10.5826/dpc.1201a10
Background: Nail involvement in psoriasis may be assessed clinically, ultrasonologically, and dermoscopically. The aim of this study was to assess the dermoscopic features of nails in psoriasis, compare them with clinical findings, and correlate them with the Nail Psoriasis Severity Index (NAPSI) score.
Methods: We recruited 120 patients with psoriatic nail changes for the study. The Psoriasis Area Severity Index (PASI) was used to assess the severity of disease. Clinical and dermoscopic (DermLite DL4, ×10, polarized and non-polarized) nail examination determined NAPSI, modified NAPSI (mNAPSI), and NAPSI determined with dermoscopic findings (dermoscopic NAPSI [dNAPSI] and dermoscopic modified NAPSI [dmNAPSI]) were used to assess severity of nail involvement.
Results: Subungual hyperkeratosis (50.8%) and nail plate thickening (56.7%) were the commonest clinical nail changes found, and dermoscopically, they were subungual hyperkeratosis and pitting (68.3% each). The average median with interquartile range of PASI and NAPSI scores were 7.5 [5.7-10.8] and 8.0 [6-12], respectively. NAPSI scores increased significantly with the increase in PASI scores (P &lt; 0.001). A comparison of NAPSI and mNAPSI with dNAPSI and dmNAPSI revealed that NAPSI, mNAPSI, and dNAPSI increased significantly with an increase in PASI scores. dNAPSI scores increased significantly with increased mNAPSI and dmNAPSI, and mNAPSI and dmNAPSI were significantly good predictors of joint involvement in psoriasis.
Conclusions: Dermoscopy allows for better visualization of nail findings. Evaluating NAPSI and mNAPSI scores in conjunction with dNAPSI and dmNAPSI increases their helps detect early psoriasis, detection of worsening moderate-to-severe psoriasis (PASI &gt;10) and predict joint involvement and their severity
text/xml
2160-9381
1716
en
Devinder Kumar Suhag
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
onychoscopy
Study of Nail Psoriasis and Dermoscopic Correlation With Dermoscopic and Modified Dermoscopic Nail Psoriasis Severity Indexes (dNAPSI and dmNAPSI)
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Original Article
2022-02-02
2021-03-12
2022-02-02
2022-02-09
e2022010
Dermatol Pract Concept
Background: Nail involvement in psoriasis may be assessed clinically, ultrasonologically, and dermoscopically. The aim of this study was to assess the dermoscopic features of nails in psoriasis, compare them with clinical findings, and correlate them with the Nail Psoriasis Severity Index (NAPSI) score.
Methods: We recruited 120 patients with psoriatic nail changes for the study. The Psoriasis Area Severity Index (PASI) was used to assess the severity of disease. Clinical and dermoscopic (DermLite DL4, ×10, polarized and non-polarized) nail examination determined NAPSI, modified NAPSI (mNAPSI), and NAPSI determined with dermoscopic findings (dermoscopic NAPSI [dNAPSI] and dermoscopic modified NAPSI [dmNAPSI]) were used to assess severity of nail involvement.
Results: Subungual hyperkeratosis (50.8%) and nail plate thickening (56.7%) were the commonest clinical nail changes found, and dermoscopically, they were subungual hyperkeratosis and pitting (68.3% each). The average median with interquartile range of PASI and NAPSI scores were 7.5 [5.7-10.8] and 8.0 [6-12], respectively. NAPSI scores increased significantly with the increase in PASI scores (P &lt; 0.001). A comparison of NAPSI and mNAPSI with dNAPSI and dmNAPSI revealed that NAPSI, mNAPSI, and dNAPSI increased significantly with an increase in PASI scores. dNAPSI scores increased significantly with increased mNAPSI and dmNAPSI, and mNAPSI and dmNAPSI were significantly good predictors of joint involvement in psoriasis.
Conclusions: Dermoscopy allows for better visualization of nail findings. Evaluating NAPSI and mNAPSI scores in conjunction with dNAPSI and dmNAPSI increases their helps detect early psoriasis, detection of worsening moderate-to-severe psoriasis (PASI &gt;10) and predict joint involvement and their severity
Devinder Kumar Suhag
2022/02/02
10.5826/dpc.1201a10
e2022010
Command Hospital Air Force Bangalore, India
2160-9381
onychoscopy
en
e2022010
Cassell S, Bieber J, Rich P, et al. The modified Nail Psoriasis Severity Index: Validation of an instrument to assess psoriatic nail involvement in patients with psoriatic arthritis. J Rheumatol. 2007;34(1):123-129. PMID: 17216680.
Study of Nail Psoriasis and Dermoscopic Correlation With Dermoscopic and Modified Dermoscopic Nail Psoriasis Severity Indexes (dNAPSI and dmNAPSI)
https://dpcj.org/index.php/dpc/article/download/1716/1460
                    Dermatology Practical & Conceptual


Study of Nail Psoriasis and Dermoscopic Correlation
 with Dermoscopic and Modified Dermoscopic Nail
 Psoriasis Severity Indexes (dNAPSI and dmNAPSI)
       Sandeep Arora1, Debatraya Paul2, Richa Kumar3, Anuj Bhatnagar2, Gulhima Arora4,
                            Sunita Mech2, Devinder Kumar Suhag2


1 Department of Dermatology, Army College of Medical Sciences & Base Hospital Delhi Cantt, India
2 Command Hospital Air Force Bangalore, India
3 Command Hospital Eastern Command Kolkota, India
4 Mehektagul Dermaclinic, New Delhi, India



Key words: Nail psoriasis, nail psoriasis severity index, psoriasis area severity index, dermoscopy, onychoscopy
Citation: Arora S, Debatraya P, Richa K et al. Study of nail psoriasis and dermoscopic correlation with dermoscopic and modified
dermoscopic nail psoriasis severity indexes (dNAPSI and dmNAPSI). Dermatol Pract Concept. 2022;12(1):e2022010. DOI: https://doi
.org/10.5826/dpc.1201a10
Accepted: May 4, 2021; Published: January 2022
Copyright: ©2022 Arora et al. This is an open-access article distributed under the terms of the Creative Commons
Attribution-NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted
noncommercial use, distribution, and reproduction in any medium, provided the original authors and source are credited.
Funding: None.
Competing interests: None.
Authorship: All authors have contributed significantly to this publication.

Corresponding author: Sandeep Arora, Army College of Medical Sciences & Base Hospital Delhi Cantt, India. E-mail: aroraderma@gmail.com




  ABSTRACT             Background: Nail involvement in psoriasis may be assessed clinically, ultrasonologically, and dermoscop-
                       ically. The aim of this study was to assess the dermoscopic features of nails in psoriasis, to compare them
                       with the clinical findings, and to correlate them with the Nail Psoriasis Severity Index (NAPSI) score.
                       Methods: We recruited 120 patients with psoriatic nail changes for the study. The Psoriasis Area
                       Severity Index (PASI) was used to assess the severity of disease. Clinical and dermoscopic (Derm-
                       Lite DL4, ×10, polarized and non-polarized) nail examination determined NAPSI, modified NAPSI
                       (mNAPSI), and NAPSI determined with dermoscopic findings (dermoscopic NAPSI [dNAPSI] and
                       dermoscopic modified NAPSI [dmNAPSI]) were used to assess severity of nail involvement.
                       Results: Subungual hyperkeratosis (50.8%) and nail plate thickening (56.7%) were the common-
                       est clinical nail changes found, and dermoscopically, they were subungual hyperkeratosis and pit-
                       ting (68.3% each). The average median with interquartile range of PASI and NAPSI scores were 7.5
                       [5.7-10.8] and 8.0 [6-12], respectively. NAPSI scores increased significantly with the increase in PASI scores
                       (P < 0.001). A comparison of NAPSI and mNAPSI with dNAPSI and dmNAPSI revealed that NAPSI,
                       mNAPSI, and dNAPSI increased significantly with an increase in PASI scores. The dNAPSI scores
                       increased significantly with increased mNAPSI and dmNAPSI, and mNAPSI and dmNAPSI were sig-
                       nificantly good predictors of joint involvement in psoriasis.
                       Conclusions: Dermoscopy allows for better visualization of nail findings. Evaluating NAPSI and mNAPSI
                       scores in conjunction with dNAPSI and dmNAPSI increases their helps detect early psoriasis, detection
                       of worsening moderate-to-severe psoriasis (PASI >10) and predict joint involvement and their severity.




Original Article | Dermatol Pract Concept. 2022;12(1):e2022010                                                                          1
Introduction                                                        Patients with coexisting onychomycosis, erythrodermic
                                                                    psoriasis, patients in remission following systemic treatment
Nail changes in psoriasis are significant findings and associ-      for psoriasis, pregnant women, patients not consenting to
ated with a significant psychological impact [1]. Nail lesions      the study, and patients with systemic disorders that may
are observed in about one-half of patients with psoriasis, with     have influenced nail changes were excluded from the study.
an estimated lifetime incidence of 80-90% [2]. Most psoriasis       The clinical-demographic profile of the participants was
cases present with nail changes, while isolated nail psoriasis      documented. Clinical images of the hands and feet and
is rare, occurring in 1-5% of patients [3]. These changes are       radiographs were taken, and the Classification Criteria for
most common in older patients, in severe forms of psoriasis,        Psoriatic Arthritis (CASPAR) scores were calculated.
in cases with longer duration of disease, and in the presence of       Disease severity was assessed using Psoriasis Area Severity
psoriatic arthritis, in which case the incidence of nails changes   Index (PASI) as a clinical assessment tool for each patient. All
is over 80% [4]. More severe nail psoriasis is associated with      nails were examined clinically followed by a dermoscopic
a more severe cases of psoriatic arthritis [5].                     examination. Dermoscopic images were captured with Der-
    The clinical presentation of nail psoriasis varies according    mLite DL4, ×10, polarized and non-polarized modes. The
to the severity and localization of the lesion: the nail matrix,    Nail Psoriasis Severity Index (NAPSI) and modified NAPSI
the nail bed, and in severe forms, the entire nail structure        (mNAPSI) scores were calculated for both fingernails and toe-
[6,7]. The most common nail lesion reported is pitting,             nails. With dermoscopic findings we recalculated NAPSI and
followed by nail bed discoloration, onycholysis, subungual          labeled it dermoscopic NAPSI (dNAPSI) and dermoscopic
hyperkeratosis, abnormalities of the nail plate, and splinter       modified NAPSI (dmNAPSI).
hemorrhages [8]. They lead to significant functional impair-
ment, pain, and psychosocial distress, and patients report          Statistical Analysis
significantly worse values in satisfaction with their treatment     All characteristics were summarized. For continuous vari-
due to the stress and time involved in treatment [2,9].             ables, the summary statistics of mean ± standard deviation
    Dermoscopy with polarized and non-polarized modes               (SD) were used. For categorical data, the number and per-
is useful in the evaluation of superficial nail plate/matrix        centage were used in the data summaries and diagrammatic
changes, such as pitting and crumbling, and deeper nail bed         presentation. If the Pvalue/ Zvalue was < 0.05, then the
psoriatic nail involvement in the form of onycholysis, oil          results were statistically significant; otherwise, they were
spots, subungual hyperkeratosis and splinter hemorrhages,           considered as not statistically significant. A receiver operating
especially when there are no typical clinical features [10,11].     characteristic (ROC) curve was plotted for NAPSI, d NAPSI,
                                                                    dmNAPSI, and mNAPSI to compare their predictive ability
                                                                    for clinical joint involvement. The odds ratio of NAPSI and
Objectives
                                                                    dmNAPSI to their correlation with CASPAR was also anal-
The focus of our study was to determine the frequency of            ysed. Data were analyzed using SPSS software v.23.0.
dermoscopic findings in psoriatic nails and to compare the
dermoscopic examination with the clinical examination to
investigate the relationships between the indicators of disease
                                                                    Results
severity.                                                           A total of 120 patients with psoriatic nail involvement were
                                                                    included in the study. The mean age of the patients was 47.3
                                                                    ± 13.1 years (range 14-74 years). Fifty-five percent of patients
Methods
                                                                    had the disease for more than 5 years, and the duration of
This was a prospective observational study conducted from           treatment ranged from 0.2 to 11 years (4.9 ± 2.6 years). The
October 2018 to October 2019 in the Department of Der-              mean body mass index (BMI) of the study population was
matology in a tertiary care teaching hospital. Approval from        26.3 ± 3.2 kg/m2. Hypertension was the commonest comor-
the institutional ethics committee of Command Hospital              bidity (Table 1).
Air Force Bangalore was obtained vide EC/CHAF Banga-                   Chronic plaque psoriasis was the commonest clinical
lore/2018/27 dated 14 May 2018. Clinically diagnosed pso-           presentation (79.2%) and 72.5% of the patients had a PASI
riasis patients who visited the dermatology Outpatient Clinic       score <10; 51.7% of study subjects had a NAPSI score bew-
were screened, and 120 patients aged 14-75 years with nail          teen 6 and10. Arthritis was noted in 11.7% of cases (n = 14),
psoriasis were examined clinically and with dermoscope              90% (n = 108) had a CASPAR score of 3 or more. The mean
(DermLite DL4, ×10; polarized and non-polarized modes).             numbers of fingernails and toenails affected were 3.5 ± 1.2
Onychomycosis was ruled out after performing KOH mount              and 3.6 ± 1.5 with a mean NAPSI score of 10.1 ± 6.1. A larger
on nails and fungal cultures from all the suspected cases.          number of nail changes were detected with dermoscopy. Nail


2                                                                      Original Article | Dermatol Pract Concept. 2022;12(1):e2022010
      Table 1. Socio-Demographic Details of                       scores by 1 unit is less likely to detect PASI scores <10 and
                 Patients (n=120)                                 between 10 and 20 by 0.69 times compared to PASI scores
                                                                  >20. Similarly, the increase in dmNAPSI scores by 1 unit is
           Demographic Details                       n (%)
                                                                  less likely to detect PASI scores <10 by 0.59 times and PASI
 Age-group, years
                                                                  scores between 10 and 20 by 0.69 times compared to PASI
 ≤ 30                                              16 (13.3)      scores >20.
 31-40                                             18 (15.0)
                                                                     The adjusted odds values showed that dNAPSI scores
 41-50                                             33 (27.5)
                                                                  were more likely to detect psoriasis at an early stage com-
 51-60                                             35 (29.2)
 >60                                               18 (15.0)      pared to NAPSI and dmNAPSI. Although the scores were not
                                                                  significant predictors in detecting psoriasis at an early stage (P
 Gender                                                           > 0.05) (Table 3), dNAPSI was likely to detect a rise in PASI
 Males                                             99 (82.5)      in moderate-to-severe psoriasis better than NAPSI. Hence,
 Females                                           21 (17.5)      follow-up of cases with this index can alert an impending
 BMI (kg/m2) (Asia-Pacific guidelines)[17]                        worsening of the condition.
 Underweight (<18.5)                                01 (0.8)         The receiver operating characteristic (ROC) curve plotted
 Normal (18.5 - 22.9)                              16 (13.3)      for NAPSI, d NAPSI, dmNAPSI, and mNAPSI to compare
 Overweight (23.0 - 24.9)                          28 (23.3)
                                                                  their predictive ability for clinical joint involvement revealed
 Obese Class I (25.0 - 29.9)                       56 (46.7)
                                                                  that mNAPSI and dmNAPSI were significantly better predic-
 Obese Class II (> 30.0)                           19 (15.8)
                                                                  tors of joint involvement compared to other nail psoriasis
 Disease duration                                                 severity indices (NAPSI, dNAPSI) (P < 0.05) (Figure 5).
 1 – 6 months                                      07 (05.8)         Though none of the severity measure scores (NAPSI,
 6 – 12 months                                     12 (10.0)      dNAPSI, mNAPSI and dmNAPSI) were statistically sig-
 1 – 5 years                                       35 (29.2)      nificant (P > 0.05) for joint involvement, dmNAPSI scores
 > 5years                                          66 (55.0)
                                                                  showed higher odds ratio values, indicating that unitary
 Comorbidities                                                    increase in dmNAPSI scores increased the odds of being in
 Hypertension                                      29 (24.2)      the CASPAR scores of 2, 3 and 4 by 2.10 times, 2.19 times,
 Diabetes                                          19 (15.8)
                                                                  and 2.13 times compared to a CASPAR score of 5. Similarly,
 Arthritis                                         14 (11.7)
                                                                  NAPSI scores showed higher odds ratio values, indicating
 Others                                            02 (01.7)
                                                                  that unit increase in NAPSI scores increased the odds of
BMI = body mass index.                                            being in the CASPAR scores of 2, 3 and 4 by 1.58 times, 1.85
                                                                  times and 2.03 times compared to a CASPAR score of 5. The
matrix signs were noted in 95.8 % of cases and nail bed signs     odds of NAPSI scores increased with increase in the grades
were noted in 85.0% of cases. Clinically, nail plate thickening   of severity of joint involvement based on CASPAR criteria,
(56.7%) and subungual hyperkeratosis (50.8%) were the             and odds of dmNAPSI remained almost the same, with no
most common presentations and, on dermoscopic examina-            statistical difference between these two (P > 0.05) (Table 4).
tion, pitting (72.5%) and subungual hyperkeratosis (68.3%)           The mean ranks of mNAPSI increased significantly with
the most frequent ones (Figure 1) (Table 2).                      the duration of the disease (1-6 months = 47.57; 12-60
   The mean (range) of PASI, NAPSI, mNAPSI, dNAPSI and            months = 60.00; >60 months = 67.34, with P < 0.05), except
dmNAPSI scores were 7.5 (1.8-36.0), 8.5 (3-39), 7.0 (0-34),       at 6-12 months (31.88, P > 0.05). The mean ranks of other
11.0 (3-45) and 11.0 (0-44), respectively. NAPSI, mNAPSI          scores, ie dNAPSI, dmNAPSI and NAPSI, did not vary sig-
and dNAPSI scores increased significantly with the rise in        nificantly in relation to the durations of the disease (P > 0.05)
PASI scores (r = 0.56, P < 0.001), (r = 0.57, P < 0.001) and (r   (Table 5).
= 0.54, P < 0.001), respectively (Figures 2 and 3).
   The scores of dNAPSI also increased significantly with the
                                                                  Conclusions
increase of mNAPSI and dmNAPSI scores (r = 0.84 with P <
0.001 and r = 0.87 with P < 0.001, respectively) (Figure 4).      Dermoscopy allows for better visualization of the nail bed
   Keeping the variables like age, gender, BMI, NAPSI scores,     and nail matrix abnormalities, and detects early or mild, as
presence of comorbidities, duration of onset of disease, and      well as late changes in the disease, as was also seen in the
duration of treatment constant in for analysis the increase in    present study [12]. With its routine use in clinical practice,
dNAPSI scores by 1 unit is likely to detect PASI scores <10       early and late descriptions of skin, nail and hair diseases are
by 1.08 times and PASI scores between 10 and 20 by 1.01           being elaborated in literature increasingly. However, their
times compared to PASI scores >20. The increase in NAPSI          relevance and importance to standard clinical findings need



Original Article | Dermatol Pract Concept. 2022;12(1):e2022010                                                                    3
                 Figure 1. Dermoscopic image. (A) subungual hyperkeratosis. (B) pitting. (C) distal onycholysis.
                 (D) splinter hemorrhages (DermLite DL4, ×10, polarized).


    Table 2. Frequency Distribution of Clinical and Dermoscopic Nail Bed and Nail Matrix Findings
                                            Among Patients
                                                             Clinical Examination               Dermoscopic Examination
                      Findings                          Number (n)       Percentage (%)       Number (n)       Percentage (%)
Nail Bed Signs
Splinter hemorrhages                                         06                05.0                31                 25.8
Subungual hyperkeratosis                                     61                50.8                82                 68.3
Distal onycholysis                                           54                45.0                62                 51.7
Oil drop sign                                                37                30.8                47                 39.2
Dilated hyponychial capillaries                              18                15.0                18                 15.0
Nail Matrix Signs
Nail plate thickening                                        68                56.7                71                 59.2
Pitting                                                      60                50.0                87                 72.5
Leukonychia                                                  13                10.8                26                 21.7
Transverse grooves                                           14                11.7                24                 20.0
Trachyonychia                                                01                 0.8                14                 11.7
Red spots on lunula                                          04                03.3                05                 04.2
Crumbling                                                    23                19.2                23                 19.2



4                                                                     Original Article | Dermatol Pract Concept. 2022;12(1):e2022010
                    40                                  R SQ LINEAR = 0.321*                      40                                     R SQ LINEAR = 0.334*



                    30                                                                            30




                                                                                 MODIFIED NAPSI
NAPSI SCORE




                    20                                                                            20



                    10                                                                            10



                     0                                                                             0
                         0          10          20          30             40                            0          10         20            30          40
                                           PASI SCORE                                                                       PASI SCORE

 Figure 2. (A) Correlation of PASI and NAPSI scores. (B) Correlation of PASI and mNAPSI scores. mNAPSI = modified Nail Psoriasis Severity
 Index; PASI = Psoriasis Area Severity Index.


                                                                                             of psoriatic patients [18-21]. According to Polat and Kapi-
                    50                              R SQ LINEAR = 0.293*                     cioglu, the most common clinical and dermoscopic findings
                                                                                             were pitting and leukonychia [12], and Wanniang et al
                    40                                                                       noted salmon patch (oil drop sign) and splinter hemorrhages
                                                                                             significantly better with the dermoscope [22]. In addition
DERMOSCOPIC NAPSI




                                                                                             to pitting, Yorulmaz and Artuz found salmon patch (oil
                    30
                                                                                             drop sign) to be associated with higher NAPSI scores [13].
                                                                                             However, in our study, pitting, subungual hyperkeratosis,
                    20
                                                                                             nail plate thickening, and distal onycholysis were present
                                                                                             in the majority of patients, and all nail changes were noted
                    10                                                                       significantly better on dermoscopy. The difference in our
                                                                                             observations from the reported literature may be due to
                     0                                                                       different disease duration and severity with an average
                         0         10          20          30          40                    NAPSI score of 8 in our study versus 23, indicating higher
                                           PASI SCORE                                        disease severity among their patients [22]. Dermoscopic nail
 Figure 3. Correlation of PASI and dNAPSI (dermoscopically as-                               findings of subungual hyperkeratosis and oil drop signs were
 sessed NAPSI) scores. dNAPSI = dermoscopic Nail Psoriasis Severity                          significantly associated with a higher median NAPSI score
 Index; PASI = Psoriasis Area Severity Index.                                                >8 in our study. The scores of NAPSI, mNAPSI and dNAPSI
                                                                                             increased significantly with the rise in PASI scores, which
to be validated. In this study we compared nail changes                                      partially corroborates the findings of studies by Hallaji et al
observed in both dermoscopic and clinical examinations and                                   and Prevezas et al [23,24].
determined their association using NAPSI score and their                                               The dNAPSI helped detect early psoriasis but did not
correlation between the indicators of disease severity, ie PASI                              perform well in detecting changes in severity in early psori-
and NAPSI scores.                                                                            asis. However, dNAPSI was better than NAPSI at detecting
                    Chronic plaque psoriasis is known to be the commonest                    worsening PASI in moderate-to-severe psoriasis.
pattern of psoriasis, as evidenced in our study. The mean age                                          Cassell et al formulated mNAPSI as a gold standard with
of our cohort (47.3 ± 13.1 years) with psoriasis was similar                                 good correlation with other disease severity measures [25].
to those reported literature [13]. In our study, we had 55%                                  The scores of dmNAPSI along with mNAPSI were found to be
males and a duration of disease of 4.9 years, which is higher                                significantly better predictors of joint involvement compared
than other studies reporting nail findings [14,15]. Elobeid et al                            to other nail psoriasis severity indices.
found a mean BMI of 25.3 kg/m , similar to our findings if not
                                                2
                                                                                                       Both mNAPSI and dmNAPSI increased with severe joint
for a marginally higher BMI (26.3 kg/m2) which may have been                                 involvement, based on the CASPAR criteria, with no statisti-
due to different study populations and study settings [16][17].                              cally significant difference between these two scores. Hence,
                    In psoriasis, nail lesions usually manifest 10 years later               dmNAPSI is consistent as mNAPSI in correlation with joint
than skin lesions, and nail involvement is present in 20%-50%                                severity.



 Original Article | Dermatol Pract Concept. 2022;12(1):e2022010                                                                                                 5
                     50.00                                   R SQ LINEAR = 0.763*                              40                                          R SQ LINEAR = 0.71*


                     40.00
DERMOSCOPIC MNAPSI




                                                                                                               30




                                                                                              MODIFIED NAPSI
                     30.00

                                                                                                               20
                     20.00


                     10.00                                                                                     10


                      0.00
                                                                                                                0
                              0      10      20      30                     40          50
                                          DERMOSCOPIC NAPSI                                                            0         10         20       30            40        50
                                                                                                                                        DERMOSCOPIC NAPSI

  Figure 4. (A) Correlation between dmNAPSI and dNAPSI scores. (B) Correlation between mNAPSI and dNAPSI scores. dNAPSI = dermo-
  scopic Nail Psoriasis Severity Index; dmNAPSI = dermoscopic modified Nail Psoriasis Severity Index; mNAPSI = modified Nail Psoriasis
  Severity Index.


                                     Table 3. Predictors of Severity of Nail Psoriasis Based on PASI Scores
                                           Measures of
                     PASI Severity         Nail Psoriasis                  Unadjusted                          Adjusted Odds            95% Confidence
                        Scores            Severity Index                  Odds Ratio (OR)                        Ratio (OR)               Interval (CI)            P-value
                                             dNAPSI               §
                                                                                 0.08                                  1.08               0.31 – 3.79                0.90
                             <10                 NAPSI                           - 0.36                                0.69               0.25 – 1.99                0.50
                                            dmNAPSI                   ¥
                                                                                 - 0.52                                0.59               0.34 – 1.06                0.08
                                             dNAPSI§                             0.02                                  1.01               0.29 – 3.52                0.98
                         10-20                   NAPSI                           - 0.36                                0.69               0.25 – 1.95                0.49
                                            dmNAPSI                   ¥
                                                                                 - 0.38                                0.69               0.39 – 1.20                0.19

 Reference Category: PASI score more than 20;
 §-dermoscopic NAPSI; ¥ - dermoscopic modified NAPSI
 dNAPSI = dermoscopic NAPSI; dmNAPSI = dermoscopic modified NAPSI; NAPSI = Nail Psoriasis Severity Index; PASI =
 Psoriasis Area and Severity Index


                                                           1.0
                                                                                                                                          D NAPSI
                                                                                                                                          NAPSI
                                                                                                                                          M NAPSI
                                                                                                                                          DM NAPSI
                                                                                                                                          REFERENCE LINE
                                                           0.8



                                                           0.6
                                             SENSITIVITY




                                                           0.4



                                                           0.2



                                                           0.0
                                                                 0.0      0.2       0.4           0.6                   0.8       1.0
                                                                                    1 - SPECIFICITY

                                              Figure 5. Predictive ability of NAPSI, mNAPSI, dmNAPSI, and dNAPSI in de-
                                              tecting joint involvement. dNAPSI = dermoscopic Nail Psoriasis Severity Index;
                                              dmNAPSI = dermoscopic modified Nail Psoriasis Severity Index; mNAPSI =
                                              modified Nail Psoriasis Severity Index; NAPSI = Nail Psoriasis Severity Index.


  6                                                                                                                 Original Article | Dermatol Pract Concept. 2022;12(1):e2022010
       Table 4. Comparison of Measures of Nail Psoriasis Severity Indices as Predictors of Psoriatic
                                Arthritis Based on CASPAR Criteria
                        Measures of Nail                               Adjusted              95%
                        Psoriasis Severity        Unadjusted          Odds Ratio         Confidence
 CASPAR Criteria              Index              Odds Ratio (OR)         (OR)            Interval (CI)        P-value
 2                            dNAPSI§                  - 0.02             0.99            0.48 -2.02            0.97
                              mNAPSI                   - 0.79             0.46           0.15 – 1.35            0.16
                               NAPSI                    0.46              1.58           0.54 – 4.62            0.40
                             dmNAPSI       ¥
                                                        0.74              2.10           0.69 – 6.45            0.19
 3                            dNAPSI   §
                                                       - 0.25             0.78           0.39 – 1.55            0.47
                              mNAPSI                    -0.87             0.42           0.15 – 1.22            0.11
                               NAPSI                    0.62              1.85           0.85 – 5.28            0.25
                             dmNAPSI       ¥
                                                        0.79              2.19           0.73 – 6.61            0.16
 4                            dNAPSI   §
                                                       - 0.31             0.74           0.35 – 1.54            0.42
                              mNAPSI                   - 0.75             0.48           0.16 – 1.40            0.18
                               NAPSI                    0.71              2.03           0.68 – 6.02            0.20
                             dmNAPSI       ¥
                                                        0.76              2.13           0.69 – 6.52            0.19

Reference Category: CASPAR criteria of 5;
§-dermoscopic NAPSI; ¥ - dermoscopic modified NAPSI
CASPAR = Classification Criteria for Psoriatic Arthritis; dNAPSI = dermoscopic NAPSI; dmNAPSI = dermoscopic modified
NAPSI; NAPSI = Nail Psoriasis Severity Index; PASI = Psoriasis Area and Severity Index.



Table 5. Comparison of Mean Ranks of Nail Psoriasis Severity Index Among Different Durations of
                                Onset of Disease in Months

                                                  Duration of Onset in Months
 Measures of nail
 psoriasis severity                                                                                             Z value
       index                1-6 (n=7)            6-12 (n=12)        12-60 (n=35)               >60 (n=66)       (P value)
     Mean ranks of                                                                                                5.39
       dNAPSI§                53.07                  69.38               69.74                   54.77           (0.15)

     Mean ranks of                                                                                                11.74
      mNAPSI¥                 47.57                  31.88               60.00                   67.34          (0.008)*

     Mean ranks of                                                                                                3.19
        NAPSI                 59.86                  63.13               68.60                   55.80           (0.36)

     Mean ranks of                                                                                                5.63
      dmNAPSI                 43.79                  45.12               58.99                   65.87           (0.13)


¥-modified NAPSI; §-dermoscopic NAPSI; *statistically significant difference at P < 0.05
dNAPSI = dermoscopic NAPSI; dmNAPSI = dermoscopic modified NAPSI; NAPSI = Nail Psoriasis Severity Index.


     The mean ranks of mNAPSI increased significantly with         assessment and detection of worsening moderate-to-severe
duration of onset of disease, except at 6-12 months. The           psoriasis (PASI >10) as compared to NAPSI. The use of der-
mean ranks of other scores, ie dNAPSI, dmNAPSI and                 moscopy for detecting joint severity as per CASPAR criteria
NAPSI, did not vary significantly across the durations of          was consistent with naked-eye assessment of nail findings.
onset of disease.                                                  However, as none of these indices proved to be statistically
     Our aim in this study was to utilize the dermoscope to        significant by themselves, their true significance may be
detect nail changes in psoriasis, and it revealed that nail        revealed with larger studies using dNAPSI and dmNAPSI. We
changes are better visualized and detected earlier. Nail scoring   do recommend the use of a dermoscope as a routine tool in
for psoriasis utilizing dNAPSI helps in the early diagnosis and    assessing nail psoriasis.



Original Article | Dermatol Pract Concept. 2022;12(1):e2022010                                                               7
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8                                                                              Original Article | Dermatol Pract Concept. 2022;12(1):e2022010
