Case and Research Letters
Ultrasound Characterization of Psoriasis of the Nails: A Case-Control Study
Caracterización ecográfica de la psoriasis ungueal: estudio de casos y controles
D. Vidala,
, F. Alfagemeb, R. Ruiz-Villaverdec, S. Arias-Santiagoc, A. Martorelld
Autor para correspondencia
a Servicio de Dermatología, Hospital de Sant Joan Despí Moisès Broggi, Sant Joan Despí, Barcelona, Spain
b Servicio de Dermatología, Hospital Universitario Puerta de Hierro-Majadahonda, Majadahonda, Madrid, Spain
c Unidad de Gestión Clínica de Dermatología, Complejo Hospitalario de Granada, Granada, Spain
d Servicio de Dermatología, Hospital de Manises, Manises, Valencia, Spain
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Vidal, F. Alfageme, R. Ruiz-Villaverde, S. Arias-Santiago, A. Martorell" "autores" => array:5 [ 0 => array:4 [ "nombre" => "D." "apellidos" => "Vidal" "email" => array:1 [ 0 => "david.vidal@sanitatintegral.org" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "F." "apellidos" => "Alfageme" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "R." "apellidos" => "Ruiz-Villaverde" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "S." "apellidos" => "Arias-Santiago" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 4 => array:3 [ "nombre" => "A." "apellidos" => "Martorell" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Servicio de Dermatología, Hospital de Sant Joan Despí Moisès Broggi, Sant Joan Despí, Barcelona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Dermatología, Hospital Universitario Puerta de Hierro-Majadahonda, Majadahonda, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Unidad de Gestión Clínica de Dermatología, Complejo Hospitalario de Granada, Granada, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Servicio de Dermatología, Hospital de Manises, Manises, Valencia, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Caracterización ecográfica de la psoriasis ungueal: estudio de casos y controles" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1008 "Ancho" => 1503 "Tamanyo" => 113240 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Doppler signal of the nail bed and matrix. Semiquantitative scale (0-3).</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">*<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>.05.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">High-frequency B-mode ultrasonography and Doppler study can reveal changes in nail anatomy and vascularization in patients with nail psoriasis (NPs). The primary objective of this study was to describe thumbnail ultrasound findings in a series of adult patients with psoriasis involving the thumbnail. It was decided to focus on the thumbnail as this is the largest finger nail and also the one most often affected in NPs. A nonprospective, multicenter, cross-sectional case-control study was performed in which hospitals in 4 Spanish provinces participated. The controls were consecutive healthy subjects with no clinical disorders of the thumbnail who attended the dermatology clinic. The 5 investigators performed a single ultrasound study of each patient with the same parameters: 18<span class="elsevierStyleHsp" style=""></span>MHz linear transducer (B mode), between 6.6 and 12.5<span class="elsevierStyleHsp" style=""></span>MHz in Doppler mode, pulse repetition frequency of 750 per second and wall filter of 3. The structure and thickness of the nail plate as well as the thickness of the nail bed (distance between the ventral lamina and the phalange) were assessed along 2 axes, and Doppler signal of the nail bed and matrix area was assessed using a semiquantitative scale (0-3).<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> The nail bed was defined as the area located below the nail plate distal to the eponychium (cuticle) and the matrix area as the area located below the proximal fold that delimits proximally with the insertion of the extensor tendon of the thumb and distally with the nail bed. The statistical analyses were performed with the SPSS program, version 21.0, and statistical significance was set at 0.05.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Seventy-nine participants were included, 36 cases and 43 controls. The mean age was 44 years, 75% were women, and the mean body mass index was 25<span class="elsevierStyleHsp" style=""></span>kg/m<span class="elsevierStyleSup">2</span>, with no significant differences between the 2 groups. In patients with psoriasis, the mean age of onset of NPs was 32 years, the mean PASI was 5, 19% were diagnosed with peripheral psoriatic arthritis (PsA) (n<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>7), and 30% were taking systemic treatment for NPs (54% methotrexate, 27% biologic agents, and 19% other agents). Of the cases, 72% had clinical involvement of the nail bed, 67% of the nail matrix, and 39% had involvement of both. The most frequent disorder was pitted nails (83%), followed by onycholysis (65%), and subungual hyperkeratosis (46%). Ultrasound of the nail plate showed a regular trilaminar structure in 95% of controls and 25% of cases (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>.05). In patients with NPs, plate thickening was observed (1.02<span class="elsevierStyleHsp" style=""></span>mm longitudinal axis and 1.08<span class="elsevierStyleHsp" style=""></span>mm transversal axis) and the nail bed (2.19<span class="elsevierStyleHsp" style=""></span>mm longitudinal axis and 2.21<span class="elsevierStyleHsp" style=""></span>mm transversal axis), with significant difference with controls (1.69<span class="elsevierStyleHsp" style=""></span>mm) (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). The Doppler signal from the nail bed showed a mean and a mode of 1 in cases and 0 in controls (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>.05). The Doppler study of the matrix area of the cases showed a median of 1 and a mode of 2 while the controls showed a median of 1 and a mode of 0 (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>.05) (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Comparison of the ultrasound findings of the psoriatic patients with or without PsA did not show any significant differences.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">In psoriatic patients, ultrasound changes in the nail plate, bed and matrix and in the insertion of the thumb extensor tendon have been observed.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">1–6</span></a> Gisondi et al.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">5</span></a> reported nail plate and bed thickening in patients with NPs, and our results were similar. Sandobal et al.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">6</span></a> assessed the thickness of the nail bed of patients with NPs, PsA, rheumatoid arthritis, and controls, and established a cutoff of 2<span class="elsevierStyleHsp" style=""></span>mm (80% sensitivity and 71% specificity) as a predictive factor for NPs and PsA, and our study supported this finding. The present study assessed, for the first time separately the Doppler signal of the nail bed and matrix area, and statistically significant differences were obtained in both assessments with respect to controls. The present study has certain limitations. First is the technological limitation inherent in all ultrasound studies, whereby the more up to date the ultrasound system, the greater the sensitivity for Doppler detection. Another limitation is the bias in the subgroups of psoriatic patients diagnosed with PsA and those receiving systemic treatment. There was a limited sample of these groups and there are biases such as time since diagnosis or treatment, severity of PsA, and dose of medication. In conclusion, the ultrasound findings of the thumbnail are significantly different between patients with NPs and healthy subjects.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of Interest</span><p id="par0020" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of Interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Please cite this article as: Vidal D, Alfageme F, Ruiz-Villaverde R, Arias-Santiago S, Martorell A. Caracterización ecográfica de la psoriasis ungueal: estudio de casos y controles. Actas Dermosifiliogr. 2017;108:968–969.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1008 "Ancho" => 1503 "Tamanyo" => 113240 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Doppler signal of the nail bed and matrix. Semiquantitative scale (0-3).</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">*<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>.05.</p>" ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="2" align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Maximum Thickness of Nail Plate</th><th class="td" title="table-head " colspan="2" align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Maximum Thickness of Nail Bed</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Longitudinal Axis (Min-Max) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Transverse Axis (Min-Max) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Longitudinal axis (Min-Max) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Transverse Axis (Min-Max) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cases \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.02<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">*</span></a><br>(0.6-2.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.08<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">*</span></a><br>(0.7-2.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.19<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">*</span></a><br>(1.0-3.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.21<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">*</span></a><br>(1.0-3.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Controls \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.69<br>(0.4-1.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.77<br>(0.4-1.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.69<br>(1.0-2.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.69<br>(1.0-2.9) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1607298.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "*" "nota" => "<p class="elsevierStyleNotepara" id="npar0005"><span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>.05.</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Thickness of the Nail Plate and Bed in Millimeters.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib0035" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Development of a preliminary US power Doppler composite score for monitoring treatment in PsA" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M. 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