncommon accounting riasis [7]. Plaque Ps and Ps of the nails, scalp, and inter-
for only 5-10% of patients with Ps [4] the proportion of triginous areas have been associated with the likelihood
patients with isolated nail involvement who will later of developing PsA which is in turn related to the magni-
develop plaque Ps is currently unknown. Conversely, tude of the lesions. Of note, the tightest correlation with
PsA has been found for patients with nail disease [8].
Received 11.11.2017 Accepted 08.02.2018
Med Ultrason The nail unit is a complex structure consisting of sev-
2018, Vol. 20, No 2, 177-184 eral elements: nail matrix, which produces the nail plate;
Corresponding author: Idolazzi Luca the nail plate itself, namely the common term used to de-
Piazzale A .Stefani 1 scribe the whole unit; nail bed epithelium, responsible
37126 Verona, Italy
Phone: +390458123996, Fax: +390458127276 for the attachment to the dermis; hyponychium; proximal
E-mail: luca.idolazzi@univr.it nail fold; dermis of the nail matrix; and nail bed [9]. Some
178 Luca Idolazzi et al Ultrasonography of the nail unit reveals quantitative and qualitative alterations

elements, such as the nail bed, nail plate, and matrix, are secondary objective is to find a quantitative measure of
involved more frequently than others in Ps or PsA. Le- nail ultrasonography which can be useful to discriminate
sions such as pitting, leukonychia, red spots in the lu- patients with Ps or PSA from healthy controls.
nula, or crumbling are found in the nail plate. Oil-drop
or salmon patches, dyschromia, splinter hemorrhage, and Patients and Methods
nail bed hyperkeratosis are the typical lesions when the
nail bed is involved [10]. These alterations are generally Study population
clearly visible to clinical examination and easily recog- This is an observational study conducted in the set-
nized by the physician. In this regard, the Nail Psoria- ting of a combined dermatology-rheumatology outpa-
sis Severity Index (NAPSI) is a useful and validated tool tient clinic of the Department of Medicine, University
for the assessment of PsO [11] and it is well accepted also of Verona. In this clinic, patients affected by Ps disease
in rheumatology for the assessment of nail involvement with or without active skin involvement are jointly evalu-
in patients affected by PsA [12]. Furthermore, PsA may ated by a dermatologist and a rheumatologist in order to
also be associated with proximal nailfold vascular chang- provide a more comprehensive assessment of their dis-
es [13] which can be detected with imaging techniques. ease. The study sample included 82 patients affected by
The nail unit has been a topic of interest shared by Ps and/or PsA and 50 healthy controls (HC). Patients re-
dermatologists and rheumatologists since McGonagle et ferred to the dermatology-rheumatology outpatient clinic
al [14,15] raised the attention to the nail enthesis complex were consecutively enrolled for a period of 6 months af-
as a possible link between skin and joint [5,16]. The nail ter their diagnosis of PSA was confirmed by a dermatolo-
unit is easy to study thanks to some imaging techniques gist. Alterations of the nails other than Ps were excluded
such as ultrasonography (US) of nails, which has been by a dermatologist as follows: infection by clinical ex-
available since high frequencies probes were introduced amination and microscopic examination or culture; trau-
in musculoskeletal examination [17–22] and the nail has matic onychopathy or other conditions by clinical data
been considered one of the possible targets for assess- and clinical examination. Patients taking biologic agents
ing the disease and defining its prognosis [23–25]. A few were excluded a priori for study design, reducing the risk
previous studies of magnetic resonance imaging (MRI) of bias due to treatment.
also described the strong relationship between the dis- The institutional review board of the Medical School
tal interphalangeal joint (DIP) and the nail [14,26]. The of Verona and the Ethical Committee approved the study.
US approach to the nail is also promising, with several All the procedures were performed in accordance with
chances of application in everyday practice [16,27]. The the ethical standards of the responsible committee on hu-
quantitative approach was explored by Wollina et al [28] man experimentation (institutional or regional) and with
with volumetric measurements of the nail and a quali- the Declaration of Helsinki of 1975, as revised in 1983.
tative description of the image, detailing the alterations Clinical assessments
which were not evident at clinical examination [19,29]. Each patient underwent a physical examination and
On the other hand, a semi quantitative approach is prob- data on disease activity and anthropometry were col-
ably the most convenient, since a standardized technique lected. Disease activity was assessed with Psoriasis Area
can be valid, reliable and feasible for studying alterations Severity Index (PASI), NAPSI, and Disease Activity in
in Ps [17,30,31]. In a previous paper we already evalu- PSoriatic Arthritis (DAPSA) respectively for skin, nail
ated the possible implementation of ultrasound examina- and joint domains [34]. C-reactive protein (CRP) was
tion for revealing changes both in the nail plate and the used for DAPSA calculation. The PASI is an measure
nail bed [32], showing that quantitative measures can be commonly used in clinical practice and in randomized
a promising tool for nail assessment. clinical trials by dermatologists for evaluating not only
Previously, Scarpa et al suggested that imaging could the extension of the psoriasis but also the thickening,
be useful even in patients with not a clear involvement at erythema, and scaling of the skin [34,35]. The NAPSI
clinical examination [33], as US can detect subclinical [11] is activity index used by dermatologists for evaluat-
nail alterations, potentially identifying patients affected ing nails and especially alterations of nail bed and nail
by PSA before they fulfil the classification sets (e.g. plate observed during clinical examination. For assess-
CASPAR criteria). ing joint involvement the DAPSA score was used, taking
The primary objective of this study was to evaluate into account four principal components: patient global
the anatomical changes in the nail revealed by US and and pain visual analog scale (VAS) scores, tender and
to describe the clinical features which can help to bet- swollen joint counts, and acute-phase reactant (CRP
ter characterize patients affected by Ps and/or PsA. The level) [36].
 Med Ultrason 2018; 20(2): 177-184 179
Ultrasound procedure
After clinical examination, the patient was led to a
separate darkened room for US evaluation. The patient
was assessed by two different sonographers blind to clin-
ical data, diagnosis and identity of the patient. Only the
hand was visible during the examination and patient and
clinician were not allowed to speak. The Cohen’s kappa
coefficient between the ultrasonographers was 0.78, pre-
viously verified on 50 selected images of the nail unit.
The US examination was performed using a General
Electric Logiq S8 machine with a multifrequency linear
probe (Li8-18) with setting at 18 MHz. Power Doppler
parameters were set selecting a PRF of 600 KHz and fre-
quency of 10 MHz. The scan was performed in a lon-
gitudinal axis by placing the probe in the middle of the
second fingernail, dominant side hand. In our previous
experience [32] we showed that the examination of the
Fig 1. Nail unit ultrasonography: a) a complete picture of a nail
second nail of the dominant hand achieved the most re- as it appears at ultrasonography. The nail plate is marked with
markable difference among other digits in Ps population the letter A, while B is the nail bed. The nail matrix (C) is easily
compared with controls. The same result was confirmed recognizable which is contiguous with the enthesis of the finger
later by other authors [19]. extensor tendon. The finger extensor tendon insertion is clearly
The normal aspect of the nail is a trilaminar struc- visible as proximal to the matrix (D); b) magnification of the
middle third, reporting an example of how the thickness of nail
ture with the first lamina which is hyperechoic, just as plate and nail bed was calculated. The thickness was measured
the third one, while the second is anechoic. This structure three times and then the mean was calculated (i.e. 0.6 mm for
goes deep below the epidermis in the proximal part of the nail plate and 2.23 mm for nail bed)
nail plate, ending just above a hypoechoic area that is the
nail matrix. The nail bed is evident below the nail plate of a normal plate. The semi quantitative approach pro-
and just above the cortical bone of the distal phalangeal posed by Gutierrez et al [40] was used for scoring the PD
joint [19,24]. The clinical evaluation of the nail permitted signal of the nail bed. Briefly, a score of 1 is given for a
to recognize the elementary lesions of the nail bed and confluent signal in less than 25% of the nail bed area,
nail plate and these structures were specifically targeted 2 for a confluent signal in more than 25% and less than
during the ultrasound assessment [37–39]. According to 50% of the nail bed area, and 3 for confluent signal in
previous data, mean values for the nail bed range from more than 50% of the nail bed area. A score of 1 or 0 was
1.5 to 3 mm [19,37,39]. given if a PD signal at the enthesis or abnormal signal
As no previous data were available in literature, we from the nail bed and was present or absent accordingly.
developed a novel score based on ultrasonographic find- Statistical analysis
ings for the assessment of nail plate and nail bed. Several Data are reported as mean values±standard deviation
measurements of the nail plate and nail bed were taken at (medians and interquartile ranges for variables deviat-
the middle third of the plate (fig 1). In order to enhance ing from normality) or percentages. Accounting for an
the accuracy of measurements, the image was magnified esteemed standard deviation of 0.02 mm, we calculated
using the zoom function during the examination. The that a sample size of at least 22 patients in each group
mean of three measurements was then considered for was sufficient to detect at least a 0.2 mm difference be-
statistical analysis. Nail structural alterations were also tween patients affected by psoriatic disease and healthy
assessed as well as the power Doppler (PD) signal of the controls with a power of 95%. No quantitative data are
nail bed and at the enthesis of the extensor tendon. The available in literature for a comparison. Between groups,
structural alterations were then evaluated using a semi comparisons of continued variables (nail plate thickness,
quantitative score for the magnitude of the alteration. nail bed thickness, PASI, NAPSI, age, and BMI) were
This score provides a value of 0 - if no alteration of the performed by univariable and multivariable analysis of
plate is found, 1 - if the double line is slightly altered, 2 - variance (ANOVA) with the Tamhane’s test for post hoc
if the alteration is severe enough to provide a large modi- analysis. Between groups, comparisons of categorical
fication of the structure detected by ultrasonography, and variables (lesions for nail plate and nail bed considered
3 - if the alterations completely loose the standard image in the PASI score) were performed by the Pearson’s chi
180 Luca Idolazzi et al Ultrasonography of the nail unit reveals quantitative and qualitative alterations

Table I. Study sample and results of ANOVA analysis.

HC (n-50) Ps (n-31) PsA (n-51) p value
Age 48.44±13.95 48.22±14.7 50.92±13.9 0.51
Male 22 22 26
BMI 24.61±3.92 28.61±4.95* 28.64±5.84* ≤0.001 vs HC
NPT (mm) 0.051±0.006 0.063±0.011* 0.065±0.014* ≤0.001 vs HC
NBT (mm) 0.22±0.02 0.25±0.05* 0.25±0.04* ≤0.001 vs HC
Clinical nail involvement1 0/50 13/18 32/19 <0.04 Ps vs PsA
US involvement2 0 (0%) 1 (3%) 5 (9%) n.a.
US involvement3 15 (30%) 13 (41.9%) 13 (25.5%) 0.49 vs HC
PASI n.a. 5.22±5 2.65±3.4 0.056
NAPSI n.a. 4.35±10.6 8.51±11.4 0.28
DAPSA n.a. n.a. 15.5±9.3
Data are presented as a mean±standard deviation or percentage. n- number of patients; BMI: body mass index; NPT: nail plate thickness;
NBT: nail bed thickness; n.a.: not applicable; HC: healthy controls; Ps: patient group with psoriasis, PsA: patient group with psoriatic arthri-
tis; 1: ratio between patients with involved or not involved nails at clinical examination; 2: absolute number and percentage of patients who
show US qualitative alterations and had no nail involvement at clinical examination; 3: absolute number and percentage of patients who show
US nail involvement if the proposed cut off is applied; US involvement: not reported as “present at clinical examination”; PASI: Psoriasis
Area Severity Index; NAPSI: Nail Psoriasis Severity Index; DAPSA: Disease Activity in PSoriatic Arthritis; *= p≤0.001 vs HC

square test and odds ratios were calculated for signifi- Table II. P values of Pearson’s Chi Square test for power Dop-
cant results. Significant correlations between nail plate pler ultrasonography nail bed and nail enthesis.
thickness and other variables (PASI, NAPSI, BMI and Nail bed Nail enthesis
DAPSA) were analyzed by stepwise linear regression. Ps vs PsA 0.883 0.789
Receiver operating characteristic (ROC) curves were Ps vs HC < 0.005 0.06
plotted to assess the accuracy of nail plate thickness and PsA vs HC <0.001 < 0.001
nail bed thickness in discriminating HC from patients. The data show values regarding the comparison between groups;
All statistical analyses were performed using SPSS Ver- Ps: patient group with psoriasis, PsA: patient group with psoriatic
arthritis; HC: healthy controls.
sion 20 (SPSS, Inc., Chicago, IL, USA) and statistical
significance was identified by two-tailed p<0.05.
We found no statistically significant difference between
Results groups for nail plate crumbling, oil drop discoloration,
onycholisis, and hyperkeratosis, although a trend was no-
Evaluation of nail plate and nail bed thickness ticed for onycholisis and crumbling (p=0.07 and p=0.06,
Fifty-one patients with PsA constituted the PsA group respectively). Nail pitting was found more frequently in
(‘PsA’) and 31 patients with Ps the Ps group (‘Ps’). Fif- the PsA group than the Ps group (OR 9.41, C.I. 0.15-
ty healthy controls (‘HC’ group) were enrolled as well. 0.99, p=0.03).
Data on demographics, anthropometry and disease activ- Nail abnormalities on physical examination were
ity are reported in Table I. The ANOVA showed signifi- found in 40% of patients affected by Ps and 62.7% af-
cant differences between groups for BMI, nail plate and fected by PsA. Conversely, the proportion of patients
nail bed thickness. BMI was significantly lower in HC who had loss of trilaminar structure (any grade) despite
than patients (p<0.01). Nail plate thickness and nail bed a normal physical examination was 3% in Ps (1/31) and
thickness were also significant lower in the HC group 9% in PsA (5/51) groups.
(p<0.05). The post hoc analyses revealed no differences We found a significant difference in PDUS of the nail
between groups, but patients affected by PsA had a high- bed when comparing HC and Ps and HC and PsA. Like-
er PASI (p=0.056 vs other groups). wise, the PDUS at the enthesis was higher than HC (Ps
Evaluation of alterations of nail bed and nail plate vs HC 13.7% vs 2.5%; PSAs 29% vs HC 3%. Statistical
The patients found with abnormalities of the items differences are shown in Table II.
categorized in NAPSI score was compared between Ps Correlations and ROC curves
and PsA groups using the Pearson’s Chi square test or We used stepwise linear regression to establish cor-
Fisher’s exact test when appropriate. Leukonychia, red relations between either nail plate thickness or nail bed
spots in lunula, and splinter hemorrhages were exclud- thickness as the dependent variables and PASI, NAPSI,
ed from this analysis due to the small number of cases. and BMI as predictors. Nail plate thickness was signifi-
 Med Ultrason 2018; 20(2): 177-184 181
with a higher mean in PsA group) and this is in line with
available data reporting that psoriatic patients with se-
vere skin involvement are more likely to develop joint
disease. Conversely, an unexpected result of our study is
that the magnitude of joint inflammation assessed with
DAPSA was not related to nail bed or nail plate thick-
ness. Of note, most of our patients had a small number of
joints involved thus disease activity was mild to moder-
ate in most patients, according to the proposed cut offs of
DAPSA score [36].
Fig 2. ROC Curve Analysis a) for nail plate thickness (AUC The absence of differences between HC and affected
0.809) and b) for nail bed thickness (AUC 0.68). The ROC groups suggests that nail alterations might be constitu-
curves shown are between people affected by PsA vs healthy
controls since the curves calculated for Ps patients are truly simi- tive of psoriatic disease and then it could be a target
lar. for discriminating healthy subjects from patients with
Ps or PsA. In addition, not all lesions detected by clini-
cantly related to nail bed thickness and NAPSI (R2 0.363 cal examination are able to discriminate between the
and 0.464, respectively, p≤0.001). Nail bed thickness groups. Intriguingly, in spite of large confidence inter-
was significantly associated with nail plate thickness and vals which suggests caution with the interpretation of
NAPSI (R2 0.363 and 0.464, respectively, p≤0.005). No our results, only patients with nail pitting had more than
correlation was found between nail plate thickness or nail 9 fold increased risk of having Ps. One of the most in-
bed thickness and DAPSA in the PsA group. teresting remarks was the high prevalence of increased
Finally, we obtained ROC curves for the different nail plate thickness despite the absence of abnormalities
possible cutoff of nail plate thickness and nail bed thick- at clinical evaluation. Approximately 3% of Ps and 9%
ness discriminating HC from the PsA group and the Ps of PsA patients had increased nail plate thickness and
group (pooled). The area under the curve (AUC) was ultrasonographic alterations not detectable at clinical
similar when comparing either the two groups with HC. examination
AUC for nail plate thickness was 0.809, showing good Linear regression models showed a good correlation
accuracy. Conversely, the ROC curve for nail bed thick- among nail bed thickness, nail plate thickness and NAP-
ness showed poor accuracy (fig 2) and no cutoff was cal- SI. Our findings strengthen the idea that nail-enthesis
culated for it. A nail plate thickness above 0.63 mm was complex is crucial in developing microalterations of the
able to discriminate HC from patients with a sensibility nail plate and the thickening of the nail bed and suggest
of 70% and a specificity of 78%. When applied to pa- that nail involvement is not only limited to the nail plate
tients who had no involvement of the nails, the cut off but also to the nail bed. This supports the hypothesis that
revealed that 15/50 HC, 13/31 PSOs and 13/51 PsAs are all nail structures are affected in an inflammatory setting
correctly classified, without differences between groups even though it should be stressed that we found sub-
(Table I). clinical abnormalities in most of the cases. Whether the
primary site of inflammation is the nail and secondarily
Discussions the enthesis or vice versa is still a matter of debate, as
observed from other studies [42]. The proximity of the
We assessed with US 82 patients and 50 healthy con- matrix to the joints and tendon structures makes it quite
trols to evaluate the presence of nail involvement and difficult to discriminate the timing of those events.
subclinical alterations in Ps and PsA. Previous data from Another point of interest is the study of quantitative
literature are scarce, though overall nail ultrasonography parameters of the nail. In literature these data are still
has been shown to be more useful than clinical evalua- lacking and we have already urged the need for a pa-
tion alone in detecting nail lesions [17,41]. Nails are one rameter standardization in clinical practice [32]. Indeed,
of the possible targets in the psoriatic spectrum [24] and a quantitative measure discriminating the healthy from
their involvement is strongly related with the develop- the pathological nail could be useful in clinical practice.
ment of PsA, especially for the entheseal subset [15,41]. In this study we provide some evidence that US may be
Our mANOVA analysis strongly highlighted the differ- useful in borderline cases, whenever clinical examina-
ences in nail plate and bed thickness between patients tion is not sufficient alone to find the presence of the dis-
and healthy controls, but not between Ps and PsA pa- ease, such in the case of minimal nail involvement. In
tients. PASI had an almost significant trend (p=0.056, this view, nail plate thickness was the parameter which
182 Luca Idolazzi et al Ultrasonography of the nail unit reveals quantitative and qualitative alterations

obtained the best AUC. However, we found no signifi- conclusions, thus we suggest to use this cut off primarily
cant differences in nail measures between Ps and PsA pa- when the clinical presentation is suggestive but not suf-
tients, the ROC curves being similar when plotting either ficient alone to make the diagnosis. Finally, it is unknown
Ps or PsA patients against HC, confirming that the nail whether other joint conditions than PsA can have similar
complex modifications could discriminate psoriatic pa- nail ultrasound abnormalities.
tients from healthy subjects, irrespective of the arthritic Our study supports the use of nail US and remarks its
involvement. Our proposed cut off of 0.63 mm for nail potential advantages in PsA and Ps. Moreover, our results
plate thickness achieved the best sensibility and speci- show that some quantitative parameters may be useful in
ficity for discriminating patients from healthy controls. the ultrasound assessment of the psoriatic nail. In conclu-
Furthermore, our results must be interpreted considering sion, the role of nail US in psoriatic disease needs further
the standard error of the ultrasound machine. Since the research but there is increasing evidence suggesting that
maximum power of imaging resolution is estimated by it could give useful information for clinical practice in
the manufacturer at 1/10 mm, the most logical value as selected patients.
a cut off for nail plate thickness is 0.6 mm. This value
retains a very good sensibility even if with a slight de- Acknowledgements: The authors thank Dr. Daniela
crease in specificity. When we applied this cut off to our Marin for helping in the clinical data collection and the
study population, we could detect US abnormalities in recruitment of patients.
up to 80% of cases. Since there is no statistical signifi-
cance between patients vs HC for the thickness itself, Conflict of interests: none
this cut off is not sufficient. This observation implies that
subclinical alterations are found more frequently with References
US than with standard examination. This might be par-
ticularly useful during the classification of the patient, 1. Jiaravuthisan MM, Sasseville D, Vender RB, Murphy F,
for example considering US for the evaluation of nail Muhn CY. Psoriasis of the nail: anatomy, pathology, clini-
cal presentation, and a review of the literature on therapy. J
alterations if CASPAR criteria are applied, although we
Am Acad Dermatol 2007; 57:1-27.
acknowledge these are preliminary and not conclusive
2. Cohen MR, Reda DJ, Clegg DO. Baseline relationships be-
findings and they should be implemented with caution in tween psoriasis and psoriatic arthritis: analysis of 221 pa-
clinical practice. tients with active psoriatic arthritis. Department of Veterans
US has been proved to be a valid and feasible instru- Affairs Cooperative Study Group on Seronegative Spondy-
ment for the assessment of PsA and Ps, and it is able to loarthropathies. J Rheumatol 1999;26:1752-1756.
give just as detailed information as more advanced imag- 3. Manhart R, Rich P. Nail psoriasis. Clin Exp Rheumatol
ing techniques [17,43], though its routine application in 2015;33:S7-S13.
everyday practice has not been proposed yet. The predic- 4. Gladman DD, Antoni C, Mease P, Clegg DO, Nash P. Pso-
tive value of the findings should be a matter of interest riatic arthritis: epidemiology, clinical features, course, and
for further studies, in order to provide a possible role of outcome. Ann Rheum Dis 2005;64 Suppl 2:ii14-ii17.
5. Acosta-Felquer ML, Ruta S, Rosa J, et al. Ultrasound en-
the cut off in this setting. An in-depth analysis is also
theseal abnormalities at the distal interphalangeal joints and
required to address peculiar features of PsA subsets (e.g. clinical nail involvement in patients with psoriasis and pso-
the inflammatory pattern involving the distal interphalan- riatic arthritis, supporting the nail-enthesitis theory. Semin
geal joints). Arthritis Rheum 2017;47:338-342.
Although our results provided quite a comprehensive 6. Nestle FO, Kaplan DH, Barker J. Psoriasis. N Engl J Med
view of the nail features in PsA and Ps as well as their re- 2009;361:496-509.
lationship with joints and clinical examination, this study 7. Wilson FC, Icen M, Crowson CS, McEvoy MT, Gabriel
has also some limitations. Firstly, to adequately visual- SE, Kremers HM. Incidence and clinical predictors of pso-
ize the nail structure a high frequency probe is needed, riatic arthritis in patients with psoriasis: a population-based
as previous studies [20] suggested that only a frequency study. Arthritis Rheum 2009;61:233-239.
8. Boehncke WH, Qureshi A, Merola JF, et al. Diagnosing
above 18 MHz can provide an accurate imaging defi-
and treating psoriatic arthritis: an update. Br J Dermatol
nition of the nail and enthesis complex. Secondly, the
2014;170:772-786.
specificity of our proposed cut off is low as a number 9. Haneke E. Anatomy of the nail unit and the nail biopsy.
of patients do not show nail abnormalities at clinical ex- Semin Cutan Med Surg 2015;34:95-100.
amination despite having quantitative or qualitative US 10. Schons KR, Knob CF, Murussi N, Beber AA, Neumaier W,
changes. For the intrinsic limitations of US, its routine Monticielo OA. Nail psoriasis: a review of the literature.
employment might mislead the clinician to diagnostic An Bras Dermatol 2014;89:312-317.
 Med Ultrason 2018; 20(2): 177-184 183
11. Rich P, Scher RK. Nail psoriasis severity index: a useful 27. Zabotti A, Idolazzi L, Batticciotto A, et al. Enthesitis of the
tool for evaluation of nail psoriasis. J Am Acad Dermatol hands in psoriatic arthritis: an ultrasonographic perspective.
2003;49:206-212. Med Ultrason 2017;19:438-443.
12. Cassell SE, Bieber JD, Rich P, et al. The modified Nail Pso- 28. Wollina U, Berger M, Karte K. Calculation of nail plate and
riasis Severity Index: validation of an instrument to assess nail matrix parameters by 20 MHz ultrasound in healthy
psoriatic nail involvement in patients with psoriatic arthri- volunteers and patients with skin disease. Skin Res Technol
tis. J Rheumatol 2007;34:123-129. 2001;7:60-64.
13. Errichetti E, Zabotti A, Stinco G, et al. Dermoscopy of nail 29. Grassi W, Filippucci E, Farina A, Cervini C. Sonograph-
fold and elbow in the differential diagnosis of early psori- ic imaging of the distal phalanx. Semin Arthritis Rheum
atic arthritis sine psoriasis and early rheumatoid arthritis. J 2000;29:379-384.
Dermatol 2016;43:1217-1220. 30. Marina ME, Botar Jid C, Roman II, Mihu CM, Tătaru
14. McGonagle D. Enthesitis: an autoinflammatory lesion link- AD. Ultrasonography in psoriatic disease. Med Ultrason
ing nail and joint involvement in psoriatic disease. J Eur 2015;17:377-382.
Acad Dermatol Venereol 2009;23 Suppl 1:9-13. 31. Aydin SZ, Castillo-Gallego C, Ash ZR, Marzo-Ortega H,
15. Ash ZR, Tinazzi I, Gallego CC, et al. Psoriasis patients Wakefield R, McGonagle D. Vascularity of nail bed by ul-
with nail disease have a greater magnitude of underlying trasound to discriminate psoriasis, psoriatic arthritis and
systemic subclinical enthesopathy than those with normal healthy controls. Clin Exp Rheumatol 2017;35:872.
nails. Ann Rheum Dis 2012;71:553-556. 32. Gisondi P, Idolazzi L, Girolomoni G. Ultrasonography re-
16. Batticciotto A, Idolazzi L, De Lucia O, Tinazzi I, Iagnocco veals nail thickening in patients with chronic plaque psoria-
A. Could nail and joint alterations make the difference be- sis. Arch Dermatol Res 2012;304:727-732.
tween psoriatic arthritis and osteoarthritis during the ultra- 33. Scarpa R, Soscia E, Peluso R, et al. Nail and distal in-
sonographic evaluation of the distal interphalangeal joints? terphalangeal joint in psoriatic arthritis. J Rheumatol
Med Ultrason 2017;19:347-348. 2016;33:1315-1319.
17. Arbault A, Devilliers H, Laroche D, et al. Reliability, valid- 34. Mease PJ. Measures of psoriatic arthritis: Tender and Swol-
ity and feasibility of nail ultrasonography in psoriatic ar- len Joint Assessment, Psoriasis Area and Severity Index
thritis. Joint Bone Spine 2016;83:539-544. (PASI), Nail Psoriasis Severity Index (NAPSI), Modi-
18. Gutierrez M, Filippucci E, De Angelis R, et al. The ultra- fied Nail Psoriasis Severity Index (mNAPSI), Mander/
sound assessment of the psoriatic arthritis: from joint to Newcastle Enthesitis Index (MEI), Leeds Enthesitis Index
skin. Reumatismo 2009;61:309–315. (LEI), Spondyloarthritis Research Consortium of Canada
19. Gutierrez M, Wortsman X, Filippucci E, De Angelis R, (SPARCC), Maastricht Ankylosing Spondylitis Enthesis
Filosa G, Grassi W. High-frequency sonography in the Score (MASES), Leeds Dactylitis Index (LDI), Patient
evaluation of psoriasis: nail and skin involvement. J Ultra- Global for Psoriatic Arthritis, Dermatology Life Quality In-
sound Med 2009;28:1569-1574. dex (DLQI), Psoriatic Arthritis Quality of Life (PsAQOL),
20. Berritto D, Iacobellis F, Rossi C, Reginelli A, Cappabianca Functional Assessment of Chronic Illness Therapy-Fatigue
S, Grassi R. Ultra high-frequency ultrasound: New capabil- (FACIT-F), Psoriatic Arthritis Response Criteria (PsARC),
ities for nail anatomy exploration. J Dermatol 2017;44:43- Psoriatic Arthritis Joint Activity Index (PsAJAI), Disease
46. Activity in Psoriatic Arthritis (DAPSA), and Composite
21. Zabotti A, Bandinelli F, Batticciotto A, et al. Musculoskel- Psoriatic Disease Activity Index (CPDAI). Arthritis Care
etal ultrasonography for psoriatic arthritis and psoriasis Res 2011;63 Suppl 11:S64-S85.
patients: a systematic literature review. Rheumatology (Ox- 35. Fredriksson T, Pettersson U. Severe Psoriasis – Oral Ther-
ford) 2017;56:1518–-1532. apy with a New Retinoid. Dermatologica 1978;157:238-
22. Marina ME, Solomon C, Bolboaca SD, Bocsa C, Mihu CM, 244.
Tătaru AD. High-frequency sonography in the evaluation 36. Schoels MM, Aletaha D, Alasti F, Smolen JS. Disease ac-
of nail psoriasis. Med Ultrason 2016;18:312-317. tivity in psoriatic arthritis (PsA): defining remission and
23. Raposo I, Torres T. Nail psoriasis as a predictor of the treatment success using the DAPSA score. Ann Rheum Dis
development of psoriatic arthritis. Actas Dermosifiliogr 2016;75:811-818.
2015;106:452-457. 37. Wortsman X, Soto R. Ultrasound Imaging of Psoriatic
24. Gutierrez M, Filippucci E, De Angelis R, Filosa G, Kane Nails. In: Rigopoulos D, Tosti A. (eds). Nail Psoriasis.
D, Grassi W. A sonographic spectrum of psoriatic arthritis: Springer International Publishing, 2014:57-63.
“the five targets”. Clin Rheumatol 2010;29:133-142. 38. Wortsman X, Gutierrez M, Saavedra T, Honeyman J. The
25. Cunha JS, Qureshi AA, Reginato AM. Nail Enthesis Ultra- role of ultrasound in rheumatic skin and nail lesions: a mul-
sound in Psoriasis and Psoriatic Arthritis: A Report from the ti-specialist approach. Clin Rheumatol 2011;30:739-748.
2016 GRAPPA Annual Meeting. J Rheumatol 2017;44:688- 39. Aluja Jaramillo F, Quiasúa Mejía DC, Martínez Ordúz HM,
690. González Ardila C. Nail unit ultrasound: a complete guide
26. Sandre MK, Rohekar S. Psoriatic arthritis and nail chang- of the nail diseases. J Ultrasound 2017;20:181-192.
es: Exploring the relationship. Semin Arthritis Rheum 40. Gutierrez M, Di Geso L, Salaffi F, et al. Development of
2014;44:162-169. a preliminary US power Doppler composite score for
184 Luca Idolazzi et al Ultrasonography of the nail unit reveals quantitative and qualitative alterations
monitoring treatment in PsA. Rheumatology (Oxford) 42. Coates LC, Anderson RR, Fitzgerald O, et al. Clues to the
2012;51:1261-1268. pathogenesis of psoriasis and psoriatic arthritis from imag-
41. Aydin SZ, Castillo-Gallego C, Ash ZR, et al. Ultrasono- ing: a literature review. J Rheumatol 2008;35:1438-1442.
graphic assessment of nail in psoriatic disease shows a 43. Aydin SZ, Castillo-Gallego C, Ash ZR, et al. Potential use
link between onychopathy and distal interphalangeal joint of optical coherence tomography and high-frequency ultra-
extensor tendon enthesopathy. Dermatology 2012;225:231- sound for the assessment of nail disease in psoriasis and
235. psoriatic arthritis. Dermatology 2013;227:45-51.