JRSSEM 2022, Vol. 02, No. 4, 588 – 596
E-ISSN: 2807 - 6311, P-ISSN: 2807 - 6494
DOI: 10.36418/jrssem.v2i04.327 https://jrssem.publikasiindonesia.id/index.php/jrssem
NAIL PSORIASIS QUALITY OF LIFE SCALE 10 (NPQ10) AS
A PREDICTOR OF QUALITY OF LIFE IN NAIL PSORIASIS
PATIENTS
Triasari Oktavriana
1
Bobby Febrianto
2
Niluh Wijayanti
3
Dita Eka Novriana
4
Ervina Rosmarwati
5
Arie Kusumawardani
6
1,2,3,4,5,6
Department of Dermatology and Venereology RSUD Dr. Moewardi
Faculty of Medicine, Sebelas Maret University, Surakarta, Indonesia
*
e-mail: dr.triasari@gmail.com, bobbyf100289@gmail.com, niluh.wijayanti85@gmail.com,
ditanovriana@gmail.com, ervinarosm[email protected], arie_dr2008@yahoo.com
*Correspondence: dr.triasari@gmail.com
Submitted
: 04 November 2022
Revised
: 16 November 2022
Accepted
: 27 November 2022
Abstract: Nail psoriasis can affect the patient's quality of life, so to evaluate the quality of life in
patients with skin diseases in general, the Dermatology Quality of Life Index (DLQI) can be used.
The questionnaire was unable to distinguish the impact on quality of life caused by nail
abnormalities or skin lesions, so a special scoring system was needed to evaluate the quality of life
for nail psoriasis patients with the Nail Psoriasis Quality of Life Scale 10 (NPQ10). To find the
relationship between the severity of nail posirais based on Nail Psoriasis Severity Index (NAPSI)
score with DLQI and NPQ10. The total respondents were 20 people with a diagnosis of nail psoriasis
who came to the Dermatovenereology Outpatient Clinic of Dr. Moewardi General Hospital,
Surakarta from April-June 2020. We took photography and dermoscopy of fingernails and toes and
then calculated the NAPSI score. All respondents filled out the DLQI and NPQ10 questionnaires.
Pearson's (r) correlation test was used to find the relationship between the mean and standard
deviations of NAPSI and DLQI and NPQ10. We also tested the correlation between DLQI and
NPQ10. The data significance value was declared significant if p <0.05. The results of the correlation
test between NAPSI scores with DLQI and NPQ10 showed a statistical relationship, where the
correlation value between NAPSI and DLQI was slightly more significant than NPQ10 (r = 0.948: r
= 0.877; p <0.05). The mean value of DLQI and NPQ10 in women was higher than men (14.12 ±
8.21: 11.5 ± 8.29 and 11.5 ± 3.58: 8.16 ± 4.52) with a correlation test value of DLQI and NPQ10 is r
= 0.888, p <0.05. We found that the association between NAPSI correlates more significantly with
DLQI than NPQ10. This may be due to some questions that do not reflect the daily activities of our
study subjects, but NPQ10 score in women is higher than men where the quality of life for nail
psoriasis is also influenced by gender.
Keywords: DLQI; nail psoriasis; NAPSI; NPQ10; quality of life.
Triasari Oktavriana
1
Bobby Febrianto
2
Niluh Wijayanti
3
Eka Novriana Day
4
Ervina Rosmarwati
5
Arie Kusumawardani
6
| 589
INTRODUCTION
Psoriasis is a chronic inflammatory skin
disease mediated by an immunological
process, where there can be disorders of
the skin and nails. Nail abnormalities in
psoriasis patients are mostly asymptomatic
and are an early marker of the course of the
disease (Gudjonsson JE, 2012). Nail
psoriasis can occur in 50-79% of patients
and more than 87% of cases are found in
arthritis psoriasis. Hoof psoriasis often
causes physiological and cosmetic
disorders, which can lead to disruptions in
the patient's quality of life (Bardazzi et al.,
2017).
Psoriasis of the nails can occur on the
nail matrix, nail pads, proximal nail folds or
hyponychium. Clinical manifestations that
can be found are nail pitting, discoloration,
onycholysis, subungual hyperkeratosis,
onychodistrophy, splinter hemorrhage,
leukonikia, red spots on the lunula, and
wavy nail plates.3 The severity of nail
psoriasis can be determined based on the
scores of the Nail Psoriasis Severity Index
(NAPSI) first discovered by (Rich & Scher,
2003) in Colombia. The score calculation by
dividing one nail unit into four quadrants
was then seen structural abnormalities in
the nail matrix and nail plate.
Research conducted by de Jong, et al
in the Netherlands in 1996 reported that in
35.4% of patients with nail psoriasis who
received therapy, as many as 45.7% did not
make clinical improvements and caused
disturbances in the quality of life (de Jong
et al., 1996). Krisnarto, et al reported the
prevalence of nail psoriasis at Semarang
Hospital in 2015 of 2.5% of 40 patients with
psoriasis vulgaris (Krisnarto E, 2016). Nail
psoriasis can affect the quality of life of
patients, So a specific questionnaire is
needed. (Ortonne et al., 2010) in Europe
proposed a special assessment system in
the form of Nail Psoriasis Quality of Life
Scale 10 (NPQ10) consisting of 10
questions with a total score of 20. (Klaassen
et al., 2014) conducted a study in the
Netherlands in 2014 to compare the
severity of psoriasis using the Self-
Administered Psoriasis Area and Severity
Index (SAPASI) score against nail quality
using the NPQ10 score reporting that the
SAPASI score correlates with NPQ10. Based
on these descriptions, the purpose of our
study was to determine the relationship
between the severity of nail psoriasis
measured using a NAPSI score on the
quality of life of patients using DLQI and
NPQ10 scores.
MATERIALS AND METHODS
This type of research is an
observational analysis conducted at the
Skin and Venereal Polyclinic of Dr.
Moewardi Surakarta Hospital during the
period from April to June 2020. The
subjects of the study numbered 20 people
(12 men and 8 women) based on a total
sample of new patients with a diagnosis of
nail psoriasis. The age range of the study
subjects was between 17-61 years, based
on the age of the respondents who came
for treatment. The research inclusion
criteria include patients with a diagnosis of
nail psoriasis, aged more than 16 years,
590 | Nail Psoriasis Quality Of Life Scale 10 (Npq10) As A Predictor Of Quality Of Life In Nail
Psoriasis Patients
willing to take clinical photos and
dermoscopy examinations on the
fingernails and toe, and sign a medical
procedure approval sheet. The exclusion
criteria for this study include patients with
onychomycosis, psoriatic erythroderma
and arthritis psoriasis.
All subjects of the study took clinical
photographs of nails using the Canon®
EOS 800D camera, and then we performed
a nail dermoscopy examination using the
Heine Delta 20T® dermatoscopy device.
Nail dermoscopy examination is carried out
in two ways, namely dry technique (without
using immersion oil) and wet technique
(using immersion oil). The severity of
psoriasis nails was calculated based on the
NAPSI score from the results of physical
examination and dermoscopy (Appendix 1),
while to evaluate the quality of life of
patients we used a DLQI score consisting of
10 questions (Appendix 2). We also
conducted a more specific assessment of
the quality of life of nail psoriasis patients
using an NPQ10 score consisting of 10
questions (Appendix 3).
The collected data was then analyzed
stastistically using the Shapiro-Wilk test to
determine the consistency of data
distribution. Descriptive statistical analysis
was carried out for several variables
including gender, age and nail structure
abnormalities based on the results of
clinical examinations and dermoscopy. The
Pearson correlation test (r) was used to find
the relationship between the mean and
default values of NAPSI with DLQI and
NPQ10 and the correlation between DQLI
and NPQ10. Data were analyzed using SPSS
version 21 (IBM, Chicago, IL, USA) with a
signification value of p<0.05.
RESULTS AND DISCUSSION
Based on the characteristic data of the
study subjects (Table 1), the highest
number of nail psoriasis patients was men
as many as 12 patients (60%) with the most
frequent age group between 36-45 years
as many as 6 patients (30%). The most
common nail psoriasis disorder found
based on the results of clinical examination
and dermoscopy is
splinter haemorrhage
(80%).
The mean value and standard
deviation of the NAPSI scores of all study
subjects were 25.85 ± 14.86, while the
average values and interchanges of DLQI
and NPQ10 standards were 12.55 ± 8.15
and 9.5 ± 4.40.
The results of the correlation test between
the NAPSI score with DLQI and NPQ10
showed a statistical relationship, where the
correlation value between NAPSI and DLQI
was slightly more significant compared to
NPQ10 (r=0.948: r=0.877; p<0.05) (Table
2).
Based on gender, the average value of
DLQI and NPQ10 in women was higher
than that of men (14.12 ± 8.21: 11.5 ± 8.29
and 11.5 ± 3.58 : 8.16 ± 4.52), while the
results of the correlation test between
DLQI and NPQ10 overall of the study
subjects showed values of r=0.888, p<0.05
(Table 3).
Triasari Oktavriana
1
Bobby Febrianto
2
Niluh Wijayanti
3
Eka Novriana Day
4
Ervina Rosmarwati
5
Arie Kusumawardani
6
| 591
Table 1. Characteristics of the subject of study.
Variable
Sum
Percentage
(%)
Gender
Man
Woman
Age
15-25 years
26-35 years
36-45 years
46-55 years
56-65 years
Dermoscopy overview
Splinter haemorrgahe
Nail pitting
Corrugated nails
Subungual 591yperkeratosis
Onikolisis
Oil drop
12
8
5
1
6
5
3
16
15
14
14
6
4
60
30
25
5
30
25
15
80
75
70
70
30
20
Table 2. The relationship between the severity of the nail and the quality of life in nail
psoriasis patients.
Variable
DLQI
(12,55 ± 8,15)
NPQ10
(9,5 ± 4,40)
NAPSI
(25,85 ± 14,86)
r=0,948
*
r=0,877
*
DLQI (
Dermatology Life of Quality Inderx
),
NAPSI (
Nail Area Psoriais Index
), NPQ10
(
Nail Psoriasis Quality of Life 10
)
*
Berkorelasi secara signifikan jika nilai
p<0,05.
Table 3. The relationship between sex and quality of life in nail psoriasis patients.
Variabl
e
NPQ1
0
Correlatio
n Test (r)
Man
Wom
an
8,16 ±
4,52
11,5 ±
3,58
r=0,88
8
*
592 | Nail Psoriasis Quality Of Life Scale 10 (Npq10) As A Predictor Of Quality Of Life In Nail
Psoriasis Patients
DLQI (
Dermatology Life of Quality Inderx
),
NPQ10 (
Nail Psoriasis Quality of Life 10
)
*
Berkorelasi secara signifikan jika nilai
p<0,05.
Discussion
Psoriasis is a chronic inflammatory
skin disease caused by disorders of the
immune system with multifactorial
etiologies such as the involvement of
genetic and environmental factors. The
prevalence of psoriasis worldwide is
estimated at 1-3%, where in 80-90% of
cases nail abnormalities are obtained.
1
Research conducted by Augustin, et al in
Germany in 2010 reported that the
incidence of nail psoriasis was more
prevalent in men by 11.2% (Augustin et al.,
2010).
Data from the
World Health
Organization
(WHO) in 2016 reported that
the incidence of psoriasis is more prevalent
in adults between the ages of 30-50 years
(3.10%) especially in some developed
countries such as the United States and the
United Kingdom (Michalek et al., 2017).
Data on the characteristics of the
subjects of this study showed that the
incidence of nail psoriasis was more
prevalent in men by 80%. Research by
Rinandari and Kusumawardani in 2019
2018 at the Skin and Venereal Polyclinic of
Dr. Moewardi Surakarta Hospital stated
that the incidence of nail psoriasis is more
prevalent in men than women (65% : 35%).
(Rinandari U, 2018). Research by Cemil, et
al in Turkey in 2015 stated that
testosterone levels in men with psoriasis
were lower than in healthy individual
controls, while the hormone estrogen in
women functioned to inhibit inflammatory
processes and immunological activity in
prosiasis (Cemil et al., 2015).
The
prevalence of nail psoriasis in this study
occurred mostly in the age range of 36-45
years, which was 30%. Research conducted
by Icen, et al in 2009 in the United States
reported that the incidence of psoriasis is
more prevalent in the age group of 30-50
years which can be influenced by several
precipitating factors both endogenous
(hormonal, psychological stress, allergies)
and exogenous (trauma, drugs, smoking,
alcohol consumption) (Icen et al., 2009).
The clinical manifestations of nail
psoriasis vary depending on the part of the
nail that has an abnormality, there can be
disturbances in the nail matrix, nail pads,
proximal nail folds or hyponicium (Tham et
al., 1988). Salomon, et al in 2003 in Paris
reported that nail psoriasis images of
subungual hyperkeratosis, onychorhexis
and discoloration of the nail plate are more
common in toenails, while nail
pitting
and
splinter haemorrhage
are more commonly
found in fingernails (Salomon et al., 2003).
The most images of nail psoriasis
dermoscopy in our study were
splinter
haemorrhage
of 80 %, where the results
were the same as the study conducted by
Yorulmaz and Artuz in Tukri in 2017
reported that the most images of nail
psoriasis dermoscopy were
splinter
hemorrhages
by 80% (Yorulmaz & Artuz,
2017).
Splinter hemorrhage
occurs due to
damage to the dermis capillaries which
causes erythrocyte extravasation and
Triasari Oktavriana
1
Bobby Febrianto
2
Niluh Wijayanti
3
Eka Novriana Day
4
Ervina Rosmarwati
5
Arie Kusumawardani
6
| 593
accumulates between the gaps of the nail
plate and the nail pads, thus forming a
longitudinal line especially on the distal
part of the nail and is brownish-red or
purplish-black (Harwood et al., 2016; Parija
et al., 2016).
A meta-analysis study conducted by
Stewart, et al in 2020 in the United States
reported that the severity of nail psoriasis
evaluated using NAPSI scores was
significantly associated with DLQI (Stewart
et al., 2021)
The results of the
Pearson
correlation test between NAPSI and DLQI
scores in our study showed a very strong
association with values r=0.948, p<0.05. A
meta-analysis study conducted by Reich
and (Stewart et al., 2021) in Poland
reported a link between DLQI and NAPSI
as well as worsening of
Health-related
Quality of Life
(HR-QoL) in nail psoriasis
patients.
19 Augustin, et al also reported
that in one year in psoriasis patients with
nail involvement more did not come to
work than without nail involvement (9.8 ±
42.0: 3.3 ± 15.9 days, p<0.001), so as to
affect the socioeconomic status as well as
the HR-QoL of the patient.
The use of DLQI in psoriasis patients
with complaints of skin and nail lesions
cannot distinguish the quality of life
impact caused by one or both. This
sparked the idea of creating a special
assessment system to evaluate quality of
life in nail psoriasis patients proposed by
Ortonne, et al in 2009 in European and
known as NPQ10. The questionnaire
consists of 10 questions to determine the
influence of physical activity related to nail
psoriasis, other precipitating factors
involved or both. The first question relates
to the intensity of pain caused by nail
psoriasis, while the other nine questions
are related to functional disorders caused
by lesions of the nails. There are three
possible answers to each question with a
value of 0 to 2, then a summation is carried
out with a minimum value range of 0 (no
disturbance in quality of life) and a
maximum value of 20 (severe degree of
quality of life disorder) (Ortonne et al.,
2010)
The NPQ10 questionnaire is the first
and latest assessment system to determine
the quality of life in patients with nail
psoriasis, so there is still little research to
use it and currently, it is still limited in use
in France. The results of a study from
(Klaassen et al., 2014) in the Netherlands
reported that the severity of psoriasis
measured using SAPASI was statistically
correlated with NPQ10 (r=0.389; p<0.001).
Based on the study, it is similar to the
results of our study where the NAPSI score
value correlates very strongly with NPQ10
(r=0.877, p<0.05). We also compared the
relationship between NAPSI scores with
DLQI and NPQ10, where NAPSI scores
correlated slightly more significantly to
DLQI compared to NPQ10 (r=0.948:
r=0.877, p<0.05). To date, there has been
no research comparing the relationship
between NAPSI scores with DLQI and
NPQ10, so we have not been able to
compare with other studies. We concluded
that there was a question on NPQ10 in the
form of interference when driving a car
due to nail psoriasis, where all respondents
did not drive a car so that the results of the
NAPSI correlation test to NPQ10 were
slightly lower compared to DLQI.
The quality of life of nail psoriasis
patients can also be influenced by gender,
594 | Nail Psoriasis Quality Of Life Scale 10 (Npq10) As A Predictor Of Quality Of Life In Nail
Psoriasis Patients
where women with nail psoriasis are more
likely to complain about their physical
appearance which has an impact on the
socioeconomic factors of the patient.
Research by Augustin, et al in 2014 in
Germany reported that women with nail
psoriasis were more often absent from
work compared to men (8.5 ± 32.1: 6.0 ±
21.9), where nail psoriasis in women had
more impact on HR-QoL compared to men
(9.5 ± 7.1: 8.6 ± 7.1). The results of the
study are the same as ours where the value
of DLQI and NPQ10 in women with nail
psoriasis is higher than that of men (14.12
± 8.21: 11.5 ± 8.29 and 11.5 ± 3.58: 8.16
± 4.52). Research conducted by Gregoriou
and Rigopoulosa in 2010 in Europe stated
that women with psoriasis skin and nail
lesions pay more attention to the
condition and development of the disease,
so it will have an impact on the patient's
social relationship with the surrounding
environment as well as limitations to carry
out daily activities (Gregoriou S, 2014).
The NPQ10 questionnaire was
developed specifically to assess the quality
of life of nail psoriasis patients by listing
some questions not found in DLQI.
Research conducted by (Klaassen et al.,
2014) in the Netherlands in 2014 reported
that nail psoriasis patients more often had
difficulty wearing shoes or socks (21.2%
and 25.1%) as well as disturbances when
carrying out activities inside the home
(25.3%). Based on the results of the study,
the questions listed on NPQ10 are more
specific to evaluate the impact of nail
psoriasis on daily activities as well as the
patient's HR-QoL.
8
Research conducted by
Ortonne, et al in 2009 in Europe reported
significant validation test results between
DLQI and NPQ10 namely r=0.48, p<0.05,
where these results were the same as ours
where the correlation test results between
DLQI and NPQ10 showed a very strong
relationship (r=0.888, p<0.05).
20
NPQ10
scores are significant enough to evaluate
HR-QoL, especially in nail psoriasis
patients, so that efforts to treat and
prevent recurrence in psoriasis patients
can be achieved better.
The limitations of this study include
the small number of study subjects due to
the coronavirus pandemic so that patients
who come for treatment decreases. We
hope that in the future further research
can be carried out with a larger number of
samples, so that it can be used as a guide
to evaluating the quality of life of nail
psoriasis patients, helping to achieve
clinical improvement and preventing
recurrence.
CONCLUSIONS
Nail psoriasis often gives rise to
physiological and cosmetic disorders, so it
can affect the patient's quality of life. The
use of DLQI in psoriasis patients with
complaints of skin and nail lesions could
not distinguish the impact of HR-QoL
caused by nail abnormalities or skin lesions,
so a more specific NPQ10 score was used
to evaluate the impact of nail psoriasis on
quality of life. Our results showed an
association between the severity of nail
psoriasis based on NAPSI scores correlated
more significantly to DLQI than NPQ10. The
difference in values was caused by several
questions in NPQ10 that were less relevant
to the daily activities of the subjects of this
Triasari Oktavriana
1
Bobby Febrianto
2
Niluh Wijayanti
3
Eka Novriana Day
4
Ervina Rosmarwati
5
Arie Kusumawardani
6
| 595
study. NPQ10 values in women are higher
than in men, which indicates that the
quality of life of patients with nail psoriasis
is also influenced by gender.
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© 2022 by the authors. Submitted
for possible open access publication
under the terms and conditions of the Creative Commons Attribution (CC BY SA) license
(https://creativecommons.org/licenses/by-sa/4.0/).