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a reflection of the presence of subclinical arthritic disease in clinically normal joints&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">7&#44;8</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Persistent joint inflammation can lead to bone damage&#44; and it is estimated that half of PsA patients develop irreversible joint lesions within the first few years of disease&#46;<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">9&#44;10</span></a> Therefore&#44; PsA is a severe&#44; erosive and deforming condition&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">PsA patients have an increased burden of disease&#44; impairment in quality of life&#44; and diminished functional capacity&#44; all reflected in a lower general health state&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">4&#44;11&#44;12</span></a> Overall&#44; this results in great physical&#44; psychological&#44; and ultimately economic burden of the disease to the individual and society&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">13</span></a> There is therefore a need to establish a clinical indicator to detect risk and ensure early diagnosis of PsA&#46; Early detection and treatment of PsA could&#44; ultimately&#44; allow the prevention of clinical and radiologic progression of the disease&#46; For this reason&#44; predictors for the presence of subclinical PsA are of considerable clinical interest&#46; If validated properly&#44; such indicators may help identify patients with subclinical disease at risk of deterioration&#44; and allow an early intervention&#46;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">2&#44;4</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Nail changes are observed in about 40&#37; of psoriasis patients&#44; a percentage that increasers to about 80&#37; in patients with PsA&#46; Nail disease in psoriasis has long been proposed as a predictor for the development of PsA&#46;<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">14&#8211;17</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Since skin lesions precede articular symptoms in more than 75&#8211;80&#37; of patients with PsA&#44; with a mean estimated delay of 10 years&#44; there is a potential window of opportunity for the early diagnosis and management PsA&#46;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">2&#44;4&#44;18</span></a> This represents a unique occasion to document the clinical changes predictive of the development of PsA&#44; or its subclinical presence&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">19</span></a> As dermatologists usually see patients with psoriasis before arthritis develops&#44; they are in a unique position to diagnose PsA in its earliest phase&#44; by detecting the precocious silent alterations of the disease even before radiological signs and symptoms have become manifest&#46;<a class="elsevierStyleCrossRefs" href="#bib0290"><span class="elsevierStyleSup">20&#44;21</span></a> The ultimate goal is early detection and appropriate treatment&#44; avoiding disease progression and irreversible bone damage&#46;</p><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Psoriatic arthritis&#58; clinical findings</span><p id="par0030" class="elsevierStylePara elsevierViewall">PsA is a seronegative spondyloarthropathy&#44; whose central defining feature is inflammation involving the entheses &#40;enthesitis&#41;&#46; PsA often presents in a characteristically asymmetrical manner&#44; commonly involving the distal joints of the hands and feet&#46; This specific distal joint affection points toward the presence of some factors&#44; intrinsic to the target joint itself&#44; which act as key drivers in the onset and perpetuation of the disease process&#46;<a class="elsevierStyleCrossRefs" href="#bib0290"><span class="elsevierStyleSup">20&#44;22&#44;23</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">A common defining feature of PsA is the clinical presence of dactylitis&#44; which represents inflammatory involvement &#40;often with diffuse swelling&#41; of the distal interphalangeal &#40;DIP&#41; joint&#46; The DIP joint involvement begins as inflammation of the entheses&#44; the main change in PsA&#46; This perpetuated&#44; chronic inflammatory process may ultimately culminate in joint cavity involvement&#44; with osteolysis and periarticular new bone formation&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">23</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">With the purpose of creating a uniform and established definition of PsA&#44; a Classification Criteria for Psoriatic Arthritis &#8211; the CASPAR classification &#8211; was introduced&#46; This classification is found to be highly specific for the diagnosis of PsA &#40;98&#46;7&#37;&#41;&#44; and easier to use than other existing classification criteria&#46; In this classification&#44; diagnosis of PsA is supported by the combined presence of a certain number of clinical features&#44; such as&#58; &#40;a&#41; established inflammatory joint disease&#59; &#40;b&#41; current psoriasis&#59; &#40;c&#41; history of psoriasis&#59; &#40;d&#41; family history of psoriasis&#59; &#40;e&#41; dactylitis&#59; &#40;f&#41; radiographic evidence of juxta-articular new bone formation&#59; &#40;g&#41; negative rheumatoid factor&#44; and &#40;h&#41; typical psoriatic nail dystrophy&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">24</span></a> As suggested by these criteria&#44; nail disease in PsA is given a prominent role in diagnosis&#44; and is given an equal footing to other important clinical and radiographic criteria&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Entheses&#58; the anatomical site of joint inflammation</span><p id="par0045" class="elsevierStylePara elsevierViewall">Enthesis is the term used for the attachment site of ligaments&#44; tendons&#44; and joint capsules to bone&#46; This anatomical structure appears to share microanatomical features with the skin&#44; both assisting in the resilience to regional compressive and shear force applications&#44; helping preserve tissue homeostasis&#46;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">25</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">As mentioned earlier&#44; several imaging and histological studies have defined enthesitis &#40;inflammation of the entheses&#41; as the central&#44; early inflammatory change in PsA&#46;<a class="elsevierStyleCrossRefs" href="#bib0290"><span class="elsevierStyleSup">20&#44;26&#44;27</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">With the aim of characterizing arthritis in PsA patients&#44; several investigators studied the DIP joint with imaging techniques such as ultrasonography and magnetic resonance imaging &#40;MRI&#41;&#46; The extent of the enthesis-associated disease in PsA became evident&#44; as these techniques allowed to detect subclinical imaging features of inflammation of the entheses in clinically normal joints&#46; Furthermore&#44; these entheseal changes were found to be consistently identified when clinically evident nail disease was present&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">7&#44;22&#44;27&#44;28</span></a> These imaging studies not only sustained the now established notion that enthesopathy is the major feature of PsA&#44; but also suggested that nail disease in psoriasis may be associated with subclinical entheseal disease&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The entheses appear to derive their nourishment from the adjacent synovium&#44; reflecting the anatomical proximity these structures&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">22</span></a> As such&#44; inflammation and consequently altered entheseal function affects not only fibrous fibers in the entheses but the synovium as well and&#44; by consequence&#44; the contents of the synovial compartment&#44; the joint surfaces&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">As mentioned above&#44; like the skin&#44; the entheses are the anatomical structures that respond to both shear and compressive forces&#44; and is now considered a prominent target of the early inflammatory process in PsA&#46; As in the skin&#44; changes observed in the nail-entheseal-joint apparatus could be explained by a Koebner response phenomenon&#46; This hypothesis defines the occurrence of a common <span class="elsevierStyleItalic">Koebnerization</span> phenomenon &#8211; the appearance of lesions at previous sites of microdamage and trauma &#8211; and ultimately&#44; inflammatory changes resulting from this stress could be responsible for the development of both nail disease and PsA joint changes&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">4&#44;29</span></a> This concept of joint <span class="elsevierStyleItalic">Koebnerization</span> can ultimately be considered an aberrant response to mechanical stress&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">4&#44;25&#44;30</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">The link between psoriasis and HLA-Cw6 is well established&#44; the latter representing the strongest genetic risk factor for the development of psoriasis&#46;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">31</span></a> Nonetheless&#44; joint and nail psoriasis-related changes appear to lack this association&#46; Currently&#44; studies so far have attested the presence of a prominent innate inflammatory infiltrate in PsA joints&#46; This helped emphasize the emerging notion that&#44; unlike psoriasis &#40;in which an autoimmune response phenomenon&#44; whose main participants are innate&#44; but most importantly the adaptive immunity&#41;&#44; PsA results from a <span class="elsevierStyleItalic">Koebnerization</span> phenomenon triggering an auto-inflammatory reaction of neutrophils in a tissue prone to stress lesions&#46; In conclusion&#44; the adaptive immune response that is presumed to be related to skin disease may not play a prominent role in PsA&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">22</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Nail apparatus relation to arthritis&#58; the entheseal complex</span><p id="par0075" class="elsevierStylePara elsevierViewall">Of all the clinical indicators studied so far in the prediction of the development of PsA&#44; the most strongly associated has been undoubtedly nail disease&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">4</span></a> An incidence study that followed a cohort of 1593 psoriatic patients for 30 years concluded that&#44; compared to subjects without nail disease&#44; psoriatic patients with nail dystrophy were almost 3 times more likely to develop PsA&#44; with an attributed hazard ratio &#40;HR&#41; of 2&#46;93 &#40;95&#37; CI&#44; 1&#46;68&#8211;5&#46;12&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">19</span></a> Additionally&#44; a retrospective analysis of 4146 psoriatic patients pointed to nail involvement as the strongest predictor for concomitant PsA&#44; with an odds ratio &#40;OR&#41; of 2&#46;93 &#40;95&#37; CI&#44; 2&#46;51&#8211;3&#46;42&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">4</span></a> In addition&#44; a prevalence study that aimed to determine the clinical implications of nail disease in 661 psoriasis patients found an association between nail changes and PsA&#44; with an OR of 3&#46;25 &#40;95&#37; CI&#44; 2&#46;16&#8211;4&#46;90&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">32</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">The nail unit is formed by&#58; &#40;1&#41; the nail plate&#59; &#40;2&#41; proximal nail fold&#59; &#40;3&#41; matrix&#59; &#40;4&#41; nail bed and &#40;5&#41; hyponychium&#46; The resulting specific nail lesion differs according to the nail structure primarily affected by the inflammatory process&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">23</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">Thus&#44; the characteristics of nail involvement are determined by the extension and site of the inflammatory reaction&#46; If the nail matrix is involved&#44; there may be development of pitting&#44; leukonychia&#44; red patches &#40;erythema&#41; in the lunula&#44; onychorrhexis&#44; and onychodystrophy&#46; In contrast&#44; if the nail bed is affected&#44; oil spots&#44; splinter hemorrhage&#44; onycholysis and subungual hyperkeratosis may develop&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">4&#44;23&#44;30&#44;33</span></a> Although various studies differ in terms of the most prevalent nail change detected in PsA patients&#44; pitting and onycholysis are defined as the most common modifications &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">33</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">Anatomical and imaging studies have made a substantial contribution to our current understanding of the nail unit and its intrinsic connections to the DIP joint&#46; These studies provided an anatomical link between the DIP extensor tendon enthesitis and the nail changes in PsA &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">26</span></a></p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">The nail is just as much an integral part of the entheseal unit as it is of the skin&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">4&#44;26</span></a> At the microanatomical level&#44; a close relationship exists between the nail and the DIP extensor tendon enthesis&#46; As represented schematically in <a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#44; the DIP extensor tendon attaches distally to the DIP joint&#44; to a region located on the dorsal surface of the distal phalanx &#40;DP&#41;&#46; Arising from this attachment site&#44; fibrous connections link nail structures&#44; namely the nail matrix&#44; to the periosteum of the DP&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">22</span></a> The DIP joint is therefore linked to the nail structures via the entheseal unit of the DIP extensor tendon&#46;<a class="elsevierStyleCrossRefs" href="#bib0320"><span class="elsevierStyleSup">26&#44;34</span></a></p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">Recognition of this joint-entheseal-nail apparatus highlights the importance of entheseal inflammatory changes in PsA&#46; This close structural relationship helps us understand why PsA patients&#44; who typically present enthesitis of the DIP joint&#44; concurrently develop inflammatory nail changes&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">4</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">As noted above&#44; clinically unrecognized enthesitis is commonly observed in early PsA and&#44; at this stage&#44; crude radiographic signs are usually absent&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">30</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">In patients with psoriasis&#44; imaging indicators of joint inflammation were found more frequently in patients with nail disease in comparison with those who presented no nail dystrophy signs&#46; For example&#44; the presence of extensor tendon entheseal thickening by ultrasound was observed in 42&#37; of psoriatic patients &#40;35&#47;83&#41; with clinical nail changes&#44; while only 17&#46;4&#37; of patients &#40;15&#47;86&#41; without nail lesions were found to have ultrasonographic findings&#46; Entheseal changes are therefore more frequently observed in patients with nail changes&#44; highlighting the relationship between nail and entheseal inflammation&#46;<a class="elsevierStyleCrossRefs" href="#bib0290"><span class="elsevierStyleSup">20&#44;27</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">In a study that evaluated the nail and DIP joint in patients with PsA using MRI&#44; it was observed that nail involvement was present in almost all PsA patients &#40;95&#46;7&#37;&#41;&#44; even when the presence of clinical onychodystrophy was not evident&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">28</span></a> These findings suggest that nail disease is virtually always present in PsA patients&#44; although not always clinically obvious&#46; Patients could therefore benefit from close follow-up and evaluation by an expert in the nail area&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Furthermore&#44; this group found that inflammatory signs of DP involvement always overlapped with nail involvement and cases of DIP joint changes alone were reported &#40;that is&#44; without nail and DP inflammatory changes&#41;&#46; This enabled the formulation of a theory in which DIP joint involvement may arise as a result of nail and DP affection&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">28</span></a> In conclusion&#44; the clinical and imaging findings of this study suggested psoriatic nail changes and distal phalanx inflammatory involvement precede DIP joint changes&#46; These observations prompted the idea that nail dystrophy in psoriatic patients could be an indicator of ongoing inflammatory involvement of the distal phalanx&#44; the site of attachment of entheseal structures of the DIP extensor tendon&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">28</span></a> Other studies corroborated this theory&#44; providing strong evidence that nail disease is a predictor of PsA before arthritic changes occur&#46;<a class="elsevierStyleCrossRefs" href="#bib0365"><span class="elsevierStyleSup">35&#44;36</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">For this reason&#44; nail disease in psoriasis may represent an accessible and readily observable indicator of future inflammatory joint affection&#46; It could therefore be used as a sensitive clinical predictor of PsA&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Nail assessment&#58; the dermatology&#8211;rheumatology gap</span><p id="par0130" class="elsevierStylePara elsevierViewall">Studies have shown that&#44; when assessing psoriatic nail disease&#44; imaging findings of nail changes correlate well with clinical nail assessments&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">27</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">Studies that assessed PsA severity did not observe a direct relation between the degree of nail affection and DIP joint inflammation&#46;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">37</span></a> From this assessment&#44; one can conclude that the smallest nail changes&#44; which may go unnoticed to the untrained observer with the naked eye&#44; could be an important indicator of the presence of major disease&#46; Expert examination&#44; particularly dermatologists who can readily detect such changes&#44; is therefore important&#46; In this setting&#44; the dermatological examination is of prime importance as a detector of a silent disease manifestation requiring referral &#40;in this case&#44; to the rheumatologist&#41;&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">In a comparison between nail change detection&#44; about 15&#37; of patients classified by rheumatologists as having clinically evident nail disease&#44; had another specific nail diagnosis unrelated to psoriasis&#44; such as onychomycosis or onychoschizia&#44; when observed by dermatologists&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">16</span></a> This underscores another essential characteristic of the dermatological assessment &#8211; high specificity&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">In this view&#44; psoriatic nail disease represents an area of overlap between dermatology and rheumatology&#46; Mutual awareness of this overlap by dermatologists and rheumatologists&#44; along with referral of psoriatic patients deemed to be at risk for arthritic disease&#44; is of particular importance for the prevention of a serious&#44; mutilating&#44; chronic disease&#46;<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">38</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">Dermatologists can&#44; therefore&#44; play a central role in the early detection and management of PsA&#46;</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusion</span><p id="par0155" class="elsevierStylePara elsevierViewall">Specific imaging techniques have shown that the central inflammatory change in PsA takes place in the entheseal compartment&#46; This structure is present in virtually every joint&#44; but enthesitis manifests clinically in PsA especially in those structures subject to major shear and stretch forces&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Nail disease in PsA results from the close relationship between this structure and the enthesis of the DIP extensor tendon &#8211; one of the main entheseal compartments affected in PsA&#46; The inflammatory change begins in the entheses&#44; affecting the nail according to the degree and site &#40;matrix vs nail bed&#41; of inflammatory activity&#44; and progresses proximally to affect the DIP joint&#46; This results ultimately in the final anatomical&#44; radiological and clinical changes of PsA in the joints&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">In this view&#44; the ability to detect nail changes by dermatologists gives them a strategic role in the early detection of subclinical entheseal disease and in the referral and management of early PsA&#44; thereby preventing severe&#44; erosive and deforming joint lesions&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">In conclusion&#44; the dermatological assessment in psoriatic patients represents a unique opportunity to prevent serious and functionally limiting disorders&#44; thereby benefiting the health system in general and&#44; most importantly&#44; improving the patient&#39;s quality of life&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Ethical responsibilities</span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Protecting people and animals</span><p id="par0180" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Data privacy</span><p id="par0185" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Right to privacy and informed consent</span><p id="par0190" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Conflict of interests</span><p id="par0195" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interests&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Psoriatic arthritis is a psoriasis-related spondyloarthropathy that occurs in 20&#8211;30&#37; of patients with psoriasis&#46; Various imaging studies have demonstrated that there is a considerable proportion of undiagnosed psoriatic arthritis among patients with psoriasis&#46; Since early detection and treatment of psoriatic arthritis could&#44; ultimately&#44; allow the prevention of clinical and radiologic progression of the disease&#44; there is the need to establish clinical indicators to detect this risk&#46;</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Nail psoriasis has been proposed as a predictor for the development of psoriatic arthritis&#46; The inflammation involving the entheses&#44; called enthesitis&#44; is an early inflammatory change seen in psoriatic arthritis&#44; and nail changes appear to result from the close relationship between the nail and the enthesis of the distal interphalangeal extensor tendon&#44; one of the main entheseal compartments affected in psoriatic arthritis&#46;</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">As skin lesions precede articular symptoms in more than 75&#8211;80&#37; of patients with psoriatic arthritis&#44; dermatologists may play a key role in the early detection and management of psoriatic arthritis&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">La artritis psori&#225;sica es una espondiloartropat&#237;a relacionada con la psoriasis que aparece en un 20&#8211;30&#37; de los pacientes con psoriasis&#46; Varios estudios por im&#225;genes han demostrado que hay una cantidad considerable de artritis psori&#225;sica no diagnosticada entre los pacientes con psoriasis&#46; Existe la necesidad de establecer indicadores cl&#237;nicos que se&#241;alen el riesgo de desarrollo de artritis psori&#225;sica&#44; ya que la detecci&#243;n y el tratamiento temprano de la misma podr&#237;a&#44; en &#250;ltima instancia&#44; permitir la prevenci&#243;n y la progresi&#243;n cl&#237;nica y radiol&#243;gica de la enfermedad&#46;</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Se ha propuesto la psoriasis ungueal como factor predictivo del desarrollo de la artritis psori&#225;sica&#46; La entesitis&#44; inflamaci&#243;n de la entesis&#44; es un cambio inflamatorio temprano observado en la artritis psori&#225;sica&#44; y los cambios en las u&#241;as parecen ser el resultado de la estrecha relaci&#243;n entre la u&#241;a y la entesis interfal&#225;ngica distal del tend&#243;n extensor&#44; que es uno de los principales compartimentos ent&#233;sicos afectados en la artritis psori&#225;sica&#46;</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Los dermat&#243;logos pueden desempe&#241;ar un papel clave en la detecci&#243;n temprana y en el manejo de la artritis psori&#225;sica&#44; ya que en m&#225;s de un 75&#8211;80&#37; de los pacientes con artritis psori&#225;sica las lesiones de la piel preceden a la aparici&#243;n de los s&#237;ntomas articulares&#46;</p></span>"
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          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Magnetic resonance imaging of a distal interphalangeal &#40;DIP&#41; joint of a 29-year-old female with a 3-year history of psoriatic arthritis affecting the joint&#58; &#40;A&#41; T2-weighted fat-suppressed coronal image of the dorsal DIP joint showing high signal around the joint and adjacent to the distal phalanx near the nail bed &#40;denoted by asterisk&#41;&#46; &#40;B&#41; T1-weighted fat-suppressed post-gadolinium axial image of the same joint showing enhancement and thickening of the tissues under the nail bed &#40;denoted by asterisk&#41;&#46; &#40;C&#41; Water-selective excitation sagittal sequence of the joint demonstrating the thickened tissues under the nail bed &#40;denoted by asterisk&#41; and an abnormal extensor tendon enthesis&#44; which was thickened and showed loss of the low signal &#40;arrow&#41;&#46; Linear regions with low signal similar to the extensor tendon could be seen enveloping the nail &#40;arrowheads&#41;&#46; These may correspond to fibers from the extensor tendon extending toward the nail bed&#46;</p>"
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Review
Nail psoriasis as a predictor of the development of psoriatic arthritis
Psoriasis ungueal como factor predictivo del desarrollo de artritis prosiásica
I. Raposoa, T. Torresa,b,
Autor para correspondencia
tiagotorres2002@hotmail.com

Corresponding author.
a Department of Dermatology, Centro Hospitalar do Porto, Portugal
b Instituto de Ciências Biomédicas Abel Salazar, University of Porto, Portugal
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Psoriasis is a chronic&#44; systemic&#44; inflammatory disorder&#44; affecting 2&#8211;3&#37; of the population worldwide&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">1</span></a> Psoriatic arthritis &#40;PsA&#41; is a psoriasis-related spondyloarthropathy that presents with typical signs and symptoms of both psoriasis and arthritis and&#44; like psoriasis&#44; follows a chronic course&#46;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">2-4</span></a> An estimated 20&#8211;30&#37; of psoriasis patients may develop PsA&#46;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">5&#44;6</span></a> Imaging studies have demonstrated the existence of considerable number of patients with psoriasis and undiagnosed PsA&#44; a reflection of the presence of subclinical arthritic disease in clinically normal joints&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">7&#44;8</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Persistent joint inflammation can lead to bone damage&#44; and it is estimated that half of PsA patients develop irreversible joint lesions within the first few years of disease&#46;<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">9&#44;10</span></a> Therefore&#44; PsA is a severe&#44; erosive and deforming condition&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">PsA patients have an increased burden of disease&#44; impairment in quality of life&#44; and diminished functional capacity&#44; all reflected in a lower general health state&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">4&#44;11&#44;12</span></a> Overall&#44; this results in great physical&#44; psychological&#44; and ultimately economic burden of the disease to the individual and society&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">13</span></a> There is therefore a need to establish a clinical indicator to detect risk and ensure early diagnosis of PsA&#46; Early detection and treatment of PsA could&#44; ultimately&#44; allow the prevention of clinical and radiologic progression of the disease&#46; For this reason&#44; predictors for the presence of subclinical PsA are of considerable clinical interest&#46; If validated properly&#44; such indicators may help identify patients with subclinical disease at risk of deterioration&#44; and allow an early intervention&#46;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">2&#44;4</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Nail changes are observed in about 40&#37; of psoriasis patients&#44; a percentage that increasers to about 80&#37; in patients with PsA&#46; Nail disease in psoriasis has long been proposed as a predictor for the development of PsA&#46;<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">14&#8211;17</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Since skin lesions precede articular symptoms in more than 75&#8211;80&#37; of patients with PsA&#44; with a mean estimated delay of 10 years&#44; there is a potential window of opportunity for the early diagnosis and management PsA&#46;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">2&#44;4&#44;18</span></a> This represents a unique occasion to document the clinical changes predictive of the development of PsA&#44; or its subclinical presence&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">19</span></a> As dermatologists usually see patients with psoriasis before arthritis develops&#44; they are in a unique position to diagnose PsA in its earliest phase&#44; by detecting the precocious silent alterations of the disease even before radiological signs and symptoms have become manifest&#46;<a class="elsevierStyleCrossRefs" href="#bib0290"><span class="elsevierStyleSup">20&#44;21</span></a> The ultimate goal is early detection and appropriate treatment&#44; avoiding disease progression and irreversible bone damage&#46;</p><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Psoriatic arthritis&#58; clinical findings</span><p id="par0030" class="elsevierStylePara elsevierViewall">PsA is a seronegative spondyloarthropathy&#44; whose central defining feature is inflammation involving the entheses &#40;enthesitis&#41;&#46; PsA often presents in a characteristically asymmetrical manner&#44; commonly involving the distal joints of the hands and feet&#46; This specific distal joint affection points toward the presence of some factors&#44; intrinsic to the target joint itself&#44; which act as key drivers in the onset and perpetuation of the disease process&#46;<a class="elsevierStyleCrossRefs" href="#bib0290"><span class="elsevierStyleSup">20&#44;22&#44;23</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">A common defining feature of PsA is the clinical presence of dactylitis&#44; which represents inflammatory involvement &#40;often with diffuse swelling&#41; of the distal interphalangeal &#40;DIP&#41; joint&#46; The DIP joint involvement begins as inflammation of the entheses&#44; the main change in PsA&#46; This perpetuated&#44; chronic inflammatory process may ultimately culminate in joint cavity involvement&#44; with osteolysis and periarticular new bone formation&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">23</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">With the purpose of creating a uniform and established definition of PsA&#44; a Classification Criteria for Psoriatic Arthritis &#8211; the CASPAR classification &#8211; was introduced&#46; This classification is found to be highly specific for the diagnosis of PsA &#40;98&#46;7&#37;&#41;&#44; and easier to use than other existing classification criteria&#46; In this classification&#44; diagnosis of PsA is supported by the combined presence of a certain number of clinical features&#44; such as&#58; &#40;a&#41; established inflammatory joint disease&#59; &#40;b&#41; current psoriasis&#59; &#40;c&#41; history of psoriasis&#59; &#40;d&#41; family history of psoriasis&#59; &#40;e&#41; dactylitis&#59; &#40;f&#41; radiographic evidence of juxta-articular new bone formation&#59; &#40;g&#41; negative rheumatoid factor&#44; and &#40;h&#41; typical psoriatic nail dystrophy&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">24</span></a> As suggested by these criteria&#44; nail disease in PsA is given a prominent role in diagnosis&#44; and is given an equal footing to other important clinical and radiographic criteria&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Entheses&#58; the anatomical site of joint inflammation</span><p id="par0045" class="elsevierStylePara elsevierViewall">Enthesis is the term used for the attachment site of ligaments&#44; tendons&#44; and joint capsules to bone&#46; This anatomical structure appears to share microanatomical features with the skin&#44; both assisting in the resilience to regional compressive and shear force applications&#44; helping preserve tissue homeostasis&#46;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">25</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">As mentioned earlier&#44; several imaging and histological studies have defined enthesitis &#40;inflammation of the entheses&#41; as the central&#44; early inflammatory change in PsA&#46;<a class="elsevierStyleCrossRefs" href="#bib0290"><span class="elsevierStyleSup">20&#44;26&#44;27</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">With the aim of characterizing arthritis in PsA patients&#44; several investigators studied the DIP joint with imaging techniques such as ultrasonography and magnetic resonance imaging &#40;MRI&#41;&#46; The extent of the enthesis-associated disease in PsA became evident&#44; as these techniques allowed to detect subclinical imaging features of inflammation of the entheses in clinically normal joints&#46; Furthermore&#44; these entheseal changes were found to be consistently identified when clinically evident nail disease was present&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">7&#44;22&#44;27&#44;28</span></a> These imaging studies not only sustained the now established notion that enthesopathy is the major feature of PsA&#44; but also suggested that nail disease in psoriasis may be associated with subclinical entheseal disease&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The entheses appear to derive their nourishment from the adjacent synovium&#44; reflecting the anatomical proximity these structures&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">22</span></a> As such&#44; inflammation and consequently altered entheseal function affects not only fibrous fibers in the entheses but the synovium as well and&#44; by consequence&#44; the contents of the synovial compartment&#44; the joint surfaces&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">As mentioned above&#44; like the skin&#44; the entheses are the anatomical structures that respond to both shear and compressive forces&#44; and is now considered a prominent target of the early inflammatory process in PsA&#46; As in the skin&#44; changes observed in the nail-entheseal-joint apparatus could be explained by a Koebner response phenomenon&#46; This hypothesis defines the occurrence of a common <span class="elsevierStyleItalic">Koebnerization</span> phenomenon &#8211; the appearance of lesions at previous sites of microdamage and trauma &#8211; and ultimately&#44; inflammatory changes resulting from this stress could be responsible for the development of both nail disease and PsA joint changes&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">4&#44;29</span></a> This concept of joint <span class="elsevierStyleItalic">Koebnerization</span> can ultimately be considered an aberrant response to mechanical stress&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">4&#44;25&#44;30</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">The link between psoriasis and HLA-Cw6 is well established&#44; the latter representing the strongest genetic risk factor for the development of psoriasis&#46;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">31</span></a> Nonetheless&#44; joint and nail psoriasis-related changes appear to lack this association&#46; Currently&#44; studies so far have attested the presence of a prominent innate inflammatory infiltrate in PsA joints&#46; This helped emphasize the emerging notion that&#44; unlike psoriasis &#40;in which an autoimmune response phenomenon&#44; whose main participants are innate&#44; but most importantly the adaptive immunity&#41;&#44; PsA results from a <span class="elsevierStyleItalic">Koebnerization</span> phenomenon triggering an auto-inflammatory reaction of neutrophils in a tissue prone to stress lesions&#46; In conclusion&#44; the adaptive immune response that is presumed to be related to skin disease may not play a prominent role in PsA&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">22</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Nail apparatus relation to arthritis&#58; the entheseal complex</span><p id="par0075" class="elsevierStylePara elsevierViewall">Of all the clinical indicators studied so far in the prediction of the development of PsA&#44; the most strongly associated has been undoubtedly nail disease&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">4</span></a> An incidence study that followed a cohort of 1593 psoriatic patients for 30 years concluded that&#44; compared to subjects without nail disease&#44; psoriatic patients with nail dystrophy were almost 3 times more likely to develop PsA&#44; with an attributed hazard ratio &#40;HR&#41; of 2&#46;93 &#40;95&#37; CI&#44; 1&#46;68&#8211;5&#46;12&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">19</span></a> Additionally&#44; a retrospective analysis of 4146 psoriatic patients pointed to nail involvement as the strongest predictor for concomitant PsA&#44; with an odds ratio &#40;OR&#41; of 2&#46;93 &#40;95&#37; CI&#44; 2&#46;51&#8211;3&#46;42&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">4</span></a> In addition&#44; a prevalence study that aimed to determine the clinical implications of nail disease in 661 psoriasis patients found an association between nail changes and PsA&#44; with an OR of 3&#46;25 &#40;95&#37; CI&#44; 2&#46;16&#8211;4&#46;90&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">32</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">The nail unit is formed by&#58; &#40;1&#41; the nail plate&#59; &#40;2&#41; proximal nail fold&#59; &#40;3&#41; matrix&#59; &#40;4&#41; nail bed and &#40;5&#41; hyponychium&#46; The resulting specific nail lesion differs according to the nail structure primarily affected by the inflammatory process&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">23</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">Thus&#44; the characteristics of nail involvement are determined by the extension and site of the inflammatory reaction&#46; If the nail matrix is involved&#44; there may be development of pitting&#44; leukonychia&#44; red patches &#40;erythema&#41; in the lunula&#44; onychorrhexis&#44; and onychodystrophy&#46; In contrast&#44; if the nail bed is affected&#44; oil spots&#44; splinter hemorrhage&#44; onycholysis and subungual hyperkeratosis may develop&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">4&#44;23&#44;30&#44;33</span></a> Although various studies differ in terms of the most prevalent nail change detected in PsA patients&#44; pitting and onycholysis are defined as the most common modifications &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">33</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">Anatomical and imaging studies have made a substantial contribution to our current understanding of the nail unit and its intrinsic connections to the DIP joint&#46; These studies provided an anatomical link between the DIP extensor tendon enthesitis and the nail changes in PsA &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">26</span></a></p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">The nail is just as much an integral part of the entheseal unit as it is of the skin&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">4&#44;26</span></a> At the microanatomical level&#44; a close relationship exists between the nail and the DIP extensor tendon enthesis&#46; As represented schematically in <a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#44; the DIP extensor tendon attaches distally to the DIP joint&#44; to a region located on the dorsal surface of the distal phalanx &#40;DP&#41;&#46; Arising from this attachment site&#44; fibrous connections link nail structures&#44; namely the nail matrix&#44; to the periosteum of the DP&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">22</span></a> The DIP joint is therefore linked to the nail structures via the entheseal unit of the DIP extensor tendon&#46;<a class="elsevierStyleCrossRefs" href="#bib0320"><span class="elsevierStyleSup">26&#44;34</span></a></p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">Recognition of this joint-entheseal-nail apparatus highlights the importance of entheseal inflammatory changes in PsA&#46; This close structural relationship helps us understand why PsA patients&#44; who typically present enthesitis of the DIP joint&#44; concurrently develop inflammatory nail changes&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">4</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">As noted above&#44; clinically unrecognized enthesitis is commonly observed in early PsA and&#44; at this stage&#44; crude radiographic signs are usually absent&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">30</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">In patients with psoriasis&#44; imaging indicators of joint inflammation were found more frequently in patients with nail disease in comparison with those who presented no nail dystrophy signs&#46; For example&#44; the presence of extensor tendon entheseal thickening by ultrasound was observed in 42&#37; of psoriatic patients &#40;35&#47;83&#41; with clinical nail changes&#44; while only 17&#46;4&#37; of patients &#40;15&#47;86&#41; without nail lesions were found to have ultrasonographic findings&#46; Entheseal changes are therefore more frequently observed in patients with nail changes&#44; highlighting the relationship between nail and entheseal inflammation&#46;<a class="elsevierStyleCrossRefs" href="#bib0290"><span class="elsevierStyleSup">20&#44;27</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">In a study that evaluated the nail and DIP joint in patients with PsA using MRI&#44; it was observed that nail involvement was present in almost all PsA patients &#40;95&#46;7&#37;&#41;&#44; even when the presence of clinical onychodystrophy was not evident&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">28</span></a> These findings suggest that nail disease is virtually always present in PsA patients&#44; although not always clinically obvious&#46; Patients could therefore benefit from close follow-up and evaluation by an expert in the nail area&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Furthermore&#44; this group found that inflammatory signs of DP involvement always overlapped with nail involvement and cases of DIP joint changes alone were reported &#40;that is&#44; without nail and DP inflammatory changes&#41;&#46; This enabled the formulation of a theory in which DIP joint involvement may arise as a result of nail and DP affection&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">28</span></a> In conclusion&#44; the clinical and imaging findings of this study suggested psoriatic nail changes and distal phalanx inflammatory involvement precede DIP joint changes&#46; These observations prompted the idea that nail dystrophy in psoriatic patients could be an indicator of ongoing inflammatory involvement of the distal phalanx&#44; the site of attachment of entheseal structures of the DIP extensor tendon&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">28</span></a> Other studies corroborated this theory&#44; providing strong evidence that nail disease is a predictor of PsA before arthritic changes occur&#46;<a class="elsevierStyleCrossRefs" href="#bib0365"><span class="elsevierStyleSup">35&#44;36</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">For this reason&#44; nail disease in psoriasis may represent an accessible and readily observable indicator of future inflammatory joint affection&#46; It could therefore be used as a sensitive clinical predictor of PsA&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Nail assessment&#58; the dermatology&#8211;rheumatology gap</span><p id="par0130" class="elsevierStylePara elsevierViewall">Studies have shown that&#44; when assessing psoriatic nail disease&#44; imaging findings of nail changes correlate well with clinical nail assessments&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">27</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">Studies that assessed PsA severity did not observe a direct relation between the degree of nail affection and DIP joint inflammation&#46;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">37</span></a> From this assessment&#44; one can conclude that the smallest nail changes&#44; which may go unnoticed to the untrained observer with the naked eye&#44; could be an important indicator of the presence of major disease&#46; Expert examination&#44; particularly dermatologists who can readily detect such changes&#44; is therefore important&#46; In this setting&#44; the dermatological examination is of prime importance as a detector of a silent disease manifestation requiring referral &#40;in this case&#44; to the rheumatologist&#41;&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">In a comparison between nail change detection&#44; about 15&#37; of patients classified by rheumatologists as having clinically evident nail disease&#44; had another specific nail diagnosis unrelated to psoriasis&#44; such as onychomycosis or onychoschizia&#44; when observed by dermatologists&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">16</span></a> This underscores another essential characteristic of the dermatological assessment &#8211; high specificity&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">In this view&#44; psoriatic nail disease represents an area of overlap between dermatology and rheumatology&#46; Mutual awareness of this overlap by dermatologists and rheumatologists&#44; along with referral of psoriatic patients deemed to be at risk for arthritic disease&#44; is of particular importance for the prevention of a serious&#44; mutilating&#44; chronic disease&#46;<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">38</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">Dermatologists can&#44; therefore&#44; play a central role in the early detection and management of PsA&#46;</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusion</span><p id="par0155" class="elsevierStylePara elsevierViewall">Specific imaging techniques have shown that the central inflammatory change in PsA takes place in the entheseal compartment&#46; This structure is present in virtually every joint&#44; but enthesitis manifests clinically in PsA especially in those structures subject to major shear and stretch forces&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Nail disease in PsA results from the close relationship between this structure and the enthesis of the DIP extensor tendon &#8211; one of the main entheseal compartments affected in PsA&#46; The inflammatory change begins in the entheses&#44; affecting the nail according to the degree and site &#40;matrix vs nail bed&#41; of inflammatory activity&#44; and progresses proximally to affect the DIP joint&#46; This results ultimately in the final anatomical&#44; radiological and clinical changes of PsA in the joints&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">In this view&#44; the ability to detect nail changes by dermatologists gives them a strategic role in the early detection of subclinical entheseal disease and in the referral and management of early PsA&#44; thereby preventing severe&#44; erosive and deforming joint lesions&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">In conclusion&#44; the dermatological assessment in psoriatic patients represents a unique opportunity to prevent serious and functionally limiting disorders&#44; thereby benefiting the health system in general and&#44; most importantly&#44; improving the patient&#39;s quality of life&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Ethical responsibilities</span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Protecting people and animals</span><p id="par0180" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Data privacy</span><p id="par0185" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Right to privacy and informed consent</span><p id="par0190" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Conflict of interests</span><p id="par0195" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interests&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Psoriatic arthritis is a psoriasis-related spondyloarthropathy that occurs in 20&#8211;30&#37; of patients with psoriasis&#46; Various imaging studies have demonstrated that there is a considerable proportion of undiagnosed psoriatic arthritis among patients with psoriasis&#46; Since early detection and treatment of psoriatic arthritis could&#44; ultimately&#44; allow the prevention of clinical and radiologic progression of the disease&#44; there is the need to establish clinical indicators to detect this risk&#46;</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Nail psoriasis has been proposed as a predictor for the development of psoriatic arthritis&#46; The inflammation involving the entheses&#44; called enthesitis&#44; is an early inflammatory change seen in psoriatic arthritis&#44; and nail changes appear to result from the close relationship between the nail and the enthesis of the distal interphalangeal extensor tendon&#44; one of the main entheseal compartments affected in psoriatic arthritis&#46;</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">As skin lesions precede articular symptoms in more than 75&#8211;80&#37; of patients with psoriatic arthritis&#44; dermatologists may play a key role in the early detection and management of psoriatic arthritis&#46;</p></span>"
      ]
      "es" => array:2 [
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">La artritis psori&#225;sica es una espondiloartropat&#237;a relacionada con la psoriasis que aparece en un 20&#8211;30&#37; de los pacientes con psoriasis&#46; Varios estudios por im&#225;genes han demostrado que hay una cantidad considerable de artritis psori&#225;sica no diagnosticada entre los pacientes con psoriasis&#46; Existe la necesidad de establecer indicadores cl&#237;nicos que se&#241;alen el riesgo de desarrollo de artritis psori&#225;sica&#44; ya que la detecci&#243;n y el tratamiento temprano de la misma podr&#237;a&#44; en &#250;ltima instancia&#44; permitir la prevenci&#243;n y la progresi&#243;n cl&#237;nica y radiol&#243;gica de la enfermedad&#46;</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Se ha propuesto la psoriasis ungueal como factor predictivo del desarrollo de la artritis psori&#225;sica&#46; La entesitis&#44; inflamaci&#243;n de la entesis&#44; es un cambio inflamatorio temprano observado en la artritis psori&#225;sica&#44; y los cambios en las u&#241;as parecen ser el resultado de la estrecha relaci&#243;n entre la u&#241;a y la entesis interfal&#225;ngica distal del tend&#243;n extensor&#44; que es uno de los principales compartimentos ent&#233;sicos afectados en la artritis psori&#225;sica&#46;</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Los dermat&#243;logos pueden desempe&#241;ar un papel clave en la detecci&#243;n temprana y en el manejo de la artritis psori&#225;sica&#44; ya que en m&#225;s de un 75&#8211;80&#37; de los pacientes con artritis psori&#225;sica las lesiones de la piel preceden a la aparici&#243;n de los s&#237;ntomas articulares&#46;</p></span>"
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          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Clinical manifestations of nail psoriasis&#46;</p>"
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        "fuente" => "From Tan et al&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">26</span></a> with permission of Oxford University Press on behalf of the British Society for Rheumatology&#46;"
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          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Magnetic resonance imaging of a distal interphalangeal &#40;DIP&#41; joint of a 29-year-old female with a 3-year history of psoriatic arthritis affecting the joint&#58; &#40;A&#41; T2-weighted fat-suppressed coronal image of the dorsal DIP joint showing high signal around the joint and adjacent to the distal phalanx near the nail bed &#40;denoted by asterisk&#41;&#46; &#40;B&#41; T1-weighted fat-suppressed post-gadolinium axial image of the same joint showing enhancement and thickening of the tissues under the nail bed &#40;denoted by asterisk&#41;&#46; &#40;C&#41; Water-selective excitation sagittal sequence of the joint demonstrating the thickened tissues under the nail bed &#40;denoted by asterisk&#41; and an abnormal extensor tendon enthesis&#44; which was thickened and showed loss of the low signal &#40;arrow&#41;&#46; Linear regions with low signal similar to the extensor tendon could be seen enveloping the nail &#40;arrowheads&#41;&#46; These may correspond to fibers from the extensor tendon extending toward the nail bed&#46;</p>"
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