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Psoriasis patients with nail disease have a greater magnitude of underlying systemic subclinical enthesopathy than those with normal nails
  1. Zoe R Ash1,
  2. Ilaria Tinazzi2,
  3. Concepción C Gallego3,
  4. Chung Kwok4,
  5. Caroline Wilson4,
  6. Mark Goodfield4,
  7. Paolo Gisondi5,
  8. Ai Lyn Tan1,
  9. Helena Marzo-Ortega1,
  10. Paul Emery1,
  11. Richard J Wakefield1,
  12. Dennis G McGonagle1,
  13. Sibel Z Aydin6
  1. 1Section of Musculoskeletal Disease, Leeds Institute of Molecular Medicine, University of Leeds and NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals, Leeds, UK
  2. 2Unit of Rheumatology, University of Verona, Verona, Italy
  3. 3Unit of Rheumatology, Hospital Universitario La Paz, Madrid, Spain
  4. 4Department of Dermatology, Leeds Teaching Hospitals, Leeds, UK
  5. 5Department of Medicine, Section of Dermatology and Venereology, University of Verona, Verona, Italy
  6. 6Unit of Rheumatology, Goztepe Training and Research Hospital, Medeniyet University, Istanbul, Turkey
  1. Correspondence to Dennis McGonagle, Section of Musculoskeletal Disease, Chapel Allerton Hospital, Chapeltown Road, Leeds, LS7 4SA, UK;


Objective Enthesopathy is a major feature of psoriatic arthritis (PsA), which is supported by imaging studies. Given that nail disease often predates PsA and that the nail is directly anchored to entheses, the authors asked whether nail involvement in psoriasis equates with a systemic enthesopathy.

Methods Forty-six patients with psoriasis (31 with nail disease) and 21 matched healthy controls (HC) were recruited. 804 entheses of upper and lower limbs were scanned by an ultrasonographer blinded to clinical details.

Results Psoriasis patients had higher enthesitis scores than HC (median (range) 21 (0–65) vs 11 (3–39), p=0.005). Enthesopathy scores were higher in patients with nail disease (23 (0–65)) than in patients without nail disease (15 (5–26), p=0.02) and HC (11 (3–39), p=0.003). Inflammation scores of patients with nail disease (13 (0–34)) were higher than patients without nail disease (8 (2–15), p=0.02) and HC (5 (0–19), p<0.001). Modified nail psoriasis severity index scores were correlated to both inflammation (r2=0.45, p=0.005) and chronicity scores (r2=0.35, p=0.04). No link between the psoriasis area and severity index and enthesitis was evident.

Conclusion The link between nail disease and contemporaneous subclinical enthesopathy offers a novel anatomical basis for the predictive value of nail psoriasis for PsA evolution.

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  • The first two authors contributed equally to this study.

  • Funding This study was supported by an unrestricted educational grant from Merck Sharp & Dohme Ltd with part funding also from the National Institute for Health Research. SZA had a grant from the Society for Education and Research in Rheumatology in Turkey. CCG was funded by EULAR and the Spanish Foundation of Rheumatology grants.

  • Competing interests None.

  • Ethics approval Ethics approval for the study was obtained from the ethics committees in Leeds and Verona.

  • Provenance and peer review Not commissioned; externally peer reviewed.