• Nu S-Au Găsit Rezultate

The microvascular and morphostructural changes of nails in psoriatic patients with nail disease; a link between ultrasound and videocapil- laroscopy findings in the nailfold

N/A
N/A
Protected

Academic year: 2022

Share "The microvascular and morphostructural changes of nails in psoriatic patients with nail disease; a link between ultrasound and videocapil- laroscopy findings in the nailfold"

Copied!
7
0
0

Text complet

(1)

DOI:

Original papers

DOI: 10.11152/mu-1274

The microvascular and morphostructural changes of nails in psoriatic patients with nail disease; a link between ultrasound and videocapil- laroscopy findings in the nailfold

Sibel Bakirci Ureyen

1

, Rabia Oztas Kara

2

, Zeynep Erturk

3

, Mahizer Yaldiz

2

1Department of Internal Medicine, Division of Rheumatology, 2Department of Dermatology, 3Department of Internal Medicine, Sakarya Education and Research Hospital, Sakarya, Turkey

Received 06.10.2017 Accepted 29.12.2017 Med Ultrason

2018, Vol. 20, No 2, 185-191

Corresponding author: Sibel Bakirci Ureyen

Sakarya Education and Research Hospital, Department of Internal Medicine, Division of Rheumatology

Şirinevler Mahallesi, Adnan Menderes Cad.

Sağlık Sok No:195

54100 Adapazarı/Sakarya, Türkiye

Phone: +90 444 5 400, Fax: 0 (264) 255 21 05 E-mail: [email protected]

Introduction

Psoriasis is a chronic, relapsing, immune-mediated inflammatory skin disease, affecting approximately 1%

to 3% of the population [1]. Nail involvement occurs in approximately 10% to 55% of patients with psoriasis but is an often-overlooked clinical manifestation of the dis-

ease [2,3]. Van Laborde et al have shown that there is an 80% to 90% lifetime incidence of nail involvement in psoriatic patients [4]. The presence of nail involvement of psoriasis is associated with an increase in patient-re- ported pain complaints, functional impairment and social burden, resulting in a significant restriction of daily ac- tivities and quality of life as well as resistance to treat- ment [5-9].

The diagnosis of psoriatic nail disease (PND) is based on clinical history and physical examination, and the de- finitive method of diagnosis is histological examination [10]. PND is most commonly diagnosed by physical ex- amination. Biopsy is painful and may cause lasting cos- metic issues, thus different diagnostic methods have been evaluated to better understand PND.

Nailfold videocapillaroscopy (NVC) is a non-inva- sive technique to assess the microcirculation and increas- Abstract

Objective: The objective of this study is to evaluate the link between nail fold vessel resistive index (NVRI) measured by ultrasound (US) and capillary loops diameters measured using nailfold videocapillarascopy (NVC), and to assess the mor- phological appearance of the nail bed in patients with psoriatic nail disease (PND) as compared with healthy controls (HCs).

Material and methods: This study was conducted in patients with PND and HCs. General demographic data were collected and clinical assessments were performed for all subjects. The nail plate thickness (NPT) was measured on gray scale using US. The NVRI was measured using color Doppler (CD) US. The measurements of the apical, arterial, venous limb diameters and morpho-structural changes (tortuous, cross-linked capillaries) were assessed using NVC. Results: Thirty-four patients with PND and 15 HCs were enrolled in this study. The two groups were matched for age and body mass index (BMI). Patients with PND had higher NPT and NVRI in comparison with HCs [(20 (17-23) vs 14 (14-15), p<0.001), (0.55 (0.51-0.61) vs 0.43 (0.38-0.49), p<0.001), respectively]. A higher proportion of patients with PND had tortuous capillaries than HCs (62% and 20% respectively, p=0.005). The mean NVRI was higher in patients with PND who had tortuous capillaries than patients who did not have tortuous capillaries (0.58 (0.7) and 0.52 (0.09), respectively p=0.033). Conclusion: Microvascular changes can be detected easily using non-invasive methods such as US and NVC. These methods can provide an objective data to better assess PND.

Keywords: psoriasis; nail; ultrasound; capillaroscopy; nailfold resistive index

(2)

ingly is used in the assessment of patients with connec- tive tissue disease. Endothelial cells play an important role in pathogenesis of psoriasis as immune-mediated inflammatory features and papillary dermis have mul- tiple blood vessels, as well as they show microvascular changes such as decreased capillary density and avascu- lar areas. Additionally, NVC can provide some informa- tion regarding morphostructural changes of capillaries including tortuosity, elongation, dilatation, and cross- linked [11-15]. Several studies with capillaroscopy have been performed in patients with psoriasis, with either nail or joint involvement [16-19]. One of the advantages of NVC is that individual capillaries can be measured, therefore abnormalities can be determined and quantified [14,20].

Ultrasound (US) has been used to identify synovitis, tenosynovitis, enthesitis, and nail fold abnormalities in patients with psoriasis [21]. US is also a non-invasive imaging method which allows viewing the anatomical and physiological details of the nails and provides infor- mation about the morphological appearance of the nail lesions, together with changes of the underlying tissue and blood flow alteration [22]. During the past decade, several studies have evaluated the usefulness of US for diagnosis, identification of disease activity and follow-up response to treatment in patients with psoriasis [23-27].

The relationship among psoriasis and nail disease are not fully understood so far, therefore a better under- standing of its mechanism is essential. The objective of this study is to evaluate the link between nail fold ves- sel resistive index (NVRI) measured using US and cap- illary loops diameters measured using NVC, as well as to assess the morphological appearance of the nail bed in patients with PND as compared with healthy controls (HCs).

Materials and methods Study design

This cross-sectional, single-center study was con- ducted in patients with PND admitted to the psoriasis unit of the dermatology outpatient clinic in Sakarya Univer- sity Education and Research Hospital (SUEAH) between 2016 and 2017. This study was approved by the local Eth- ics Committee at SUEAH (No:16214662/050.01.04/138) and all individuals gave their written informed consent before enrolment. We included adult patients (age ≥18 years), with skin and nail psoriasis who were systemic treatment-naive. Patients who were on topical corticoster- oids for psoriasis plaques on the skin were not excluded.

Patients who had used any treatment for nail involvement within last 3 months, including any topical treatment

agent and patients with clinical psoriatic arthritis or other inflammatory conditions affecting joints were excluded.

In order to avoid potential microvascular changes due to other systemic diseases including; patients with arterial hypertension, diabetes mellitus, and smoking history in the last 5 years were also excluded from study. Healthy volunteers working in the SUEAH and patients’ immedi- ate acquaintances without kinship were recruited as HCs.

The control group consisted of non-smoking, healthy subjects without any arthritis, diabetes mellitus and arte- rial hypertension. The two groups were matched for age and body mass index (BMI).

Clinical assessment

General demographic data were collected includ- ing age, gender, BMI, duration of psoriasis, the current medications and past medical history. The severity of skin psoriasis was evaluated by the Psoriasis Area and Severity Index (PASI) (range 0-72), psoriasis nail in- volvement was assessed by the Nail Psoriasis Severity Index (NAPSI), quality of life was assessed by the Der- matology Quality of Life Index (DQOL) (mild<10, mod- erate=10-20, severe>20) [28]. These assessments were performed by a clinician (ZE) who was blinded to NVC and US findings.

Ultrasonography assessment

US was performed by an experienced sonographer (ROK) blinded to clinical assessments and NVC find- ings. The US scanner used was a LOGIQ P9 (General Electric Company, United Kingdom), equipped with a 7-13 MHz linear transducer. The imaging parameters for Doppler US were set to increase the detection of low- velocity, low-volume flows within the nail bed (Color Doppler (CD): PRF 500-1000 Hz, wall filter 25-50 Hz).

Color gain was maximized for optimal sensitivity while avoiding excessive color noise. Particular attention was paid not to apply pressure on the tissue to avoid blanch- ing of CD signal. Each US examination took 20 minutes.

All images were stored and anonymously numbered, be- fore scoring.

The nails were assessed at 24°C room temperature after a 20 minute resting period. The US scan was per- formed with the patient seated and the hands in neutral position. Morphostructural evaluation of the nail (depos- its in dorsal nail plate, irregularities and thickness of nail plates and nail bed thickness) was assessed by gray scale (GS). GS findings were scored by proper scoring system [29]. The measurement of nail plate thickness (NPT) was performed on the right 2nd finger. NPT was measured as the maximum distance between the dorsal and ventral nail plates and GS changes in psoriatic nails were catego- rized into four types: type1-focal hyperechoic involve- ment of the ventral plate with or without involvement of

(3)

the dorsal plate; type 2-loosening of the borders of the ventral plate; type3-appearance of wavy plates; type4- loss of definition on both plates [29].

NVRI was measured on the 4th finger of the non- dominant hand by CD US (fig 1a,b).The CD signal with Spectral Doppler analysis was used to obtain a graphi- cal representation of blood flow over time. The maximum speeds of flow in systole (Qs) and in diastole (Qd) were recorded. NVRI was reported as the following ratio: (Qs- Qd) ⁄ Qs. Three measures were obtained for each patient and the arithmetic mean was considered as the definitive NVRI. The NVRI ratio ranged from 0 (no resistance to blood flow) to 1 (maximum resistance to blood flow) [30].

Nailfold videocapillaroscopy assessment

NVC was performed by an experienced rheumatolo- gist (SBU) blinded to the results of clinical examination and US findings. The machine used was a Dino-lite cap- illaroscope device (Dinocapture 2.0 windows software) (magnification ×500).However, all images were con- verted to the same calibration as seen in a capillaryscope device x 200 magnification lenses. NVC device consists of the combination of an optical microscope with a digi- tal video camera that can be attached to any computer.

A drop of immersion oil was placed on the cuticle of the fingers to better visualize the capillaries and reduce re- fractive defects.

The patient undergoing the exam was initially seated in an acclimatized room for 15-20 minutes, with a tem- perature set around 22 -23° for the prevention of tem- perature related changes in the vessel wall [31]. Apical, arterial, venous limb diameters were measured on the 4th finger of the non-dominant hand, as it is less subject to trauma. NVC was applied to 8 fingers (excluding the thumbs). Some capillaroscopic parameters (tortuous, cross-linked) were recorded (1×1mm in size) from the middle of the nailfold in each finger. These measure- ments were taken from the thickest part of the capillary loops (fig 1c). Cross-linked capillaries were describes as similar to braches that intersect like a number eight and

Fig 1. Color Doppler ultrasound, longitudinal view- normal NVRI in healthy controls (a) and increased NVRI in patients with pso- riatic nail disease (b); c) The measurement of the diameter of arterial – a, venous – b, and apical – c in nail fold videocapillarascopy.

tortuous like capillaries with branches in an undulating, sinuous or twisted arrangement [14,32-35]. The capilla- roscopic changes (tortuous, cross-linked capillary) were scored as “absent” or “present” as described previously [33]. If more than 50% of the capillaries in a nailfold were affected, the given abnormality was scored as “pre- sent“. After all images were stored, they were anony- mously numbered, before scoring.

Statistical analysis

Continuous data were described as mean (standard deviations (SD)) or median (first and third quartile) ac- cording to the distribution and categorical variables were expressed as frequencies and percentages. Comparisons between the 2 categories were made using 2-tailed t tests for normally distributed data or the Mann-Whitney U test for non-normally distributed variables. The Mann- Whitney U test was used for comparing US and NVC findings. The Chi-square test was used to compare cate- gorical variables. P values less than 0.05 were considered statistically significant. SPSS V-15 was used for analysis (SPSS Inc., Chicago, IL, USA).

Results

Thirty-four patients with PND (16 female and 18 male) and fifteen HCs (13 female and 2 male) were con- secutively recruited for this study. A diagnosis of psoria- sis was made by an experienced dermatologist (ROK) on the basis of clinical findings. Demographics and disease characteristics of patients were summarized in Table I.

Nailfold videocapillarascopy findings

No statistical differences were observed between pa- tients with PND and HCs with respect to arterial limb, venous limb, and apical diameters of capillaries.

Analyzing the patients depending on PASI (<6 and

≥6) we found no statistical differences between the two groups concerning the arterial limb, venous limb, and api- cal diameters of capillaries (p=0.968, p=0.887, p=0.839, respectively).

(4)

There was also no statistical difference between the arterial limb, venous limb, and apical diameters when the patients were divided into 2 groups depending on NVRI (<0.6 and ≥0.6) (Table II).

Ultrasound findings

Patients with PND had higher NPT and NVRI than HCs [(20 (17-23) vs 14 (14-15), p<0.001), (0.55 (0.51- 0.61) vs 0.43 (0.38-0.49), p<0.001, respectively]. Pa- tients with PND were categorized into two groups by NPT measured by US as NPT <20 mm (n=16) and NPT

≥20 mm (n=18) and the median NAPSI in two groups were 20.5 (12.2-33) and 28.5 (22-35), respectively (p=

0.05). There were 6 patients in type 1GS changes of pso- riatic nails, 6 patients in type 2, 20 patients in type 3, and 2 patients in type 4. The US findings and NVC findings were summarized in Table III.

The comparisons of clinical assessments

No statistical difference was observed when NAPSI, NAPSI nail bed, and NAPSI nail matrix were compared in patients with PASI<6 and PASI≥6 (Table IV).

Table I. Demographics of patients with psoriatic nail disease and healthy controls

Patients with PND (n=34) HCs (n=15) p value

Age (years) 42.17 (10.5) 40.7 (5.1) 0.769

Male/female 18/16 2/13 0.009

BMI (kg/m2) 27.1 (7.1) 26.3 (3.2) 0.828

Disease duration (years) 13.8 (7.7) - -

PASI 4.2 (2.7) - -

NAPSI 24.0 (18.5-7.5)* - -

DQOL 7.5 (4.5) - -

The results are expressed as mean (standard deviations) or median (first and third quartile)*. PND – psoriatic nail disease; HCs – healthy controls; n – number of patients; BMI – body mass index; PASI – psoriasis activity severity index; NAPSI – Nail Psoriasis Severity Index;

DQOL – Dermatology Quality of Life Index

Table II. Comparison between patients with NVRI <0.6 and NVRI ≥0.6 regarding the arterial, venous limb, and apical diameters of capillaries.

NVRI <0.6 NVRI ≥0.6 p value

Arterial diameters 25.3 (19.4-32.3) 24.8 (22.2-28.5) 0.943

Venous diameters 31.8 (23.7-36.7) 31.1 (25.7-39.4) 0.576

Apical diameters 32.6 (24.2-39.8) 31.1 (25.7-39.4) 0.576

The results are expressed as median (first and third quartile); NVRI- nailfold vessel resistive index

Table III. US findings and NVC findings of all subjects

Patients with PND (n=34) HCs(n=15) p value

Arterial limb diameter (NVC) µm* 25.3 (21.2-29.7) 21.2 (19.1-29.9) 0.448

Venous limb diameter (NVC) µm* 31.8 (24.7-37.2) 27.4 (24-35) 0.649

Apical diameters (NVC) µm* 32.6 (26.6-36.6) 36.6 (27.8-42.1) 0.329

Tortuous capillaries n (%) 22 (62) 3 (20) 0.005

Cross-linked capillaries n (%) 9 (25) 6 (40) 0.333

NPT mm* 20 (17-23) 14 (14-15) <0.001

NVRI* 0.55 (0.51-0.61) 0.43 (0.38-0.49) <0.001

The results are expressed as median (first and third quartile)* or number (percent %). NVC – nailfold videocapillarascopy; PND – psoriatic nail disease; HCs – healthy controls; n – number of patients; NPT – nail plate thickening; NVRI – nailfold vessel resistive index

Table IV. NAPSI, NAPSI nail bed and NAPSI nail matrix compared to PASI<6 and PASI≥6 in patients with PND

PASI<6 PASI≥6 p value

NAPSI 23.5 (17.7-30.2) 33 (13.7-56.2) 0.238

NAPSI nail bed 17.0 (10.5-22) 22 (10.2-39) 0.230

NAPSI nail matrix 7 (3.7-10) 9 (2-29.7) 0.618

The results are expressed as median (first and third quartile); NAPSI – Nail Psoriasis Severity Index; PASI – psoriasis activity severity index

(5)

Patients with PND, DLQI 0-9, and ≥10 were com- pared with respect to NAPSI scores and no significant difference was observed (p= 0.618).

Discussions

To the best of our knowledge, this is the first study to evaluate the link between microvascular nailfold changes detected with NVC and NVRI findings in patients with PND. Patients with PND had a higher resistance to blood flow, higher thickening of the nail plate and higher tor- tuous capillary loops in comparison with HCs. Further- more, NVRI was higher in PND patients with tortuous capillaries. There has been an increasing interest in the last decade to diagnose earlier the nail involvement of psoriasis, after the link between psoriatic arthritis and nail disease were discovered. US provides high quality information regarding both structural and blood flow changes in the nail unit. The ventral nail plate deposits were seen in 17.72% of involved nails and 4.62% of the nails without clinical signs of involvement (p<0.05) [36].

The dorsal and ventral nail plates appear as bilaminar, parallel, hyperechoic lines with a hypoechoic space in between in healthy subjects. The US features of nail pso- riasis are represented as the thickening of the nail, poorly defined ventral plate with focal hyperechoic areas, and thickening of both ventral and dorsal plates [37].

Espinoza et al reported endothelial cell swelling and thickening of the vessel wall in patients with psoriasis due to immune complex deposition and activation [38].

El-Ahmed et al illustrated that endothelial cell dysfunc- tion that triggers inflammatory response and thickening of the vessel wall is associated with increased resistance in the bloodstream and decreased blood flow in patients with psoriasis [30]. In our study, patients with psoriasis had a higher NPT in comparison with HCs (p<0.001). Gi- sondi et al and Marina et al found similar results in their studies [36,39]. Patients with PND had a significantly higher NVRI than HCs in the present study (p<0.001).

Similar NVRI results were reported by El-Ahmed et al and Marina et al [30,36]. These results can be explained by the decreased blood supply in the nail bed in psoriatic patients due to endothelial dysfunction and wall vessel thickening [36]. Peripheral vascular resistance is related to vessel length and blood viscosity and the major deter- minant of resistance is the vessel diameter [30,40]. Vas- cular changes are implicated in the pathogenesis of PND and it is suggested that increased NVRI can play a role in nail involvement.

Errichetti et al have highlighted the usefulness of nail fold and elbow dermoscopy to differentiate early PsA sine psoriasis from early RA in terms of typical vascular find-

ings such as dotted vessels [41]. Cross-linked and tortu- ous capillaries representing microvascular changes have been observed in a number of studies in patients with psoriasis [11,16,18,40]. Several authors also observed that psoriatic patients have short capillaries by capilla- roscopic examination [16-18]. In our study, patients with PND had a higher frequency of tortuous capillaries in comparison with HCs. We additionally, observed a mild deterioration of quality of life in patients with PND in this study.

This study had some limitations such as small sam- ple size and the use of a medium frequency probe for US. Further studies with a large sample size are required to support these results. Another limitation of this study was that the sonographers could not be blinded due to the need to visualize the clinical condition of the nail while performing the scan; therefore, all images stored and were anonymously numbered, before scoring. Before the US scan started, all subjects were asked to avoid any con- versation with the sonographer regarding their diagnosis.

The presence of nail involvement in psoriatic patients was related with elevated vessel resistance and the pres- ence of tortuous capillaries. These findings highlighted the involvement of the nail fold vessel in PND patients

In conclusion, the microvascular changes in patients with PND can be easily detected using non-invasive methods such as US and NVC. These methods can pro- vide objective means to better understand microvascular changes of PND. Based on these findings, further longi- tudinal studies are necessary to understand the signifi- cance and implications of microvascular changes in the psoriatic nail.

Conflict of interest: none

Acknowledgments: We would like to thank Dr Ali Akdogan and Koray Tascilar for their valuable criticism and their assistance in improving our manuscript.

Reference

1. Nestle FO. Psoriasis. Curr Dir Autoimmun 2008;10:65-75.

2. Salaffi F, De Angelis R, Grassi W; MArche Pain Preva- lence; INvestigation Group (MAPPING) Study. Prevalence of musculoskeletal conditions in an Italian population sam- ple: results of a regional community-based study, I: the MAPPING study. Clin Exp Rheumatol 2005;23:819-828.

3. Salomon J, Szepietowski JC, Proniewicz A. Psoriatic nails:

a prospective clinical study. J Cutan Med Surg 2003;7:317- 4. Van Laborde S, Scher RK. Developments in the treatment 321.

of nail psoriasis, melanonychia striata, and onychomycosis.

A review of the literature. Dermatol Clin 2000;18:37-46.

(6)

5. Gupta AK, Cooper EA. Psoriatic nail disease: quality of life and treatment. J Cutan Med Surg 2009;13:S102-S106.

6. Reich A, Szepietowski JC. Health-related quality of life in patients with nail disorders. Am J Clin Dermatol 2011;12:313-320.

7. Baran R. The burden of nail psoriasis: an introduction. Der- matology 2010;221:1-5.

8. Schons KR, Beber AA, Beck Mde O, Monticielo OA.

Nail involvement in adult patients with plaque-type pso- riasis: prevalence and clinical features. An Bras Dermatol 2015;90:314-319.

9. Schons KR, Knob CF, Murussi N, Beber AA, Neumaier W, Monticielo OA. Nail psoriasis: a review of the literature.

An Bras Dermatol 2014;89:312-317.

10. Selkin B, Rajadhyaksha M, Gonzalez S, Langley RG. In vivo confocal microscopy in dermatology. Dermatol Clin 2001;19:369-377.

11. Ribeiro CF, Siqueira EB, Holler AP, Fabrício L, Skare TL.

Periungual capillaroscopy in psoriasis. An Bras Dermatol 2012;87:550-553.

12. Gallucci F, Russo R, Buono R, Acampora R, Madrid E, Uomo G. Indications and results of videocapillaroscopy in clinical practice. Adv Med Sci 2008;53:149-157.

13. Kayser C, Andrade LEC. Capilaroscopia periungueal: im- portância para a investigação do fenômeno de Raynaud e doenças do espectro da esclerose sistêmica. Rev Bras Reum 2004;44:16-52.

14. Grassi W, De Angelis R. Capillaroscopy: questions and an- swers. Clin Rheumatol 2007;26:2009.

15. Braverman IM, Yen A. Ultrastructure of the capillary loops in the dermal papillae of psoriasis. J Invest Dermatol 1977;68:53-60.

16. Zaric D, Clemmensen OJ, Worm AM, Stahl D. Capillary microscopy of the nail fold in patients with psoriasis and psoriatic arthritis. Dermatologica 1982;164:10-14.

17. Ohtsuka T, Yamakage A, Miyachi Y. Statistical definition of nailfold capillary pattern in patients with psoriasis. Int J Dermatol 1994;33:779-782.

18. Zaric D, Worm AM, Stahl D, Clemmensen OJ. Capillary microscopy of the nailfold in psoriatic and rheumatoid ar- thritis. Scand J Rheumatol 1981;10:249-252.

19. Grassi W, Core P, Carlino G, Cervini C. Nailfold capil- lary permeability in psoriatic arthritis. Scand J Rheumatol 1992;21:226-230.

20. Hern S, Mortimer PS. In vivo quantification of microves- sels in clinically uninvolved psoriatic skin and in normal skin. Br J Dermatol 2007;156:1224-1229.

21. Zabotti A, Bandinelli F, Batticciotto A, et al; Musculo- skeletal Ultrasound Study Group of the Italian Society of Rheumatology. Musculoskeletal ultrasonography for psori- atic arthritis and psoriasis patients: a systematic literature review. Rheumatology 2017;56:1518-1532.

22. Machet L, Ossant F, Bleuzen A, Grégoire JM, Machet MC, Vaillant L. High-resolution ultrasonography: utility in diag- nosis, treatment, and monitoring of dermatologic diseases.

J Radiol 2006;87:1946-1961.

23. Gupta AK, Turnbull DH, Harasiewicz KA, et al. The use of high-frequency ultrasound as a method of assess- ing the severity of a plaque of psoriasis. Arch Dermatol 1996;132:658-662.

24. Vaillant L, Berson M, Machet L, Callens A, Pourcelot L, Lorette G. Ultrasound imaging of psoriatic skin: a nonin- vasive technique to evaluate treatment of psoriasis. Int J Dermatol 1994;33:786-790.

25. El Gammal S, El Gammal C, Kaspar K, et al. Sonography of the skin at 100 MHz enables in vivo visualization of stra- tum corneum and viable epidermis in palmar skin and pso- riatic plaques. J Invest Dermatol1999;113:821-829.

26. El Gammal S, Auer T, Popp C, et al. Psoriasis vulgaris in 50 MHz B-scan ultrasound: characteristic features of stratum corneum, epidermis and dermis. Acta Derm Venereol Suppl (Stockh) 1994;186:173-176.

27. Olsen LO, Serup J. High-frequency ultrasound scan for noninvasive cross-sectional imaging of psoriasis. Acta Der- mVenereol 1993;73:185-187.

28. Mease PJ. Measures of psoriatic arthritis: Tender and Swol- len Joint Assessment, Psoriasis Area and Severity Index (PASI), Nail Psoriasis Severity Index (NAPSI), Modi- fied Nail Psoriasis Severity Index (mNAPSI), Mander/

Newcastle Enthesitis Index (MEI), Leeds Enthesitis Index (LEI), Spondyloarthritis Research Consortium of Canada (SPARCC), Maastricht Ankylosing Spondylitis Enthesis Score (MASES), Leeds Dactylitis Index (LDI), Patient Global for Psoriatic Arthritis, Dermatology Life Quality In- dex (DLQI), Psoriatic Arthritis Quality of Life (PsAQOL), Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F), Psoriatic Arthritis Response Criteria (PsARC), Psoriatic Arthritis Joint Activity Index (PsAJAI), Disease Activity in Psoriatic Arthritis (DAPSA), and Composite Psoriatic Disease Activity Index (CPDAI). Arthritis Care Res (Hoboken) 2011;63:S64-S85.

29. Gutierrez M, Wortsman X, Filippucci E, De Angelis R, Filosa G, Grassi W. High-frequency sonography in the evaluation of psoriasis: nail and skin involvement. J Ultra- sound Med 2009;28:1569-1574.

30. Husein El-Ahmed H, Garrido-Pareja F, Ruiz-Carrascosa JC, Naranjo-Sintes R. Vessel resistance to blood flow in the nailfold in patients with psoriasis: a prospective case-control echo Doppler-based study. Br J Dermatol 2012;166:54-58.

31. Cutolo M, Sulli A, Secchi ME, Olivieri M, Pizzorni C. The contribution of capillaroscopy to the differential diagnosis of connective autoimmune diseases. Best Pract Res Clin Rheumatol 2007;21:1093-1108.

32. Cutolo M, Pizzorni C, Sulli A. Capillaroscopy. Best Pract Res Clin Rheumatol 2005;19:437-452.

33. Grassi W, Del Medico P. Atlas of Capillaroscopy. Milan:

Edra Medical Publishing & New Media. 2004.

34. Cutolo M, Grassi W, Matucci Cerinic M. Raynaud’s phe- nomenon and the role of capillaroscopy. Arthritis Rheum 2003;48:3023-3030.

35. Lambova S, Hermann W, Muller-Ladner U. Capillaro- scopic pattern at the toes of systemic sclerosis patients:

(7)

does it ‘tell’ more than those of fingers? J Clin Rheumatol 2011;17:311-314.

36. Marina ME, Solomon C, Bolboaca SD, Bocsa C, Mihu CM, Tătaru AD. High-frequency sonography in the evaluation of nail psoriasis. Med Ultrason 2016;18:312-317.

37. Wortsman X, Jemec GB. Ultrasound imaging of nails. Der- matol Clin 2006;24:323-328.

38. Espinoza LR, Vasey FB, Espinoza CG, Bocanegra TS, Germain BF. Vascular changes in psoriatic synovium.

A light and electron microscopic study. Arthritis Rheum 1982;25:677-684.

39. Gisondi P, Idolazzi L, Girolomoni G. Ultrasonography re- veals nail thickening in patients with chronic plaque psoria- sis. Arch Dermatol Res 2012;304:727-732.

40. Creamer D, Allen MH, Sousa A, Poston R, Barker JN.

Localization of endothelial proliferation and microvas- cular expansion in active plaque psoriasis. Br J Dermatol 1997;136:859-865.

41. Errichetti E, Zabotti A, Stinco G, et al. Dermoscopy of nail fold and elbow in the differential diagnosis of early psori- atic arthritis sine psoriasis and early rheumatoid arthritis. J Dermatol 2016;43:1217-1220.

Referințe

DOCUMENTE SIMILARE

The evolution to globalization has been facilitated and amplified by a series of factors: capitals movements arising from the need of covering the external

Using a case study designed for forecasting the educational process in the Petroleum-Gas University, the paper presents the steps that must be followed to realise a Delphi

Key Words: American Christians, Christian Right, Christian Zionism, US-Israel Relations, Conservative Christians Theology, State of Israel, Jews, Millennial beliefs,

The aim of the study was to assess the rela- tionship between lung ultrasound findings with the degree of respiratory failure measured by the PaO2/FiO2 ratio (PaFi) and the

In multiple regression analysis, geniohyoid muscle thick- ness and echo intensity were significantly associated with jaw-opening strength (β=0.29, adjusted R2=0.36 for mus-

The above results suggest two important conclusions for the study: The factors affecting the adoption of the de-internationalization strategy for both case A and case B,

This fact could be explained by different anatomical sites of ultrasound measurement (we performed this measure- ment at 2.5 mm from the proximal nail fold) or by dif- ferent stages

The number of vacancies for the doctoral field of Medicine, Dental Medicine and Pharmacy for the academic year 2022/2023, financed from the state budget, are distributed to