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Background:Delayed diagnosis is associated with worse outcomes and poor treatment responses in patients with SpA, including psoriatic arthritis (PsA) and axial spondyloarthritis.1Misclassification may be associated with this delay, as SpA and RA, especially seronegative RA, may present with similar manifestations such as joint pain, swelling, fatigue, and disability. Key features that typically distinguish SpA from RA include spine pain, dactylitis, enthesitis, psoriasis, and nail psoriasis.2Increased physician awareness of the potential overlap and distinctions between SpA and RA manifestations is needed for the early diagnosis and appropriate treatment for SpA.Objectives:To identify and summarise the published literature on the prevalence of SpA-related clinical manifestations among patients with RA and SpA.Methods:Publications were retrieved from Embase®, Cochrane, MEDLINE®, and MEDLINE® In-Process databases. Studies were included if they were non-interventional, recruited patients with RA and SpA, or patients with seronegative/seropositive RA, and reported the following manifestations: enthesitis, dactylitis, axial symptoms, psoriasis, or nail psoriasis. Two reviewers assessed each citation against predefined eligibility criteria, with discrepancies reconciled by a third independent reviewer.Results:Of the 4479 publications retrieved, 18 studies were included (Figure 1). All studies compared SpA populations to patients with RA. Of the 18 studies, 11 studies reported patients with only PsA, 2 studies reported patients with only ankylosing spondylitis (AS), and 5 studies reported mixed SpA populations. Three studies each reported data pertaining to seropositive/seronegative RA and early RA, defined as symptom onset Conclusion:While this review found a higher prevalence of key SpA-related clinical manifestations in SpA vs. RA, overlap was present suggesting that misclassification could occur. Differences in the prevalence of manifestations were also seen in the early vs. late RA populations as well as by RA serostatus. This suggests that an earlier and comprehensive evaluation, including advanced imaging of peripheral manifestations such as enthesitis, dactylitis, axial symptoms, and skin signs such as psoriasis and nail disease, among RA and SpA patients may reduce misclassification and inappropriate treatment. Further research is needed to confirm these findings.References:[1]Seo et al. Clin Rheumatol. 2015;34:1397-1405.[2]Merola et al. RMD. 2018;4:e000656.Acknowledgments:This study was sponsored by Novartis Pharmaceuticals Corporation, East Hanover, NJ.Disclosure of Interests:Philip J Mease Grant/research support from: Abbott, Amgen, Biogen Idec, BMS, Celgene Corporation, Eli Lilly, Novartis, Pfizer, Sun Pharmaceutical, UCB – grant/research support, Consultant of: Abbott, Amgen, Biogen Idec, BMS, Celgene Corporation, Eli Lilly, Novartis, Pfizer, Sun Pharmaceutical, UCB – consultant, Speakers bureau: Abbott, Amgen, Biogen Idec, BMS, Eli Lilly, Genentech, Janssen, Pfizer, UCB – speakers bureau, Mohit Kumar Bhutani Employee of: Novartis Healthcare Pvt Ltd, Peter Hur Employee of: Novartis Pharmaceuticals Corporation, Esther Yi Employee of: Novartis Pharmaceuticals Corporation, Nina Kim Employee of: Postdoctoral fellow at the University of Texas at Austin and Baylor Scott and White Health, providing services to Novartis Pharmaceuticals Corporation

Background:Psoriatic onychopathy is an independent predictor of the onset of psoriatic arthritis (PsA). Assessment of nail disease is difficult given the limited utility of clinical assessment tools for the nail.Recently, ultrasound (US) proved to be informative in the assessment of nail involvement.Objectives:We aimed to describe morphologic ultrasonographic nail disease changes and to look for correlations between these features and the characteristics of the PsA.Methods:The study included patients who met the CASPAR criteria for PsA.An US scan of patient’s nails was performed in order to study the nail, matrix and skin thickness.Results:We included 33 patients with PsA with a mean age of 51.2±12.5 years. The mean DAPSA was 22.8±19.7 (remission:9 patients, low activity: 5 patients, moderate activity: 11 patients and high activity: 8 patients).Twenty-nine patients had a personal history of skin psoriasis, present in 64 % of the patients the day of the examination with a mean PASI of 2.76 ±3.9.Eleven patients (33.4%) presented with psoriatic onychopathy (45 fingernails) with a mean mNAPSI of 14.1± 16.The most common patterns of nail involvement were:Oil-drop patches (5 fingernails), pitting (4 fingernails), onycholysis (3 fingernails), crumbling (3 fingernails), subungual hyperkeratosis (2 fingernails), leukonychia (2 fingernails),paronychia(2 fingernails), splinter hemorrhages (1 fingernail).We scanned 330 fingernails. The US study revealed dystrophy in 75 nails (22.7%) of the nails, in 17 patients (51.5%): Undulations or pitting (n=47), followed by disappearance of the anechoic space (n=38) and anechoic ventral nail plate (n=18).The mean thickness of skin, nail plate and nail matrix region were 2.25±0.32 mm, 0.38±0.07 mm and 1.89±0.33, respectively.We found a positive correlation between nail plate thickness and both skin and nail matrix region thickness (r=0.561, p=0.001 and r=0.523, p=0.002).Skin, nail and nail matrix thickness were significantly higher in men and in smokers. Manual workers did not have greater skin, nail plate nor nail matrix thickness.There were no correlations between disease activity evaluated by the ASDAS-CRP, DAS28, PASI, ESR or by CRP and any of the US parameters.In contrast, there was a significant negative correlation between psoriatic disease duration and nail plate thickness (r=-0.372, p=0,036).Conclusion:Ultrasound offers an appropriate alternative for the evaluation of the nail unit. In our study it was able to detect subclinical involvement of the nail in 30 fingernails and in two patients.Disclosure of Interests:None declared

Background:Longitudinal observational data on psoriatic nail dystrophy is scarce, in part due to the lack of a validated outcome measure that is feasible in routine care. The Severity of Nail Psoriasis Score (SNAPS; range 0-40: scored one point each for the presence of pitting, onycholysis, hyperkeratosis and/or severe nail disease#in each fingernail) has face validity and has recently demonstrated feasibility, reliability and cross-sectional construct validity against the modified Nail Psoriasis Severity Index (mNAPSI; range 0-130)1.Objectives:We aimed to assess the longitudinal construct validity of SNAPS against the mNAPSI and physician nail VAS (PhNVAS), and to determine the effect size and measurement error of these tools.Methods:Consenting consecutive patients enrolled in the Bath Psoriatic Arthritis (PsA) longitudinal cohort underwent photography of their fingernails at baseline1and 6 months alongside routine clinical assessments. Dorsal images of individual fingernails were acquired using a tripod mounted DSLR camera. An angled mirror positioned distally aided identification of hyperkeratosis. Photograps were scored using SNAPS, mNAPSI and PhNVAS1. Paired statistical analyses were conducted to assess for change in scores from baseline to follow-up. Pairwise correlations between change in SNAPS and change in mNAPSI and PhyNVAS were assessed using Spearman’s rho. Effect sizes and measurement error were calculated.Results:Fifteen patients with a mean (±SD) age of 54.5 (±10.59) were assessed at 6 months. There was a significant reduction in both the mNAPSI and SNAPS scores (p1i.e. pitting, onycholysis, hyperkeratosis and crumbling (Table 1). No other feature specific to mNAPSI improved over time. There was no significant change using the PhyNVAS. There was a strong correlation between changes in SNAPS and the mNAPSI (Figure 1; rho = 0.838, pConclusion:SNAPS demonstrates longitudinal construct validity against the mNAPSI in a small observational cohort of PsA patients as evidenced by a strong correlation between the measures, comparable effect sizes and sensitivity to change over time. Whilst measurement error parameters favored the mNAPSI, SNAPS may be a more feasible measure for studying nail disease in cohort studies.References:[1]Antony A, Hart D, Cavill C, Korendowych E, McHugh N, Lovell C, Tillett W. The ‘Severity of Nail Psoriasis Score’ (SNAPS) Is Feasible, Reliable and Demonstrates Construct Validity Against the mNAPSI in an Observational Cohort of Patients with Psoriatic Arthritis [abstract].Arthritis Rheumatol.2019; 71 (suppl 10).Table 1.Outcomes at Baseline and at Follow-Up:OutcomeMean (SD) or Median (IQR) N=15t-test or Wilcoxon Sign Rank test (p-value)BaselineFollow-upSNAPS13.0 [8.00-21.00]5.0 [2.00-11.00]0.002*mNAPSI22.0 [12.00-35.00]6.0 [4.00-15.00]0.001*Physician Nail VAS23.3 (22.90)15.8 (15.22)0.147Physician Global VAS18.0 [10.75-32.75]15.0 [10.00-30.00]0.455Table 2.Measurement error of SNAPS, mNAPSI, PtNVAS and PhyNVASSRMSEMSDCSDC % (% of total score)SDDSDD% (% of total score)SNAPS1.151.716.7216.793.368.40mNAPSI1.153.5113.7410.576.875.29Physician Nail VAS0.404.7118.4714.219.237.10Figure 1.Correlation between changes in SNAPS and changes in mNAPSIDisclosure of Interests:Anna Antony: None declared, Sadaf Saeed: None declared, Darren Hart: None declared, Preeti Nair: None declared, Charlotte Cavill: None declared, Eleanor Korendowych: None declared, Neil McHugh: None declared, Christopher Lovell: None declared, William Tillett Grant/research support from: AbbVie, Celgene, Eli Lilly, Janssen, Novartis, Pfizer Inc, UCB, Consultant of: AbbVie, Amgen, Celgene, Lilly, Janssen, Novartis, MSD, Pfizer Inc, UCB, Speakers bureau: AbbVie, Amgen, Celgene, Lilly, Janssen, Novartis, Pfizer Inc, UCB

Background:The Severity of Nail Psoriasis Score (SNAPS; range 0-40: scored one point each for the presence of pitting, onycholysis, hyperkeratosis and/or severe nail disease#in each fingernail) has been utilised to collect data regarding psoriatic nail dystrophy in the Bath Psoriatic Arthritis (PsA) Longitudinal cohort for many years. SNAPS has construct validity in PsA with the modified Nail Psoriasis Severity Index (mNAPSI) as a comparator instrument and appears to be more feasible than mNAPSI with excellent reliability1.Objectives:We aimed to determine if SNAPS could demonstrate longitudinal sensitivity to change in a cohort of patients treated with biological disease modifying anti-rheumatic drugs (bDMARDs) and therefore be utilized prospectively in observational and clinical trial settings.Methods:Patients enrolled in the Bath PsA longitudinal cohort routinely undergo clinical assessments including a 66/68 Swollen and Tender Joint Count (SJC/TJC), Psoriasis Area Severity Index (PASI), Patient Global Assessment (PtGA) and Physician Global Assessment (PhGA), as well as complete patient-reported outcome measures such as the Health Assessment Questionnaire (HAQ) and Dermatology Quality of Life (Derm-QoL). All patients who commenced treatment with Etanercept and had available outcome data at baseline, 3 months and 6 months were included in this retrospective analysis. Baseline demographics were recorded and paired t-tests were utilized to assess the change in SNAPS at 3 and 6 months. The effect size and measurement error of SNAPS in this cohort were measured. Correlations between SNAPS and other outcome measures were assessed using Pearson’s r.Results:Fifty-seven patients (32 male and 25 female) with available data were retrospectively analysed. The mean (±SD) age of the cohort and duration of disease was 61.3 (±11.55) and 13.3 (±10.82) years respectively. The mean SNAPS at baseline was 3.7 (±6.13) and improved to 2.0 (3.74, p=0.018) at 3 months and 1.2 (2.40) at 6 months (p=0.001 for change from baseline and p=0.039 for change from month 3). The smallest detectable difference at 3 months for SNAPS in this cohort was 1.35, representing 3.37% of the range of the score (Table 2). The standardised response mean (SRM) was 0.32 at 3 months and 0.44 at 6 months. There was a modest correlation between the improvement in the SNAPS score and the improvement in PASI and Derm QOL at 3 months (r = 0.511 and 0.558 respectively, p=0.001) and 6 months (r= 0.672, pConclusion:SNAPS demonstrates sensitivity to change in response to treatment with a bDMARD and could be a potential outcome measure for the assessment of treatment efficacy in prospective studies.References:[1]Antony A, Hart D, Cavill C, Korendowych E, McHugh N, Lovell C, Tillett W. The ‘Severity of Nail Psoriasis Score’ (SNAPS) Is Feasible, Reliable and Demonstrates Construct Validity Against the mNAPSI in an Observational Cohort of Patients with Psoriatic Arthritis [abstract].Arthritis Rheumatol.2019; 71 (suppl 10).Table 1.Outcomes at Baseline, 3 months and 6 monthsMean (SD) or Median [IQR]Baseline3 Months(p for change from baseline)6 Months(p for change from baseline)PASI (0-72)3.0 (4.80)1.6 (2.12) p=0.011.3 (1.6) p=0.002SNAPS (0-40)3.7 (6.13)2.0 (3.73) p=0.0181.2 (2.39) p=0.001Derm-QoL (0-30)5.7 (7.07)1.95 (3.23) p=0.001 (n=33)1.9(4.72) p=0.037 (n=31)Table 2.Measurement Error for SNAPS in an Etanercept CohortTimeframeStandardised Response MeanStandard Error of MeanSmallest Detectable ChangeSmallest Detectable Change (% of total score)Smallest Detectable DifferenceSmallest Detectable Difference (% of total score)0-3 months0.320.691.914.771.353.370-6 months0.440.742.065.151.463.64Disclosure of Interests:Anna Antony: None declared, Sadaf Saeed: None declared, Darren Hart: None declared, Preeti Nair: None declared, Charlotte Cavill: None declared, Eleanor Korendowych: None declared, Neil McHugh: None declared, Christopher Lovell: None declared, William Tillett Grant/research support from: AbbVie, Celgene, Eli Lilly, Janssen, Novartis, Pfizer Inc, UCB, Consultant of: AbbVie, Amgen, Celgene, Lilly, Janssen, Novartis, MSD, Pfizer Inc, UCB, Speakers bureau: AbbVie, Amgen, Celgene, Lilly, Janssen, Novartis, Pfizer Inc, UCB

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.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.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), p0.001). Modified nail psoriasis severity index scores were correlated to both inflammation (r(2)=0.45, p=0.005) and chronicity scores (r(2)=0.35, p=0.04). No link between the psoriasis area and severity index and enthesitis was evident.The link between nail disease and contemporaneous subclinical enthesopathy offers a novel anatomical basis for the predictive value of nail psoriasis for PsA evolution.

Evaluation of the preclinical phases of the classic autoimmune diseases including rheumatoid arthritis has been facilitated by the availability of autoantibody and genetic markers that point firmly towards the early dysregulation of the adaptive immune responses. The association of psoriatic disease with the human leucocyte antigen-Cw0602 (HLA-Cw0602) gene has likewise led to the perception that autoimmunity has a pivotal role in early psoriatic arthritis (PsA). However, this HLA-Cw0602 genetic association does not appear to hold for PsA or associated nail, scalp and intergluteal skin involvement. Of note, these three sites of psoriasis are predictive of PsA evolution. For initiation of both skin and nail disease there is a link with Koebnerisation, or site-specific trauma. Nail disease is most common in the dominant hand thumbnail, pointing towards local tissue factors as disease initiators Likewise, for PsA, there is also good evidence for a history of previous joint trauma and histological studies showing microdamage in normal entheses which are typical locations where PsA frequently occurs. Furthermore, subclinical enthesopathy including osteitis is common in subjects with psoriasis but without arthritis. Collectively, these findings indicate that the classic model of adaptive immune dysregulation does not generally hold for the early stages of PsA. The way in which knowledge pertaining to tissue-specific factors in PsA, combined with the emerging data relating to monogenic disorders and animal models, points towards perturbation in the healing response and dysregulation of innate immune responses in early PsA is discussed. The way in which this model explains the clinical disconnect between skin and joint disease and the emerging human data that support it are demonstrated.

Key messages #### What is already known about this subject? #### What does this study add? #### How might this impact on clinical practice? Nail involvement is part of the clinical spectrum of psoriatic disease and is microanatomically associated with distal interphalangeal joint (DIPJ) entheses.1 Tumour necrosis factor (TNF) inhibitors have shown efficacy for psoriasis, arthritis, enthesitis, dactylitis and nail disease.2 Given the intimate links between psoriatic arthritis (PsA) and nail disease, it might be expected that nail disease improvement would be associated with resolution of the underlying arthropathic features. All participants gave written consent. All cases fulfilled the Classification Criteria for Psoriatic Arthritis (CASPAR) criteria for PsA.3 All cases were due to …

Objectives o evaluate the efficacy of etanercept and methotrexate as monotherapies and as combination therapy in subjects with active psoriatic arthritis (PsA). Methods he Study of Etanercept and Methotrexate in Combination or as Monotherapy in Subjects with Psoriatic Arthritis (SEAM-PsA) is an ongoing, global, doubleblind, 48-week, randomised, controlled study. Subjects are randomised (1:1:1) to etanercept monotherapy, methotrexate monotherapy or etanercept-methotrexate combination therapy. Endpoints include rates of ACR20 response and Minimal Disease Activity, measures to characterise extra-articular manifestations (dactylitis, enthesitis, nail disease) and safety. Conclusion SEAM-PsA will characterise the effects of etanercept with and without background methotrexate and methotrexate alone on PsA manifestations, and provide information of practical importance to clinicians on the optimal treatment of PsA.

To further characterise spontaneous arthritis in aging male DBA/1 mice as a model of spondyloarthropathy and psoriatic arthritis with particular attention to signs of inflammation and nail involvement.Aging male DBA/1 mice from different litters were caged together (4-6 mice per cage) at the age of 12 weeks, checked twice a week for signs of arthritis, and killed at different times. Hind paws were dissected and processed for histology.Disease incidence varied between 50% and 100% in four different experiments. Besides clinical signs of arthritis, nail abnormalities were noticed. Pathological examination showed the occurrence of dactylitis characterised by diffuse neutrophil infiltration in 6 of 50 paws examined. Onycho-periostitis with progressive destruction of the nail bed and the underlying distal phalanx was seen in 5 of 50 paws examined.Although dactylitis and onychoperiostitis are rare manifestations of the disease process, these data strongly suggest that spontaneous arthritis in aging male DBA/1 mice shares important features with human psoriatic arthritis. This model may therefore be an important tool to study links between stress, sex, inflammation, and new bone formation with particular relevance to human psoriatic arthritis.

A 7-year-old South Asian boy was evaluated in a district general child assessment unit following a 4-week history of daily fevers with associated pain and swelling in the thumb and middle finger phalanges of the right hand. There was no history of cough, weight loss, night sweats or trauma. On examination, he appeared well with no anaemia or jaundice. There was a spindle-shaped deformity of the right thumb and middle finger, with concomitant non-tender right axillary lymphadenopathy. No other joints were affected. The rest of the physical examination was unremarkable. Radiographs of the affected fingers demonstrated …

Objective: To compare the efficacy and safety of continuous terbinafine with intermittent itraconazole in the treatment of toenail onychomycosis. Design: Prospective, randomised, double blind, double dummy, multicentre, parallel group study lasting 72 weeks. Setting:35 centres in six European countries. Subjects: 496 patients aged 18 to 75 years with a clinical and mycological diagnosis of dermatophyte onychomycosis of the toenail. Interventions: Study patients were randomly divided into four parallel groups to receive either terbinafine 250 mg a day for 12 or 16 weeks (groups T12 and T16or itraconazole 400 mg a day for 1 week in every 4 weeks for 12 or 16 weeks (groups I and I). Main outcome measures: Assessment of primary efficacy at week 72 was mycological cure, defined as negative results on microscopy and culture of samples from the target toenail. Results: At week 72 the mycological cure rates were 75.7% (81/107) in the T12 group and 80.8% (80/99) in theT16 group compared with 38.3% (41/107) in theI group and 49.1 % (53/108) in the I4 group.All comparisons (T v I,T12vI4, T16v I3, T16vI4) showed significantly higher cure rates in the terbinafine groups (all P Conclusion: Continuous terbinafine is significantly more effective than intermittent itraconazole in the treatment of patients with toenail onychomycosis.

This case report describes a patient with thallium poisoning caused by repeated exposure to low doses of thallium. Alopecia and nail changes were the most prominent features of this case. There was dystrophy of nails in the form of whitish lunular stripes. This is the first report of complete erosion of proximal parts of nails following thallium poisoning. This case is the first report of thallium poisoning from India occurring from repeated low dose exposure.

Summary points The term onychomycosis refers to fungal infection of the nails whether this is a primary event or a secondary infection of a previously diseased or traumatised nail. Infection may be due to dermatophyte (ringworm, tinea unguium), yeast, or other non-dermatophyte (mould) species, and the clinical appearance may indicate the nature of the infecting organism. In paronychia chronic infection of the nail fold is most often caused by Candida species, but bacterial infection with Gram negative species such as Pseudomonas may coexist. Acute paronychia (whitlow) due to staphylococcal infection may also occur, and the presence of these bacterial infections will influence management. Invasion of the nail plate by Candida species may occur in the presence of paronychia, immune deficiency states (including chronic mucocutaneous candidiasis), Raynaud's disease, or endocrine disorders. This paper reviews the clinical features of onychomycosis and the differential diagnosis of nail dystrophy, gives the reasons for appropriate mycological investigation, and discusses guidelines for appropriate treatment on the basis of laboratory findings and particular clinical situations. Treating onychomycoses is difficult but is important because they do not resolve spontaneously. About 30% of all superficial fungal infections affect the nail.1 2 A recent population survey of dermatophyte onychomycosis has suggested a prevalence of 2.8% for men and 2.6% for women in the United Kingdom.3 …

We describe a second family with four affected members in three successive generations with a rare nail dysplasia syndrome. The syndrome, which was first reported by Cooks et al in 1985, is characterised by bilateral nail hypoplasia of digits 1-3, with absence of nails of digits 4-5 of the hands, and total absence of all toe nails. In addition, there is absence/hypoplasia of the distal phalanges of the hands and feet. Our family confirms this syndrome as a distinct entity with autosomal dominant inheritance.

Background Some patients with psoriatic arthritis (PA) in optimizing biological therapy present joint and/or skin activity, and they need to return to the standard dose of the drug. We present the articular and skin Activity Data in our cohort of patients with polyarticular psoriatic arthritis (PPA) in therapeutic optimization Objectives Assessment of the cutaneous activity by the PASI (Psoriasis Area Severity Index) and NAPSI (Nails Psoriasis Severity Index) scales and the analysis of the joint clinical course by DAS28 in PPA patients with biological treatment followed in the Rheumatology section of an university hospital of Jerez (Cadiz, Spain), which are undergoing therapeutic optimization. Methods An observational, descriptive, longitudinal and retrospective study by reviewing medical records, between January 2013 and January 2016, of PPA patients carrying at least 6 months in remission (DAS28 Results From a total of 120 patients with PA in biological treatment, 26 of them with only polyarticular involvement (20.83%) were performed optimization of the therapy. 61.5% are male. Mean age 50±13 years. Average time optimized treatment dose: 31±14 months. 11 patients (42%) performed adalimumab 40 mg/15 days optimizing his administration every 21 days; 15 (57%) patients initially performed etanercept 50 mg/7 days were optimized to 25 mg/7 days (9 patients (34%)), 50 mg/10 days (2 (7%)) or 50 mg/15 days (4 (15%)). At the time of optimization, 25 (96.2%) patients presented remission DAS28 and 1 (3.8%) low activity, continuing in the same situation at the time of the end of the study (30 months after optimization). However, 5 patients (19.2%) (4 from etanercept group and 1 from adalimumab group) required to return to full doses of biologic drug for clinical worsening, agreeing worsening skin, remaining stable clinical joint. The skin evaluation was average PASI 1.95±2.13 (0–72) and medium NAPSI 11.19±11.38 (0–160), presenting patients who required back to initial biological dose PASI values between 1.6 and 5.8 and NAPSI values between 20 and 32, with prevalence of nail disease in the lower limbs. One patient (3.8%) required changing biological undesirable effects (anal fistula) Conclusions 77% of patients with PPA in remission or low activity subject to therapeutic optimization in our center remained stable at an average of 31 months of optimization, allowing continued the biological treatment in optimized doses. The main cause of return to full doses of biologic therapy in the remaining 33% of cases was worsening cutaneous involvement, remaining stable clinical joint in 100% of patients of our study Disclosure of Interest None declared

Background Psoriatic arthritis (PsA) is a heterogeneous disease that includes features of peripheral arthritis, spondylitis, dactylitis, enthesitis, and skin and nail disease. PsA affects about 30% of patients with psoriasis (PsO). 1 Measuring outcome in psoriatic arthritis (MOPsA) is a web-based tool, freely available to use (see https://mopsa.ie), that collects clinical information about all domains affected in PsA including skin disease and patient reported outcome measures (PROMs). MOPsA also calculates the composite psoriatic disease activity index (CPDAI) and minimal disease activity (MDA). 2,3 Assessment of skin disease in rheumatology clinics can be challenging. Availability of patient self-assessment questionnaires that correlate with, and possibly can replace, physical examination would address this challenge. Objectives Our aim was to correlate skin-related patient self-assessment questionnaires and skin sores assessed by physicians using MOPsA. Methods 189 patients with PsA, fulfilling CASPAR criteria, were recruited in this study. 137 patients from rheumatology clinic and 52 patients from dermatology clinic. We calculated the following skin scores: Dermatology Quality of Life Index (DLQI), Psoriasis Symptom Inventory (PSI), Body Surface Area (BSA) and Psoriasis Area Severity Index (PASI). GraphPad Prism version 6 was used for statistical analysis. Results Data from 189 patients with skin scores were included in this analysis. Mean ± SD age of 44.61 (± 12.54), 99 (52%) patients were males. 96 (51%) patients had nail involvement. Mean ± SD DLQI was 5.57 (± 6.93), PSI 7.36 (±8.68), BSA 7.27 (± 12.17), and PASI 4.57 (± 5.56). There was strong correlation between PASI and BSA (r=0.8502, P Conclusions Our analysis confirms the correlation between PASI and DLQI. The strongest correlation was between PASI and BSA. DLQI correlates very well with all three parameters (PASI, BSA and PSI). These preliminary results suggest that the combination of BSA and DLQI might work equally well to PASI and DLQI when accurately accessing skin involvement in rheumatology clinics. References Mease PJ, et al: Prevalence of rheumatologist-diagnosed psoriatic arthritis in patients with psoriasis in European/North American dermatology clinics, J Am Acad Dermatol. 69(5):729–35, 2013 Mumtaz A, et al: Development of a preliminary composite disease activity index in psoriatic arthritis, Ann Rheum Dis. 70(2):272–7, 2011 Coates LC, et al. Defining minimal disease activity in psoriatic arthritis: a proposed objective target for treatment. Ann Rheum Dis. 69(1):48–53, 2010 Disclosure of Interest M. Elmamoun: None declared, C. Loftus: None declared, A. Szentpetery: None declared, P. Gallagher: None declared, L. Barnes: None declared, O. FitzGerald Grant/research support from: Pfizer, AbbVie, BMS, UCB, Consultant for: Pfizer, AbbVie, Janssen, MSD, Cellgene, Novartis, Speakers bureau: Pfizer, AbbVie, Janssen, Cellgene

Twenty-nail dystrophy is a rare disease, typically with all 20 nails affected, which normally occurs as an idiopathic condition in childhood but can be linked to other diseases. We report a case of a 7-year-old girl with a 3-year history of 20-nail dystrophy and no associated diseases or family history of skin or nail diseases. She was followed and treated conservatively and, after 6 years of follow-up, we found a marked improvement and almost full resolution of her nail dystrophy. The aim of this report is to show that idiopathic 20-nail dystrophy in children is a self-limiting condition and thus can be treated conservatively.

A 75 year old man presented with a four month history of presumed paronychia of his right index finger. Antibiotic and antifungal treatment had not been effective. Destruction of the distal phalanx …

Background Psoriatic disease comprises psoriatic arthritis (PsA), cutaneous psoriasis (PSO) and psoriatic nail disease. 1 PsA shows both bone erosion and proliferation. However, the latter seems to be present in PSO even in absence of joint manifestations. 2 Objectives (I) To compare the bone microstructure in PSO patients, without signs and symptoms of PsA, and in PsA patients and (II) to investigate whether specific demographic and clinical variables accompany bone changes. Methods Prospective cross-sectional study based on high-resolution peripheral quantitative computed tomography (HR-pQCT) examination of the metacarpal head and phalangeal base of the MCP joints 2 and 3 of the dominant hand. We assessed erosions and enthesiophytes by frequency, volume (for erosions, mm 3 ) and size (for enthesiophytes, mm). Erosions were defined as breaks in the cortical shell within the joint visible in two planes, enthesiophytes as bony protrusions emerging from the cortical shell in the periarticular region. The study was approved by the local ethic committee, and the National Radiation Safety Agency (BfS). Patients signed consent. Results 101 PsA patients (mean age 50.8±13.2 years, N=51 female) and 55 PSO patients (49.0±11.4, N=20 female) were included. Mean age and sex distribution were comparable. In the PsA group skin disease duration was 18.9±14.8 years, joint disease duration was 6.4±7.3 years. Mean PASI score was 3.4±5.5 with 20.8% of the PsA patients showing nail and 19.8% scalp involvement. PSO patients mean disease duration was 15.2±15.4 years, PASI score 6.2±8.0. Nail disease was present in 50.9%, scalp involvement in 29.1%. 52 PsA patients were treated with conventional DMARDs, 49 with biological DMARDs. 140 erosions were identified in the PsA group and 27 in the PSO group (mean ± SD/patient: 1.39±2.16 (PsA) vs. 0.49±0.94 (PSO); p =0.002, U=2023.5). Erosions mean volume differed between the groups, with the PsA patients showing larger lesions (6.29±9.71 mm 3 vs. 3.29±3.09 mm 3 , p =0.003, U=2005.0). PsA patients showed a higher number of enthesiophytes (963 vs. 306), which accounted for a statistically significant difference in mean number per patient (mean ± SD/patient: 9.53±6.66 vs. 5.62±3.30, p ≤0,001, U=1468.5). Additionally, enthesiophytes were larger in PsA compared to PSO patients (Fig. 1 A,B). Mean enthesiophyte size was 6.79±5.62 mm in the PsA group and 4.01±2.19 mm in the PSO group ( p ≤0.001, U=1722.0). With respect to PSO and PsA patients, two linear regression models investigating the role of age, sex, PASI score, BMI, and duration of psoriasis showed that only the duration of psoriasis is independently and positively related to the number of erosions and enthesiophytes (b ero. =0.23, p =0.031; b enthe. =0.24, p =0.023). Conclusions HR-pQCT analysis of the bone microstructure of PsA and PSO subjects indicates that PsA patients show significant more anabolic and catabolic bone changes. Duration of skin disease seems to play a decisive role for pathologic changes of the periarticular bone microstructure of psoriatic patients. References Scarpa R, et al. J Rheumatol 2006;33:210-2. Simon D, et al. Ann Rheum Dis 2014;73(Suppl 2):464-5. Disclosure of Interest None declared

OBJECTIVES--To establish the clinical significance of isolated nail fold vasculitis in patients with rheumatoid arthritis (RA). METHODS--Patients attending hospital with established RA were assessed by a single observer using unaided vision. Isolated nail fold vasculitis (NFV) was diagnosed as small nail edge or nail fold lesions without any evidence of other extra-articular or systemic vasculitis. Patients were followed prospectively. RESULTS--Thirty patients with isolated NFV were identified and followed for a median interval of 22 months. Three patients died within three months of diagnosis and six developed complications possibly indicative of extra-articular disease: xerostomia (three), pericarditis (one), pleural effusion and empyaema (one), pulmonary fibrosis (one). No patient developed systemic vasculitis. CONCLUSION--Isolated NFV has a favourable prognosis compared with systemic vasculitis. There is a low risk of developing systemic or extra-articular disease.

Background Delay in diagnosis of psoriatic arthritis (PsA) remains a significant contributor to poor patient outcome. Clinical predictors of the development of arthritis among patients with psoriasis (Ps) have been proposed and a number of screening questionnaires have been developed. Objectives The objectives of this study were: 1) to assess the prevalence of PsA among Ps patients attending dermatology clinics; 2) to identify clinical predictors of the development of PsA; and 3) to compare the performance of 3 PsA screening questionnaires [Psoriatic Arthritis Screening and Evaluation (PASE), Psoriasis Epidemiology Screening Tool (PEST), and the Toronto Psoriatic Arthritis Screening tool (ToPAS)]. Methods This study was carried out in general dermatology and rheumatology clinics. Patients were divided into two groups: group 1, consecutive patients with skin psoriasis attending dermatology clinics who have no known diagnosis of inflammatory arthritis; group 2, consecutive patients attending rheumatology clinics with a confirmed diagnosis of PsA. The diagnosis of PsA was made using the CASPAR criteria. In group 1, patients completed the screening questionnaires, which were followed by a thorough rheumatologic evaluation whether or not patients reported musculoskeletal symptoms. Results 200 patients were recruited; 100 in each group. 84% of patients in Group1 were using systemic therapy for their skin disease, and 99% of patients in Group 2 were on systemic immunosuppressives. In Group 1, 29% of patients were diagnosed with PsA after rheumatologic evaluation. Compared to Group 2, patients in Group1 had significantly higher PASIs (p=0.001), more scalp psoriasis at the time of assessment (p=0.0001) and less nail disease ever in the disease course (p=0.04). There was no significant difference in the presence of scalp disease ever in the disease course among Group 1, Group 2 and even in the subgroup of newly diagnosed patients with PsA. On univariate and multivariate analysis, the only significant positive association was noted between high PASIs and the new diagnosis of PsA (p=0.046), even after adjusting for confounders such as, age, gender, use of TNFi, duration of psoriasis and the presence of nail and scalp disease ever in the disease course. A strikingly different pattern of joint involvement was noted in patients with newly diagnosed PsA vs. patients with established PsA with fewer non-polyarticular disease (p=0.0001). In Group 1, the PEST, PASE and ToPAS had sensitivities of 27.5%, 24% and 41%, and specificities of 98%, 94% and 90%, respectively; however, in Group 2, the sensitivities were 86%, 62% and 83%, and specificities were 98%, 94% and 90%, respectively. Conclusions When patients with known PsA were excluded, 29% of Ps patients attending dermatology clinics had PsA diagnosed following rheumatologic assessment. Psoriasis severity as measured by PASI was associated with the diagnosis of PsA even after adjusting for the use of TNFi, duration of psoriasis, and the presence of nail or scalp disease. Nail disease ever in the disease course was commoner in patients with known PsA. Poor sensitivities for the screening questionnaires was noted among patients with psoriasis, perhaps due in part to inadequate recognition of patterns of arthritis other than that of polyarticular disease. Disclosure of Interest None Declared

Background Several classification criteria for Psoriatic Arthritis (PsA) have been proposed, being CASPAR criteria the most accepted at present. Recently ASAS has proposed classification criteria for patients with axial and peripheral spondyloarthritis, which have not been assessed in patients with psoriasis. Objectives To determine the prevalence of PsA according to CASPAR criteria, and to compare such prevalence with that resulting from the use of ASAS peripheral and axial criteria, and New York criteria for AS. Methods The first 100 patients that consecutively attended a Psoriasis clinic of a Dermatology Service were assessed. Demographic and clinical data were collected, and all patients were questioned and examined by a rheumatologist for joint manifestations. In all cases, rheumatoid factor was determined and radiographies of hands, feet, cervical spine and pelvis for sacroiliac joints were obtained. All X-rays were read independently by two observers in blind fashion. Patients with objective joint manifestations, both axial and peripheral, were considered to fulfill CASPAR, ASAS peripheral and axial, and New York criteria. Correlations were calculated by Spearman’s test. Categorical variables were compared by x 2 , and continuous variables were compared by Student’s test Results Of the 100 patients included(62 males), median age was 48 years and median duration of psoriasis of 11 years. 93% of patients presented psoriasis vulgaris, and 56% nail involvement. Seventeen patients had peripheral arthritis, mono or oligoarticular in 9 and polyarticular in 8. Median time of arthritis duration was of 8 years. Seven patients had chronic neck pain while 6 had chronic back pain. 13 patients had cervical limitation and 6 patients lumbar limitation. Radiographic sacroiliitis grade 2 and 3 was fiund in 12% of patients, and grade 4 in 2%, being symmetric in 7% of patients. At a cervical level, 10 patients had syndesmophytes whereas 3 had interapophyseal ankylosis. Of all patients, 17% fulfilled CASPAR and ASAS peripheral criteria, 6% New York and 5% ASAS axial criteria. Patients who met CASPAR criteria showed significantly higher time of psoriasis duration compared to those without arthritis ( m 16 vs 10 years p=0.02), and a higher frequency of nail disease (88.2% vs 49.4% p=0.003). Five patients (29.4%) fulfilled ASAS axial criteria; all of them had peripheral involvement: mono/oligoarticular in 3 and polyarticular in 2 patients. Patients with peripheral and axial involvement presented a significantly higher frequency of erythrodermic psoriasis compared to the other patients (35.3% vs 1.2% p=0.0006 and 80% vs 16.7% p=0.02). Among the 95 patients without ASAS axial criteria, 9 showed sacroiliitis grade 2 or higher. Among the 83 patients without arthritis, only 1 presented peripheral radiological changes, whereas 5 presented sacroiliitis grade 2 or 3 Conclusions Prevalence of PsA, for both CASPAR and ASAS peripheral criteria, was 17%. According to ASAS criteria, 5% of patients presented axial involvement, while 6% had axial involvement according to New York criteria. All cases with arthritis presented a higher frequency of nail involvement and skin severity. It is worth noting that few patients without signs or symptoms of arthritis presented radiological changes, both axial and peripheral, avoiding a proper classification. Disclosure of Interest None Declared

Background Nail psoriasis is acknowledged to be associated with Psoriatic Arthritis (PsA). Onycho-Psoriasis (ONPS), however, is extremely common in psoriatic population and correlate poorly with skin involvement. Further, not all clinical subsets of PsA may be linked to ONPS. Objectives Our aim was to investigate clinical risk factors predictive for PsA in a population of psoriatic subjects. Methods Patients were enrolled in a dermatological clinic dedicated to psoriasis care. Subjects reporting muscolo-skeletal discomfort and/or articular swelling were referred to rheumatologist. Dermatological features (PASI score, age of onset, previous/current therapies) were recorded. Rheumatological parameters encompassed joint counts (tender, swollen, damaged), entheses counts and others as suggested in the international consensus. Patients also underwent radiographic evaluation of painful areas. PsA diagnosis was established through rheumatologist opinion. After univariate analysis for possible risk factors, a multivariate model was built for unconditional logistic regression. Statistical significance was set on P Results Overall, among 1200 subjects followed up at our center, 277 consecutive patients were evaluated (131 males). The mean age was 55.7 years (SD 13; median 58, range 21-81), 79.1% suffered from plaque psoriasis (41.8% had nail disease, 2.8% isolated ONPS). Median PASI score was 3.1 (IQR 1.2-5.8), 12.3% of patients had a score of 10 or more. Only 16% of patients had a previous diagnosis of PsA. We diagnosed 110 PsA, 59.1% of whom as consequence of enrolment. PsA was early (onset within 1 year since enrolment) in 33.6%. PsA was classified in 82.7% of cases as peripheral arthritis, 34.5% of patients had dactylitis and 15.5% showed axial disease. Radiographic damage due to PsA was present in 38.2% of cases. At univariate level, risk factors for PsA were: male sex; younger age at enrolment and at psoriasis onset. The multivariate analysis (shown in table 1) confirmed statistical significance only for male sex, although at low level (95% CI 1.3-3.9). Conclusions PsA seems to be hardly linkable to clinical parameters easily available in daily dermatological practice. Above all, our data alert for the first time that the mere presence of nail psoriasis does not confer increased risk for PsA. Disclosure of Interest None Declared

Background In the era of modern anti-rheumatic therapy, it is now possible to contemplate the idea of clinical remission in patients with psoriatic arthritis (PsA) 1 . It is however unknown whether patients in clinical remission can stop methotrexate (MTX) or tumor necrosis factor inhibitor (TNFi) treatment 2 . Objectives To investigate drug-free remission in patients with PsA and potential predictors for flare. Methods Patients with PsA in remission (no musculoskeletal symptoms, no or minimal skin/nail disease) for at least 6 months were included. At baseline the following parameters were assessed: age, sex, BMI, disease duration, duration of remission, swollen joint count, tender joint count, VAS-pain, VAS-global, NAPSI, PASI, MASES, LDI, HAQ-DI, SF-36, FACIT-F, anti-rheumatic therapy (MTX, TNFi), ESR and CRP. In addition, ultrasound of 20 joints and 20 enthesis was performed. After discontinuation of therapy at day 1, patients were followed for 6 months for the occurrence of flares. Results 26 patients (20 males, 6 females) were enrolled. Mean ± SD age was 55 ± 14 years, mean ± SD disease duration was 6.1 ± 6.2 years, mean ± SD duration of remission was 23.9 ± 23.7 months. 15 patients received MTX monotherapy, 11 were treated with TNFi (6 in combination with MTX). We observed a high incidence of flares (76.9%, N= 20), with flares occurring relatively early (74.50 ± 50.79 days). There was no difference in flare rates between the MTX and TNFi groups. Due to our low number of patients, predictors of flare could not be determined but some important trends were observed. Male patients were more likely to flare (OR=18.00; [95%CI: 1.92-168.99]; p=0.011); patients with lower BMI (U=33.50, z=-1.61, p=0.107, r=0.32) and longer disease duration (U=35.50, z=-1.51, p=0.132, r=0.30) showed medium effect trends to flare. Further, presence of calcifications at the enthesial sites was associated with flares (U=33.50, z=-1.50, p=0.133, r=0.30). Conclusions This study showed a high incidence of flare in patients with PsA after discontinuing therapy. Although remission in PsA is an obtainable goal, drug-free remission may not be realistic for the majority of patients. Our study suggests that some baseline characteristics, such as male sex, low BMI, longer disease duration and enthesial calcifications predict flares of PsA after discontinuation of anti-rheumatic therapy. References Kavanaugh A., Fransen J., Defining remission in psoriatic arthritis. Clin Exp Rheumatol 2006: 24(Suppl. 43): S83-S87. Saber TP, et al., Remission in psoriatic arthritis: is it possible and how can it be predicted? Arthritis Research & Therapy 2010, 12:R94. Disclosure of Interest None Declared

Psoriatic Arthritis (PsA) is a complex multisystem disease with involvement of synovial structures, entheseal sites, spine, and skin and nails all common features. The extended clinical phenotype has recently received some attention with obesity, hypertension, Type 2 Diabetes Mellitus, hypercholesterolemia and metabolic syndrome all found more frequently in PsA as compared to controls. An excess of cardiovascular-related events including early mortality is a likely consequence. Radiographic change is also heterogeneous with features including erosive disease and osteolysis and also new bone formation, sacroiliitis and ankylosis. Disease activity measures in PsA have either focused on joint or skin disease or have been borrowed from rheumatoid arthritis. The Psoriatic Arthritis Response Criteria (PsARC) was developed as a specific PsA response measure but the measure is dichotomous and poorly discriminates responders from placebo. More recently, a number of composite disease activity measures have been proposed. These measures are designed to capture disease activity across all of the involved domains; as not all domains are active in all individuals with PsA and as there may be a differential treatment response, ideally it should also be possible to access disease activity and response in individual domains as well. The individual composite measures and their relative performance in clinical trial data to date will be presented and discussed. Measuring disease severity may well relate to disease activity but this is yet to be clearly demonstrated. There would be little argument with the statement that patients with the arthritis mutilans phenotype have severe disease but there are many patients with polyarticular disease and high inflammatory markers who do not develop this severe phenotype. Severe disease whether it is defined on the basis of radiographic change, severe skin/nail disease, some of the cardiovascular risk factors such as presence of the metabolic syndrome or even some composite score requires further study in order to identify as early as possible risk factors which predict its development. Some recent results based on analysis of detailed clinical and genetic data will be presented. If risk factors are modifiable or if early treatment intervention for patients with potentially severe disease can bring about a change in outcome, then some progress for PsA patients will have been made. Disclosure of Interest O. Fitzgerald Grant/research support from: Pfizer, Abbott, BMS, Roche, Merck

A 54-year-old diabetic female patient with type 2 diabetes of 7 years’ duration presented with pain in her big toe. She had previously sustained foot ulceration several times and hence worried for recurrence. On examination she had a laminated, thickened, dark yellow toe nail of an extremely rare structure (figure1). Figure 1 Laminated, thickened, dark …

The authors present two patients referred by colleagues after traumatic hand injury. However, upon closer inspection, both patients had pigmented lesions under the nail bed, which upon biopsy showed proven subungual malignant melanoma. The authors wish to emphasise the importance of this diagnosis, especially in emergency care.

A 67-year-old Caucasian male presented with persistent diarrhoea, weight loss of 15 kg in 3 months, and onychodystrophy. Family history is negative for colon carcinoma. He worked in oil trading and had extensive exposure to sulfuric acid, ammonia and gum resin. Physical examination revealed a vaguely palpable mass and tenderness in the left lower abdominal quadrant. Onycholysis of the fingernails (figure 1) and toenails, alopecia (figure 2) and hyperpigmentation of the skin were noted. CT demonstrated two circular thickenings in the sigmoid and colon ascendens. A …

Capsule endoscopy in the management of a patient with a rare syndrome--yellow nail syndrome with intestinal lymphangiectasia.

An 8 year old boy with a history of perinatally acquired HIV, who was CDC immunological category 3 (T CD4+ = 4/μl),1 and had been treated for six years with zidovudine and ritonavir, developed white lines in all fingernails three months after having pneumonia (fig 1). The …

The Netherlands Pharmacovigilance Centre Lareb received five reports concerning photo-onycholysis associated with the use of doxycycline (table). All five patients used 200 mg of doxycycline a day for the prophylactic treatment of Lyme disease after tick bite. In all cases the affected nails had been exposed to the sun during the summer. All patients showed (partial) recovery after several months. To our …

A short cut review was carried out to establish whether antibiotic prophylaxis is indicated after trephining of a subungual haematoma. Two papers were found using the reported search, of which neither presented any evidence to answer the clinical question. It is concluded that there is no evidence available to answer this question. Further research is needed.

EDITOR—The patient in the case presented by Moule et al in Minerva had several narrow transverse white bands on her nail plates after receiving five cycles of combined chemotherapy for non-Hodgkin's lymphoma.1 We studied …

Editor—Evans and Sigurgeirsson show that one form of treatment for toenail onychomycosis (continuous terbinafine) is significantly better than another (intermittent itraconazole).1 But I find it disturbing that the journal has given such prominence (the first paper in the journal and the first item in This Week in the BMJ) to a comparative drug trial of two well established drugs that was financed entirely by the manufacturer of one of the drugs. The introduction to the paper cites a prevalence of onychomycosis of 2-4%, yet the study population consisted of patients with severe onychomycosis (on average a 10 year history with six toenails affected; this fact is tucked away in the last paragraph). No evidence is presented to show the relevance of the study to a wider population of patients with mild or moderate onychomycosis. The optimistic key message (repeated in This Week in the BMJ) that “fungal nail disease is curable” is correct only in the sense that about half of the patients who took terbinafine showed a complete cure at 72 weeks. This accords with Epstein's recent review of the success of oral treatment of onychomycosis.2 Would it not have been equally true (although more pessimistic, and certainly less promotional) to say “fungal nail disease is incurable”? The paper states: “As with the mycological cure rates the clinical cure rates for the continuous terbinafine groups continued to increase after treatment through to week 72. This was not the case for the intermittent itraconazole groups.” The graphs on p 1034, however, tell a different story. They show that the cure rates for both forms of treatment continued to increase substantially after treatment stopped. I was particularly disturbed to see that the authors acknowledged the “constant help and guidance throughout this project” of an employee of Novartis Pharmaceuticals Corporation. Why, I asked myself, was it necessary to have the constant help and guidance of the manufacturer of one of the drugs being studied? As a general practitioner who often receives letters from podiatrists asking me to prescribe 12-16 week courses of systemic terbinafine for relatively mild and insignificant nail discoloration, I am also concerned about the cost (£134-£178) and the cost-benefit analysis of such treatment. I predict that the paper's final key message—“Continuous terbinafine should be the current treatment of choice for onychomycosis”—will soon appear in promotional material for terbinafine. But is it a claim that should be made in the scientific pages of the BMJ, or should it be confined to the advertisements?

Out of 300 patients who had taken benoxaprofen for a mean of 6.4 months, 196 (65.3%) reported side effects, resulting in 104 patients (34.6%) having the drug withdrawn. Out of 42 patients aged over 70, 35 (83.3%) had side effects and 29 (69.0%) had the drug withdrawn because of them. cutaneous side effects accounted for 180 (69.5%) of all 259 side effects reported. The commonest cutaneous side effect was photosensitivity, which occurred in 86 patients (28.6%). Photosensitivity, which occurred in half of the patients treated in the summer, resulted in withdrawal of benoxaprofen in 26 (30.2%) of the patients who experienced it. Onycholysis was observed in 38 patients (12.6%) and was frequently unnoticed by patients. The overall incidence of gastric side effects was 12.6% (38 patients), and the figure rose to 40.5% (17 cases) in patients over 70. During treatment with benoxaprofen one patient developed an active duodenal ulcer but no cases of major gastrointestinal haemorrhage occurred. Multiple subepidermal cysts (milia) were observed in 16 patients, who had been treated for a mean of 10.8 months. These findings show that benoxaprofen is a potent phototoxic drug and that the manufacturers' recommended dosage of 600 mg daily is associated with an unacceptable incidence of side effects in the elderly.

Nail beading has previously been reported as an accompaniment of rheumatoid arthritis. In order to assess the clinical significance of this form of nychodystrophy the fingernails and toenails of 119 patients with rheumatoid arthritis and an equal number of control subjects were studied. Analysis of data based on 4642 nails indicates that the presence of a global pattern of beading (i.e. greater than or equal to 50% involvement of the nail area) on the surface of at least six fingernails or four toenails is highly suggestive of underlying rheumatoid disease. The positive predictive value of these configurations is in the order of 95%. Nail beading, however, is infrequent in early disease and therefore its diagnostic value is limited. Although there is a strong association between nail beading and rheumatoid arthritis, the aetiology and prognostic implications of this clinical sign remain obscure.

In 1964 Samman and White described 13 patients with lymphoedema of the lower extremities associated with an unusual dystrophy of the finger and toe nails: this they termed the 'yellow-nail' syndrome. Affected nails were thickened, excessively curved along both axes, very slow growing and of yellowish-grey hue; cuticle and lunula were usually absent and onycholysis was frequently evident. Lower limb lymphangiography in most individuals revealed hypoplasia, or aplasia of the lymphatics, similar to that occurring in primary lymphoedema: other patients also developed pleural effusions of high protein content or ascites suggestive of a more generalised disorder of the lymphatic system. Here we describe a patient in whom the classical 'yellow-nail' syndrome was associated with intestinal and chylous ascites.

Chylous ascites has rarely been reported in yellow nail syndrome. A case of chylous ascites in yellow nail syndrome is described which was treated successfully with dietary restriction of fat and supplements of medium chained triglycerides.