Long-Pulsed Nd:YAG Laser Treatment of Nail Psoriasis: Clinical and Ultrasonographic Assessment

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The 1064nm Nd:YAG laser was reported to yield satisfactory results in the treatment of nail psoriasis. OBJECTIVE To assess the clinical and ultrasonographic efficacy of long-pulsed 1064nm Nd:YAG laser in the treatment of fingernail psoriasis and compare its effect to control fingernails. METHODS This intra-patient randomized controlled trial analyzed 86 fingernails collected from 13 patients suffering from cutaneous and nail psoriasis. The nails were randomized into two groups. Group A was treated with Nd:YAG laser once monthly for three sessions while group B served as control. Assessment took place at baseline, 1 and 3 months after the last treatment session. For scoring, the 32-points target NAPSI scoring systems was used. Additionally, two blinded dermatologists’ score of improvement, patients’ pain assessment by visual analogue score and ultrasonographic assessment were all performed. RESULTS At the end of follow up, the medians of tNAPSI score, plate definition, matrix thickness, bed thickness and bed vascularity decreased significantly in the Nd:YAG laser treated group in comparison to baseline ( p = 0.001 , 0.006 , 0.039 , < 0.001 and 0.010 , respectively). While, there was a non-significant reduction in median tNAPSI score in the control group at last follow up, however, ultrasonography recorded a significant reduction in the medians of plate definition, bed thickness and vascularity ( p = 0.002 , 0.011 and 0.033 , respectively) from the baseline. Comparison of the Nd:YAG laser and the control groups showed no significant difference from baseline regarding the medians of tNAPSI, tNAPSI percentile improvement, pits count, blinded evaluation of photographs and ultrasonographic assessments. CONCLUSION Nd:YAG laser showed clinical and ultrasonographic improvement in fingernail psoriasis. Ultrasonography is a useful noninvasive tool in diagnosing and monitoring the clinical and even the subclinical changes in nail psoriasis. Nail psoriasis although difficult to treat, may show spontaneous improvement. Nd:YAG laser ultrasonography target NAPSI nail psoriasis Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Figure 9 INTRODUCTION Nail psoriasis (NP) is a chronic, difficult to treat clinical presentation of psoriasis, associated with greater severity of the disease, characterized by a higher risk and earlier onset of psoriatic arthritis. Accordingly, it can be painful, and may be associated with anxiety and depression with significant functional impairment and reduction of the quality of life. 1 The prevalence of NP varies widely and prevalence studies are rare. Augustin et al. (2010) reported 40.9% of 3531 German patients with psoriasis during the years 2005 and 2007 in a cross-sectional study complained of NP, Armesto et al. (2011) undertook a prospective case-control study on 661 Spanish patients with psoriasis between 2007 and 2009 and reported that 47.4% of them had NP and, El-Komy et al. (2020) conducted a retrospective single-center study on 2534 Egyptian patients with psoriasis during the period from 2015 to 2018 and found that nail involvement was present among 524 (20.7%) of the patients. 2–4 Treatment of NP is challenging as the clinical improvement takes time to be observed and treatment is often met with poor compliance. 5 Therapies include patient’s education, topical, intra-lesional and systemic treatments, including biological therapies. Therapies are selected according to the disease severity, presence of comorbidities, and the impact of psoriatic nail dystrophy on the patient’s quality of life due to impaired function, pain, and aesthetics. 6 Laser modalities gained much attention in the treatment of NP; due to their penetrability into nail bed and/or nail matrix. 7 The 595nm pulsed dye laser results showed significant improvement in treatment of NP, but causes some pain and leaves transient petechiae, hyperpigmentation and purpura. 8 Also, the 1064nm neodymium doped: Yttrium Aluminum Garnet (Nd:YAG) laser was used in the treatment of NP, based on selective photo-thermolysis of hemoglobin mainly, to target the dermal vasculature of the nail bed with satisfactory results. 9–11 High-frequency ultrasound (US) with power Doppler (PD) assessment provides details of nails’ soft tissue structures and microvasculature. Thickened nail bed and matrix, alteration of nail plate definition and nail bed vascularization are the major US manifestation of nail psoriasis. 12 The aim of this study was to assess clinically and by ultrasonography the efficacy of Nd:YAG laser in the treatment of fingernail psoriasis and to compare its effect with control fingernails. PATIENTS AND METHODS Subjects This randomized controlled study included 13 psoriasis vulgaris patients with evidence of nail psoriasis affecting at least six fingernails, recruited from Kasr Al-Aini Psoriasis Unit (KAPU), Cairo University and the dermatology clinic of the National Research Center (NRC), Egypt. All patients received an explanation of the steps of the study and signed an informed consent to participate in the study. The study was approved by the ethical committee of the National Institute of Laser Enhanced Sciences (NILES), Giza, Egypt with reference number “NILES-EC-CU 23/12/27”. Patients were excluded if they received any systemic therapies for psoriasis in the last 6 months or any topical treatments for the last two weeks. Other exclusion criteria included patients with any other chronic illnesses and patients with proven onychomycosis. For all included recruits, each fingernail was dealt with as a different case to a total of 86 fingernails. The card randomization procedure was used to distribute the affected fingernails to receive either long-pulsed Nd:YAG 1064nm laser treatment or serve as control. Accordingly, 43 fingernails were included in group A to receive long-pulsed Nd:YAG 1064nm laser treatment and 43 fingernails were included in group B to serve as control (Fig. 1 ). Long-Pulsed 1064nm Nd:YAG Laser Long-pulsed Nd:YAG 1064nm laser was applied using the (Cynosure®, INC, 5 Carlisle Road, Westford, MA 01886, USA). Patients received 3 sessions with 1-month intervals, with 2 passes of energy 20 Joules/cm 2 , pulse duration 10ms and spot size 5mm, together with continuous cold air cooling. Assessment Methods: Clinical Assessment Assessments were done at the baseline, 1 month from last treatment session (EOS) and 2 months later at the last follow up (FU). For clinical scoring of nail psoriasis, we used the 32-points target NAPSI (tNAPSI) scoring system where nails were examined for pitting, leukonychia, lunular red spots, crumbling, onycholysis, subungual hyperkeratosis, salmon patches and splinter hemorrhages. 13 Nail pits were counted and analyzed separately at every evaluation point. Assessment included photography using a digital camera (Canon DS126291, CANON INC. Taiwan) and a dermoscope (Dermlite DL4, USA) to be evaluated by two blinded dermatologists experienced in psoriasis management at FU according to the physician's global assessment of fingernail psoriasis score that ranged from 0–4 corresponding to clear, minimal, mild, moderate and severe. 14 Ultrasonographic Assessment A musculoskeletal ultrasound evaluation was carried out at the baseline and FU using a GE LOGIQ P6 device (Model 183995SUO, India) in conjunction with a high-frequency broadband linear array transducer (10-13MHz). The settings for Doppler were a 500Hz pulse repetition frequency, with color gain optimized for optimal sensitivity while minimizing excessive color noise. The patients were seated with their forearms, hands, and fingers in a neutral and relaxed posture on a table, and their fingernails were scanned longitudinally. To ensure an adequate acoustic interface and prevent compression of the structures, a thick gel layer was applied. The severity of psoriatic nail changes was assessed using the Wortsman’s classification (0–4), which includes Grade 0 (normal nail plate consisting of two parallel hyperechoic bilaminar bands together with a virtual anechoic space between them), Grade I (focal hyperechoic involvement of the ventral nail plate without involvement of the dorsal nail plate), Grade II (continuous loss of the borders of the ventral nail plate), Grade III (wavy plates without blurring of both plates), and Grade IV (loss of definition of both nail plates). 15 The thickness of the hypoechoic nail bed was measured as the maximum distance between the ventral plate of the nail and the edge of the phalangeal bone, while the thickness of the isoechoic area of the nail matrix was measured at the proximal end of the nail bed. The vascularity of the nail bed was assessed using the power Doppler (PD) technique on a scale of 0 to 3, with 0 indicating no PD signal (normal), Grade I indicating a signal present in less than 25% of the examined area, Grade II indicating a signal present on 25% but less than 50% of the examined area, and Grade III indicating a signal present on 50% or more of the examined area. 16 Patients’ Self-Assessment Patients were asked to report the degree of pain they felt during the first session for Nd:YAG laser through the pain visual assessment score (0–10) where “0” =no pain, “1–3” =mild pain, “4–6” =moderate to severe, “7–9” =very severe and “10” =worst pain possible. 17 Statistical Analysis Sample size: Using the Power Analysis and Sample Size (PASS) 11th release, 18 a sample size of 21 nails in each group was calculated to have at least an 80% power to detect the differences at α = 0.050 between the Nd:YAG laser and control groups with total score mean ± SD at FU of 16.0 ± 5.8 and 22.85 ± 9.0, among Nd:YAG laser and placebo sides respectively. 11 We increased the sample for possible attrition up to 40 nails in each of the two studied groups. Data were coded and entered using the Statistical Package for the Social Sciences (SPSS) version 28, 2021 (IBM Corp., Armonk, NY, USA). Data was summarized using mean, standard deviation, median, minimum and maximum in quantitative data and using frequency (count) and relative frequency (percentage) for categorical data. For comparison of serial measurements within each patient the non-parametric Wilcoxon signed rank test was used, comparisons between quantitative variables were done using the non-parametric Mann-Whitney test. 19 For comparing categorical data, Chi square (χ2) test was performed. Exact test was used instead when the expected frequency is less than 5. 20 Testing for inter-rater and intra-rater reliability was done using the Intra Class Coefficient (ICC) and Cronbach's alpha reliability coefficient with their 95% confidence interval (95%CI). 21 P-values less than 0.05 were considered as statistically significant. RESULTS Thirteen patients (86 fingernails), seven males and six females; completed the study and were analyzed. Patients ages ranged from 18–63 years with a median of 31 years, the duration of skin psoriasis ranged from 1–35 years with a median of 7 years and the duration of nail psoriasis ranged from 4 months-14 years with a median of 1.5 years. Six patients were cigarette smokers. Three patients had a family history of psoriasis. Urban residents were nine and four were rural residents. Twelve of the thirteen patients (92.3%) were manual workers. Changes in Target NAPSI and Pitting At baseline, we did not detect any significant differences between the studied groups regarding medians of tNAPSI scores and counted numbers of pits. Comparison between Nd:YAG laser and control groups at the end of FU did not show any statistically significant differences regarding the medians of tNAPSI score or pits count, and this was the case with both blinded dermatologists and ultrasonographic assessments as well. However, when groups were analyzed separately, there was a statistically significant difference in tNAPSI score between baseline and FU in group A ( p = 0.001), while in group B this was non-significant ( p = 0.054). The median percentage of improvement of tNAPSI score at FU in group A and B were 33.33% and 12.50%, respectively (Table 1 , Figs. 2 , 3 and 4 ). Table 1 Changes in target NAPSI scores and pits count at baseline and FU among studied groups. Group A (Nd:YAG) Group B (control) p value Median (range) Median (range) Target NAPSI Baseline 8 ( 2 – 18 ) p value = 0.001* 8 (0–15) p value = 0.054 0.501 FU 6 (0–14) 6 (0–16) 0.801 (%) Improvement 33.33% 12.50% 0.247 Pits count Baseline 4 (0–13) p value = 0.514 1 (0–9) p value = 0.181 0.133 FU 3 (0–18) 2 (0–15) 0.558 (%) Improvement 33.33% 28.57% 0.557 FU: Follow up after 3 month of last laser session. Data is presented as median and range (non-normally distributed). p < 0.05* is considered significant. Also, blinded dermatologists’ photographic assessment of clinical as well as dermoscopic photos showed statistically significant improvement at FU in group A when analyzed separately, while this was not the case in the control group except for dermoscopic evaluation of the 2nd observer (Figs. 5 , 6 ). Changes in Ultrasonography Ultrasonographic assessment of the Nd:YAG and control groups detected a statistically significant improvement in the median nail plate definition grade ( p = 0.006 and 0.002, respectively) at end of FU period. Median nail matrix thickness showed significant reduction in the Nd:YAG treated group ( p = 0.039) but not in the control group. Median nail bed thickness was reduced significantly in both Nd:YAG and control groups ( p < 0.001, 0.011, respectively) and bed vascularity grade also showed significant improvement in both groups ( p = 0.010, 0.033, respectively) (Table 2 , Figs. 7 , 8 and 9 ). Table 2 Analysis of baseline and follow up values of ultrasonographic findings among studied groups. Group A (Nd:YAG) Group B (control) p value Median (range) Median (range) Nail Plate Definition Baseline 1 (0–4) p = 0.006* 1 (0–4) p = 0.002* 0.883 FU 0 (0–4) 0 (0–4) 0.733 (%) Improvement 100% 100% 0.736 Nail Matrix Thickness (um) Baseline 16 ( 9 – 25 ) p = 0.039* 14 (08–22) p = 0.075 0.029* FU 14 (08–24) 14 ( 8 – 23 ) 0.108 (%) Improvement 12% 6% 0.870 Nail Bed Thickness (um) Baseline 18 ( 10 – 31 ) p < 0.001* 16 ( 8 – 25 ) p = 0.011* 0.034* FU 15 ( 9 – 23 ) 14 ( 8 – 23 ) 0.087 (%) Improvement 18% 16% 0.383 Nail Bed Vascularity Baseline 0 (0–3) p = 0.010* 0 (0–3) p = 0.033* 0.966 FU 0 (0–1) 0 (0–3) 0.666 (%) Improvement 100% 100% 0.186 FU: Follow up after 3 month of last laser session. um: Micrometer. Data is presented as median and range (non-normally distributed). p < 0.05* is considered significant. The median degree of pain assessed through the pain visual assessment score (from 0–10) after the first session with the long-pulsed Nd:YAG laser was 2 (0–4). DISCUSSION Treatment of nail psoriasis include topical, intra-lesional and systemic therapies selected according to the disease severity, its impact on the patient’s quality of life and comorbidities. 5 The penetrability of topical agents into the nail bed and/or matrix is essential to achieve therapeutic effect. 6 Nd:YAG laser, based on selective photo-thermolysis of hemoglobin, targets the dermal vasculature of the nail bed; the site of new changes occurring in psoriatic nail lesions. 9–11 In the current work treatment of NP with Nd:YAG laser was associated with significant improvements in tNAPSI, PGA and US measurements of matrix thickness in comparison to untreated nails with no adverse events reported in any of our patients. The improvement of NP with Nd:YAG treatments we observed as well as previous investigators 9–11,22 can be attributed to its ability to penetrate down to 5–6 mm in the tissue thus reaching the nail bed vascularity deep enough to target the abnormally increased vasculature in nail psoriasis by selective photo-thermolysis of hemoglobin. 23,24 In addition, Nd:YAG laser reduces T cytotoxic cells in the epidermis, and T helper cells and CD3 + lymphocytes in the dermis, which in turn normalizes the epidermal proliferation and improve the clinical signs of psoriasis. 10 It is worth mentioning that Elwan et al. (2021) did not find significant improvements with Nd:YAG laser Vs controls in a left to right sided comparison of NP treatment after 6 month. Unlike the current study, the latter authors included toenail psoriasis, used NAPSI score and applied one pass with spot size 2.5mm with laser energy of 110J/cm 2 to 130J/cm 2 . They assumed that this non-significance was because they treated both finger-and toenails and that toenails may be more resistant than fingernails. 25,26 In the current study, we observed a non-significant spontaneous improvement in our “ untreated ” control group as regards tNAPSI score and this was also observed in the blinded physicians’ PGA score. Surprisingly, this non-significant clinical improvement was associated with significant ultrasonographic changes suggestive of a tendency towards normalization of nail plate definition, nail bed thickness and vascularity. Such observations are not unusual, as the course of NP is unpredictable and it may improve spontaneously or show unexpected remissions and exacerbations. 25–29 These improvements we report for the control group may also be attributed to the small sample size, or the systemic effect of locally targeted laser and thermal energies. Anders et al. (2015) and Khalkhal et al. (2020) described that laser irradiation can alter cellular metabolism and cellular functions in the body. They reported that local photo-biomodulation can produce systemic effects and that local irradiation produces distant effects. In a study performed on rats, the application of laser on a standardized skin wound had systemic effects on the wounds located distally from the point of laser application. 30–32 LIMITATIONS The limitations in the present study were the relatively small sample. Also, the fact that 92.3% were manual workers and housewives using unprotected bare hands may have hindered the therapeutic effects desired from treatment. CONCLUSION In conclusion, Nd:YAG laser can be considered safe, efficacious, local method of treating nail psoriasis. Ultrasonography is a useful noninvasive diagnostic and follow up tool that helps in detection of even subclinical changes. Our results also confirm that, nail psoriasis although a treatment challenge; may sometimes improves spontaneously. RECOMMENDATION Further larger scale studies for extended time periods are needed to verify our results and investigate the usefulness of US monitoring of nail changes in the treatment of NP. Declarations Financial support and sponsorship: Nil Declaration of patient consent: The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published, and due efforts will be made to conceal their identity. Ethical committee approval: Approved Clinical trials registration: The trial was registered on ClinicalTrials.gov with the reference number “NCT05695833”. Authors Contribution: Conceptualization: [Mohamed Hussein Medhat El-Komy]; Methodology: [Mohamed Hussein Medhat El-Komy, Hagar El Sayed, Mohamed Ahmed Salem El-Basiony, Hala El Gendy]; Formal analysis and investigation: [Mohamed Ahmed Salem El-Basiony,]; Writing - original draft preparation: [Mohamed Ahmed Salem El-Basiony,]; Writing - review and editing: [Mohamed Hussein Medhat El-Komy, Hagar El Sayed]; Resources: [Mohamed Ahmed Salem El-Basiony]; Supervision: [Mohamed Hussein Medhat El-Komy, Nevien Ahmed Samy, Dalia Gamal Aly, Hala El-Gendy, Mohamed Fouad Abdel Salam Hassan, Hagar El Sayed, Mohamed Mohsen Soliman]. Conflict of interest: The authors declare no conflict of interest. References Canal-García E, Bosch-Amate X, Belinchón I, Puig L. [Translated article] Nail Psoriasis. Actas dermo-sifiliograficas. 2022 May 1;113(5):T481-90. Augustin M, Reich K, Blome C, Schäfer I, Laass A, Radtke MA. Nail psoriasis in Germany: epidemiology and burden of disease. 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Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 26 Apr, 2024 Reviewers agreed at journal 26 Apr, 2024 Reviewers invited by journal 26 Apr, 2024 Editor assigned by journal 12 Apr, 2024 Submission checks completed at journal 12 Apr, 2024 First submitted to journal 11 Apr, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4254041","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":292317852,"identity":"00eea239-19dc-4ab8-b290-c9d9f7f853fe","order_by":0,"name":"Mohamed Ahmed Salem El-Basiony","email":"","orcid":"","institution":"National Research Centre","correspondingAuthor":false,"prefix":"","firstName":"Mohamed","middleName":"Ahmed Salem","lastName":"El-Basiony","suffix":""},{"id":292317853,"identity":"ed2e3b43-c37e-4991-9949-e8529a995636","order_by":1,"name":"Mohamed Hussein Medhat El-Komy","email":"","orcid":"","institution":"Cairo 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Sayed","email":"data:image/png;base64,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","orcid":"","institution":"Cairo University","correspondingAuthor":true,"prefix":"","firstName":"Hagar","middleName":"El","lastName":"Sayed","suffix":""},{"id":292317859,"identity":"c717854d-6b2a-4317-8a19-31c2767be9f1","order_by":7,"name":"Mohamed Mohsen Soliman","email":"","orcid":"","institution":"National Institute of Laser Enhanced Sciences, Cairo University","correspondingAuthor":false,"prefix":"","firstName":"Mohamed","middleName":"Mohsen","lastName":"Soliman","suffix":""}],"badges":[],"createdAt":"2024-04-11 18:44:21","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4254041/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4254041/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":55322555,"identity":"0de9aa85-651a-4cd8-85d2-331f8e91bffc","added_by":"auto","created_at":"2024-04-25 16:28:33","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":34386,"visible":true,"origin":"","legend":"\u003cp\u003ePatients flow chart.\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-4254041/v1/6cb1494df68d4bbba2cba6a5.png"},{"id":55322554,"identity":"f9ca7810-aa20-4cb8-b8e4-97ddf326b9bc","added_by":"auto","created_at":"2024-04-25 16:28:33","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":11765,"visible":true,"origin":"","legend":"\u003cp\u003eChanges in median tNAPSI scores over time among studied groups.\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-4254041/v1/021b642ae0ff10ba1ac987a4.png"},{"id":55322556,"identity":"9d952046-c0cd-44c6-8a73-1fd74d078da8","added_by":"auto","created_at":"2024-04-25 16:28:33","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":12323,"visible":true,"origin":"","legend":"\u003cp\u003eChanges in median pits count over time among studied groups.\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-4254041/v1/cf7bac0e4362f42cc1f46c68.png"},{"id":55323173,"identity":"bc002ceb-c324-4c9b-a7c1-e325b14f81c6","added_by":"auto","created_at":"2024-04-25 16:36:33","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":163405,"visible":true,"origin":"","legend":"\u003cp\u003eClinical assessment of laser-treated and control nails of one patient at baseline and follow up.\u003c/p\u003e","description":"","filename":"Figure4.png","url":"https://assets-eu.researchsquare.com/files/rs-4254041/v1/3381a057779292a369d8f01c.png"},{"id":55322574,"identity":"1d30fb2a-968f-43fc-b21e-9b811a851236","added_by":"auto","created_at":"2024-04-25 16:28:33","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":12236,"visible":true,"origin":"","legend":"\u003cp\u003ePhysicians’ global assessment by first blinded dermatologist at FU.\u003c/p\u003e","description":"","filename":"Figure5.png","url":"https://assets-eu.researchsquare.com/files/rs-4254041/v1/5f97d997bf5472e9b79d5b7b.png"},{"id":55322575,"identity":"542bdbab-f1b8-4071-9b45-c11638e22245","added_by":"auto","created_at":"2024-04-25 16:28:33","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":12500,"visible":true,"origin":"","legend":"\u003cp\u003ePhysicians’ global assessment by second blinded dermatologist at FU.\u003c/p\u003e","description":"","filename":"Figure6.png","url":"https://assets-eu.researchsquare.com/files/rs-4254041/v1/fe8889d20d3aca7ea7a0549d.png"},{"id":55322573,"identity":"9523ea36-416c-486b-8462-c33a2557091b","added_by":"auto","created_at":"2024-04-25 16:28:33","extension":"png","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":13743,"visible":true,"origin":"","legend":"\u003cp\u003eUltrasonographic assessment at baseline and FU of nail plate definition grades (0-4) and nail bed vascularity grades (0-3).\u003c/p\u003e","description":"","filename":"Figure7.png","url":"https://assets-eu.researchsquare.com/files/rs-4254041/v1/87f3d037ba06fc4d7f342762.png"},{"id":55322576,"identity":"8120e282-115c-43a8-a414-bc403043a877","added_by":"auto","created_at":"2024-04-25 16:28:34","extension":"png","order_by":8,"title":"Figure 8","display":"","copyAsset":false,"role":"figure","size":12761,"visible":true,"origin":"","legend":"\u003cp\u003eUltrasonographic assessment at baseline and FU of nail matrix and bed thickness (um).\u003c/p\u003e","description":"","filename":"Figure8.png","url":"https://assets-eu.researchsquare.com/files/rs-4254041/v1/32c6d4451b988cb06e53fc0b.png"},{"id":55322578,"identity":"1fb2bac1-3ba6-4328-8995-7bfe6e2d2fe0","added_by":"auto","created_at":"2024-04-25 16:28:34","extension":"png","order_by":9,"title":"Figure 9","display":"","copyAsset":false,"role":"figure","size":140349,"visible":true,"origin":"","legend":"\u003cp\u003eUltrasonographic assessment of laser-treated and control nails of another patient at baseline and follow up.\u003c/p\u003e","description":"","filename":"Figure9.png","url":"https://assets-eu.researchsquare.com/files/rs-4254041/v1/c57f75b9f4365224bf63994d.png"},{"id":55323392,"identity":"b369f286-8af5-403b-8542-8641a6e59f01","added_by":"auto","created_at":"2024-04-25 16:44:34","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":953695,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4254041/v1/4a20dab1-a638-436b-ac02-74f5c39d6ce1.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Long-Pulsed Nd:YAG Laser Treatment of Nail Psoriasis: Clinical and Ultrasonographic Assessment","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eNail psoriasis (NP) is a chronic, difficult to treat clinical presentation of psoriasis, associated with greater severity of the disease, characterized by a higher risk and earlier onset of psoriatic arthritis. Accordingly, it can be painful, and may be associated with anxiety and depression with significant functional impairment and reduction of the quality of life.\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe prevalence of NP varies widely and prevalence studies are rare. \u003cb\u003eAugustin et al. (2010)\u003c/b\u003e reported 40.9% of 3531 German patients with psoriasis during the years 2005 and 2007 in a cross-sectional study complained of NP, \u003cb\u003eArmesto et al. (2011)\u003c/b\u003e undertook a prospective case-control study on 661 Spanish patients with psoriasis between 2007 and 2009 and reported that 47.4% of them had NP and, \u003cb\u003eEl-Komy et al. (2020)\u003c/b\u003e conducted a retrospective single-center study on 2534 Egyptian patients with psoriasis during the period from 2015 to 2018 and found that nail involvement was present among 524 (20.7%) of the patients.\u003csup\u003e2\u0026ndash;4\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eTreatment of NP is challenging as the clinical improvement takes time to be observed and treatment is often met with poor compliance.\u003csup\u003e5\u003c/sup\u003e Therapies include patient\u0026rsquo;s education, topical, intra-lesional and systemic treatments, including biological therapies. Therapies are selected according to the disease severity, presence of comorbidities, and the impact of psoriatic nail dystrophy on the patient\u0026rsquo;s quality of life due to impaired function, pain, and aesthetics.\u003csup\u003e6\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eLaser modalities gained much attention in the treatment of NP; due to their penetrability into nail bed and/or nail matrix.\u003csup\u003e7\u003c/sup\u003e The 595nm pulsed dye laser results showed significant improvement in treatment of NP, but causes some pain and leaves transient petechiae, hyperpigmentation and purpura.\u003csup\u003e8\u003c/sup\u003e Also, the 1064nm neodymium doped: Yttrium Aluminum Garnet (Nd:YAG) laser was used in the treatment of NP, based on selective photo-thermolysis of hemoglobin mainly, to target the dermal vasculature of the nail bed with satisfactory results.\u003csup\u003e9\u0026ndash;11\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eHigh-frequency ultrasound (US) with power Doppler (PD) assessment provides details of nails\u0026rsquo; soft tissue structures and microvasculature. Thickened nail bed and matrix, alteration of nail plate definition and nail bed vascularization are the major US manifestation of nail psoriasis.\u003csup\u003e12\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe aim of this study was to assess clinically and by ultrasonography the efficacy of Nd:YAG laser in the treatment of fingernail psoriasis and to compare its effect with control fingernails.\u003c/p\u003e"},{"header":"PATIENTS AND METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eSubjects\u003c/h2\u003e \u003cp\u003eThis randomized controlled study included 13 psoriasis vulgaris patients with evidence of nail psoriasis affecting at least six fingernails, recruited from Kasr Al-Aini Psoriasis Unit (KAPU), Cairo University and the dermatology clinic of the National Research Center (NRC), Egypt. All patients received an explanation of the steps of the study and signed an informed consent to participate in the study. The study was approved by the ethical committee of the National Institute of Laser Enhanced Sciences (NILES), Giza, Egypt with reference number \u0026ldquo;NILES-EC-CU 23/12/27\u0026rdquo;.\u003c/p\u003e \u003cp\u003ePatients were excluded if they received any systemic therapies for psoriasis in the last 6 months or any topical treatments for the last two weeks. Other exclusion criteria included patients with any other chronic illnesses and patients with proven onychomycosis.\u003c/p\u003e \u003cp\u003eFor all included recruits, each fingernail was dealt with as a different case to a total of 86 fingernails. The card randomization procedure was used to distribute the affected fingernails to receive either long-pulsed Nd:YAG 1064nm laser treatment or serve as control. Accordingly, 43 fingernails were included in group A to receive long-pulsed Nd:YAG 1064nm laser treatment and 43 fingernails were included in group B to serve as control (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eLong-Pulsed 1064nm Nd:YAG Laser\u003c/h2\u003e \u003cp\u003eLong-pulsed Nd:YAG 1064nm laser was applied using the (Cynosure\u0026reg;, INC, 5 Carlisle Road, Westford, MA 01886, USA). Patients received 3 sessions with 1-month intervals, with 2 passes of energy 20 Joules/cm\u003csup\u003e2\u003c/sup\u003e, pulse duration 10ms and spot size 5mm, together with continuous cold air cooling.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eAssessment Methods:\u003c/h2\u003e \u003cdiv id=\"Sec6\" class=\"Section3\"\u003e \u003ch2\u003eClinical Assessment\u003c/h2\u003e \u003cp\u003eAssessments were done at the baseline, 1 month from last treatment session (EOS) and 2 months later at the last follow up (FU).\u003c/p\u003e \u003cp\u003eFor clinical scoring of nail psoriasis, we used the 32-points target NAPSI (tNAPSI) scoring system where nails were examined for pitting, leukonychia, lunular red spots, crumbling, onycholysis, subungual hyperkeratosis, salmon patches and splinter hemorrhages.\u003csup\u003e13\u003c/sup\u003e Nail pits were counted and analyzed separately at every evaluation point.\u003c/p\u003e \u003cp\u003eAssessment included photography using a digital camera (Canon DS126291, CANON INC. Taiwan) and a dermoscope (Dermlite DL4, USA) to be evaluated by two blinded dermatologists experienced in psoriasis management at FU according to the physician's global assessment of fingernail psoriasis score that ranged from 0\u0026ndash;4 corresponding to clear, minimal, mild, moderate and severe.\u003csup\u003e14\u003c/sup\u003e\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eUltrasonographic Assessment\u003c/h2\u003e \u003cp\u003eA musculoskeletal ultrasound evaluation was carried out at the baseline and FU using a GE LOGIQ P6 device (Model 183995SUO, India) in conjunction with a high-frequency broadband linear array transducer (10-13MHz). The settings for Doppler were a 500Hz pulse repetition frequency, with color gain optimized for optimal sensitivity while minimizing excessive color noise. The patients were seated with their forearms, hands, and fingers in a neutral and relaxed posture on a table, and their fingernails were scanned longitudinally. To ensure an adequate acoustic interface and prevent compression of the structures, a thick gel layer was applied.\u003c/p\u003e \u003cp\u003eThe severity of psoriatic nail changes was assessed using the Wortsman\u0026rsquo;s classification (0\u0026ndash;4), which includes Grade 0 (normal nail plate consisting of two parallel hyperechoic bilaminar bands together with a virtual anechoic space between them), Grade I (focal hyperechoic involvement of the ventral nail plate without involvement of the dorsal nail plate), Grade II (continuous loss of the borders of the ventral nail plate), Grade III (wavy plates without blurring of both plates), and Grade IV (loss of definition of both nail plates).\u003csup\u003e15\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe thickness of the hypoechoic nail bed was measured as the maximum distance between the ventral plate of the nail and the edge of the phalangeal bone, while the thickness of the isoechoic area of the nail matrix was measured at the proximal end of the nail bed.\u003c/p\u003e \u003cp\u003eThe vascularity of the nail bed was assessed using the power Doppler (PD) technique on a scale of 0 to 3, with 0 indicating no PD signal (normal), Grade I indicating a signal present in less than 25% of the examined area, Grade II indicating a signal present on 25% but less than 50% of the examined area, and Grade III indicating a signal present on 50% or more of the examined area.\u003csup\u003e16\u003c/sup\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003ePatients\u0026rsquo; Self-Assessment\u003c/h2\u003e \u003cp\u003ePatients were asked to report the degree of pain they felt during the first session for Nd:YAG laser through the pain visual assessment score (0\u0026ndash;10) where \u0026ldquo;0\u0026rdquo; =no pain, \u0026ldquo;1\u0026ndash;3\u0026rdquo; =mild pain, \u0026ldquo;4\u0026ndash;6\u0026rdquo; =moderate to severe, \u0026ldquo;7\u0026ndash;9\u0026rdquo; =very severe and \u0026ldquo;10\u0026rdquo; =worst pain possible.\u003csup\u003e17\u003c/sup\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eSample size: Using the Power Analysis and Sample Size (PASS) 11th release,\u003csup\u003e18\u003c/sup\u003e a sample size of 21 nails in each group was calculated to have at least an 80% power to detect the differences at α\u0026thinsp;=\u0026thinsp;0.050 between the Nd:YAG laser and control groups with total score mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD at FU of 16.0\u0026thinsp;\u0026plusmn;\u0026thinsp;5.8 and 22.85\u0026thinsp;\u0026plusmn;\u0026thinsp;9.0, among Nd:YAG laser and placebo sides respectively.\u003csup\u003e11\u003c/sup\u003e We increased the sample for possible attrition up to 40 nails in each of the two studied groups.\u003c/p\u003e \u003cp\u003eData were coded and entered using the Statistical Package for the Social Sciences (SPSS) version 28, 2021 (IBM Corp., Armonk, NY, USA). Data was summarized using mean, standard deviation, median, minimum and maximum in quantitative data and using frequency (count) and relative frequency (percentage) for categorical data. For comparison of serial measurements within each patient the non-parametric Wilcoxon signed rank test was used, comparisons between quantitative variables were done using the non-parametric Mann-Whitney test.\u003csup\u003e19\u003c/sup\u003e For comparing categorical data, Chi square (χ2) test was performed. Exact test was used instead when the expected frequency is less than 5.\u003csup\u003e20\u003c/sup\u003e Testing for inter-rater and intra-rater reliability was done using the Intra Class Coefficient (ICC) and Cronbach's alpha reliability coefficient with their 95% confidence interval (95%CI).\u003csup\u003e21\u003c/sup\u003e P-values less than 0.05 were considered as statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003eThirteen patients (86 fingernails), seven males and six females; completed the study and were analyzed. Patients ages ranged from 18\u0026ndash;63 years with a median of 31 years, the duration of skin psoriasis ranged from 1\u0026ndash;35 years with a median of 7 years and the duration of nail psoriasis ranged from 4 months-14 years with a median of 1.5 years. Six patients were cigarette smokers. Three patients had a family history of psoriasis. Urban residents were nine and four were rural residents. Twelve of the thirteen patients (92.3%) were manual workers.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eChanges in Target NAPSI and Pitting\u003c/h2\u003e \u003cp\u003eAt baseline, we did not detect any significant differences between the studied groups regarding medians of tNAPSI scores and counted numbers of pits. Comparison between Nd:YAG laser and control groups at the end of FU did not show any statistically significant differences regarding the medians of tNAPSI score or pits count, and this was the case with both blinded dermatologists and ultrasonographic assessments as well.\u003c/p\u003e \u003cp\u003eHowever, when groups were analyzed separately, there was a statistically significant difference in tNAPSI score between baseline and FU in group A (\u003cem\u003ep\u0026thinsp;=\u003c/em\u003e\u0026thinsp;0.001), while in group B this was non-significant (\u003cem\u003ep\u0026thinsp;=\u003c/em\u003e\u0026thinsp;0.054). The median percentage of improvement of tNAPSI score at FU in group A and B were 33.33% and 12.50%, respectively (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, Figs.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e and \u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eChanges in target NAPSI scores and pits count at baseline and FU among studied groups.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c2\" namest=\"c1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eGroup A (Nd:YAG)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eGroup B (control)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e p value\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eMedian (range)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eMedian (range)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eTarget NAPSI\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eBaseline\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003cp\u003e(\u003cspan additionalcitationids=\"CR3 CR4 CR5 CR6 CR7 CR8 CR9 CR10 CR11 CR12 CR13 CR14 CR15 CR16 CR17\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ep value\u0026thinsp;=\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8\u003c/p\u003e \u003cp\u003e(0\u0026ndash;15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ep value\u0026thinsp;=\u0026thinsp;0.054\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.501\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eFU\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003cp\u003e(0\u0026ndash;14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6\u003c/p\u003e \u003cp\u003e(0\u0026ndash;16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.801\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e(%) Improvement\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e33.33%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e12.50%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.247\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003ePits count\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eBaseline\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003cp\u003e(0\u0026ndash;13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ep value\u0026thinsp;=\u0026thinsp;0.514\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e(0\u0026ndash;9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ep value\u0026thinsp;=\u0026thinsp;0.181\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.133\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eFU\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003cp\u003e(0\u0026ndash;18)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003cp\u003e(0\u0026ndash;15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.558\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e(%) Improvement\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e33.33%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e28.57%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.557\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eFU: Follow up after 3 month of last laser session. Data is presented as median and range (non-normally distributed). \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05* is considered significant.\u003c/p\u003e \u003cp\u003eAlso, blinded dermatologists\u0026rsquo; photographic assessment of clinical as well as dermoscopic photos showed statistically significant improvement at FU in group A when analyzed separately, while this was not the case in the control group except for dermoscopic evaluation of the 2nd observer (Figs.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e, \u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eChanges in Ultrasonography\u003c/h2\u003e \u003cp\u003eUltrasonographic assessment of the Nd:YAG and control groups detected a statistically significant improvement in the median nail plate definition grade (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.006 and 0.002, respectively) at end of FU period. Median nail matrix thickness showed significant reduction in the Nd:YAG treated group (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.039) but not in the control group. Median nail bed thickness was reduced significantly in both Nd:YAG and control groups (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001, 0.011, respectively) and bed vascularity grade also showed significant improvement in both groups (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.010, 0.033, respectively) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, Figs.\u0026nbsp;\u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e7\u003c/span\u003e, \u003cspan refid=\"Fig8\" class=\"InternalRef\"\u003e8\u003c/span\u003e and \u003cspan refid=\"Fig9\" class=\"InternalRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAnalysis of baseline and follow up values of ultrasonographic findings among studied groups.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c2\" namest=\"c1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eGroup A (Nd:YAG)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eGroup B (control)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ep value\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eMedian (range)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eMedian (range)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eNail Plate Definition\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eBaseline\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e(0\u0026ndash;4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.006*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e(0\u0026ndash;4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.002*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.883\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eFU\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003cp\u003e(0\u0026ndash;4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003cp\u003e(0\u0026ndash;4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.733\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e(%) Improvement\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e100%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e100%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.736\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eNail Matrix Thickness (um)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eBaseline\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16\u003c/p\u003e \u003cp\u003e(\u003cspan additionalcitationids=\"CR10 CR11 CR12 CR13 CR14 CR15 CR16 CR17 CR18 CR19 CR20 CR21 CR22 CR23 CR24\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.039*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e14\u003c/p\u003e \u003cp\u003e(08\u0026ndash;22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.075\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.029*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eFU\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14\u003c/p\u003e \u003cp\u003e(08\u0026ndash;24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e14\u003c/p\u003e \u003cp\u003e(\u003cspan additionalcitationids=\"CR9 CR10 CR11 CR12 CR13 CR14 CR15 CR16 CR17 CR18 CR19 CR20 CR21 CR22\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.108\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e(%) Improvement\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e12%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.870\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eNail Bed Thickness (um)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eBaseline\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18\u003c/p\u003e \u003cp\u003e(\u003cspan additionalcitationids=\"CR11 CR12 CR13 CR14 CR15 CR16 CR17 CR18 CR19 CR20 CR21 CR22 CR23 CR24 CR25 CR26 CR27 CR28 CR29 CR30\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e16\u003c/p\u003e \u003cp\u003e(\u003cspan additionalcitationids=\"CR9 CR10 CR11 CR12 CR13 CR14 CR15 CR16 CR17 CR18 CR19 CR20 CR21 CR22 CR23 CR24\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.011*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.034*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eFU\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003cp\u003e(\u003cspan additionalcitationids=\"CR10 CR11 CR12 CR13 CR14 CR15 CR16 CR17 CR18 CR19 CR20 CR21 CR22\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e14\u003c/p\u003e \u003cp\u003e(\u003cspan additionalcitationids=\"CR9 CR10 CR11 CR12 CR13 CR14 CR15 CR16 CR17 CR18 CR19 CR20 CR21 CR22\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.087\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e(%) Improvement\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e18%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e16%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.383\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eNail Bed Vascularity\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eBaseline\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003cp\u003e(0\u0026ndash;3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.010*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003cp\u003e(0\u0026ndash;3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.033*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.966\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eFU\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003cp\u003e(0\u0026ndash;1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003cp\u003e(0\u0026ndash;3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.666\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e(%) Improvement\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e100%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e100%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.186\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eFU: Follow up after 3 month of last laser session. um: Micrometer. Data is presented as median and range (non-normally distributed). \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05* is considered significant.\u003c/p\u003e \u003cp\u003eThe median degree of pain assessed through the pain visual assessment score (from 0\u0026ndash;10) after the first session with the long-pulsed Nd:YAG laser was 2 (0\u0026ndash;4).\u003c/p\u003e \u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eTreatment of nail psoriasis include topical, intra-lesional and systemic therapies selected according to the disease severity, its impact on the patient\u0026rsquo;s quality of life and comorbidities.\u003csup\u003e5\u003c/sup\u003e The penetrability of topical agents into the nail bed and/or matrix is essential to achieve therapeutic effect.\u003csup\u003e6\u003c/sup\u003e Nd:YAG laser, based on selective photo-thermolysis of hemoglobin, targets the dermal vasculature of the nail bed; the site of new changes occurring in psoriatic nail lesions.\u003csup\u003e9\u0026ndash;11\u003c/sup\u003e In the current work treatment of NP with Nd:YAG laser was associated with significant improvements in tNAPSI, PGA and US measurements of matrix thickness in comparison to untreated nails with no adverse events reported in any of our patients.\u003c/p\u003e \u003cp\u003eThe improvement of NP with Nd:YAG treatments we observed as well as previous investigators\u003csup\u003e9\u0026ndash;11,22\u003c/sup\u003e can be attributed to its ability to penetrate down to 5\u0026ndash;6 mm in the tissue thus reaching the nail bed vascularity deep enough to target the abnormally increased vasculature in nail psoriasis by selective photo-thermolysis of hemoglobin.\u003csup\u003e23,24\u003c/sup\u003e In addition, Nd:YAG laser reduces T cytotoxic cells in the epidermis, and T helper cells and CD3\u0026thinsp;+\u0026thinsp;lymphocytes in the dermis, which in turn normalizes the epidermal proliferation and improve the clinical signs of psoriasis.\u003csup\u003e10\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eIt is worth mentioning that \u003cb\u003eElwan et al. (2021)\u003c/b\u003e did not find significant improvements with Nd:YAG laser Vs controls in a left to right sided comparison of NP treatment after 6 month. Unlike the current study, the latter authors included toenail psoriasis, used NAPSI score and applied one pass with spot size 2.5mm with laser energy of 110J/cm\u003csup\u003e2\u003c/sup\u003e to 130J/cm\u003csup\u003e2\u003c/sup\u003e. They assumed that this non-significance was because they treated both finger-and toenails and that toenails may be more resistant than fingernails.\u003csup\u003e25,26\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eIn the current study, we observed a non-significant spontaneous improvement in our \u0026ldquo;\u003cem\u003euntreated\u003c/em\u003e\u0026rdquo; control group as regards tNAPSI score and this was also observed in the blinded physicians\u0026rsquo; PGA score. Surprisingly, this non-significant clinical improvement was associated with significant ultrasonographic changes suggestive of a tendency towards normalization of nail plate definition, nail bed thickness and vascularity. Such observations are not unusual, as the course of NP is unpredictable and it may improve spontaneously or show unexpected remissions and exacerbations.\u003csup\u003e25\u0026ndash;29\u003c/sup\u003e These improvements we report for the control group may also be attributed to the small sample size, or the systemic effect of locally targeted laser and thermal energies. \u003cb\u003eAnders et al. (2015)\u003c/b\u003e and \u003cb\u003eKhalkhal et al. (2020)\u003c/b\u003e described that laser irradiation can alter cellular metabolism and cellular functions in the body. They reported that local photo-biomodulation can produce systemic effects and that local irradiation produces distant effects. In a study performed on rats, the application of laser on a standardized skin wound had systemic effects on the wounds located distally from the point of laser application.\u003csup\u003e30\u0026ndash;32\u003c/sup\u003e\u003c/p\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eLIMITATIONS\u003c/h2\u003e \u003cp\u003eThe limitations in the present study were the relatively small sample. Also, the fact that 92.3% were manual workers and housewives using unprotected bare hands may have hindered the therapeutic effects desired from treatment.\u003c/p\u003e \u003c/div\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eIn conclusion, Nd:YAG laser can be considered safe, efficacious, local method of treating nail psoriasis. Ultrasonography is a useful noninvasive diagnostic and follow up tool that helps in detection of even subclinical changes. Our results also confirm that, nail psoriasis although a treatment challenge; may sometimes improves spontaneously.\u003c/p\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eRECOMMENDATION\u003c/h2\u003e \u003cp\u003eFurther larger scale studies for extended time periods are needed to verify our results and investigate the usefulness of US monitoring of nail changes in the treatment of NP.\u003c/p\u003e \u003c/div\u003e "},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFinancial support and sponsorship:\u0026nbsp;\u003c/strong\u003eNil\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration of patient consent:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published, and due efforts will be made to conceal their identity.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical committee approval:\u0026nbsp;\u003c/strong\u003eApproved\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trials registration:\u0026nbsp;\u003c/strong\u003eThe trial was registered on ClinicalTrials.gov with the reference number \u0026ldquo;NCT05695833\u0026rdquo;.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eAuthors Contribution:\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConceptualization: [Mohamed Hussein Medhat El-Komy]; Methodology: [Mohamed Hussein Medhat El-Komy, Hagar El Sayed, Mohamed Ahmed Salem El-Basiony, Hala El Gendy]; Formal analysis and investigation: [Mohamed Ahmed Salem El-Basiony,]; Writing - original draft preparation: [Mohamed Ahmed Salem El-Basiony,]; Writing - review and editing: [Mohamed Hussein Medhat El-Komy, Hagar El Sayed]; Resources: [Mohamed Ahmed Salem El-Basiony]; Supervision: [Mohamed Hussein Medhat El-Komy, Nevien Ahmed Samy, Dalia Gamal Aly, Hala El-Gendy, Mohamed Fouad Abdel Salam Hassan, Hagar El Sayed, Mohamed Mohsen Soliman].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eConflict of interest:\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no conflict of interest.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eCanal-Garc\u0026iacute;a E, Bosch-Amate X, Belinch\u0026oacute;n I, Puig L. [Translated article] Nail Psoriasis. Actas dermo-sifiliograficas. 2022 May 1;113(5):T481-90.\u003c/li\u003e\n\u003cli\u003eAugustin M, Reich K, Blome C, Sch\u0026auml;fer I, Laass A, Radtke MA. Nail psoriasis in Germany: epidemiology and burden of disease. British Journal of Dermatology. 2010 Sep 1;163(3):580-5.\u003c/li\u003e\n\u003cli\u003eArmesto S, Esteve A, Coto-Segura P, Drake M, Galache C, Mart\u0026iacute;nez-Borra J, Santos-Juanesc J. Nail psoriasis in individuals with psoriasis vulgaris: a study of 661 patients. Actas Dermo-Sifiliogr\u0026aacute;ficas (English Edition). 2011 Jan 1;102(5):365-72.\u003c/li\u003e\n\u003cli\u003eEl-Komy MH, Mashaly H, Sayed KS, Hafez V, El-Mesidy MS, Said ER, Amer MA, AlOrbani AM, Saadi DG, El-Kalioby M, Eid RO. Clinical and epidemiologic features of psoriasis patients in an Egyptian medical center. JAAD international. 2020 Dec 1;1(2):81-90.\u003c/li\u003e\n\u003cli\u003eKassir M, Kircik L, Weinberg J, Fatima F, Yamauchi P, Lotti T, Wollina U, Grabbe S, Goldust M. Treatment of Nail Psoriasis. Journal of Drugs in Dermatology: JDD. 2022 Feb 1;21(2):146-50.\u003c/li\u003e\n\u003cli\u003eRich P, Manhart R. Nail psoriasis. Psoriasis. 2017 Apr 11;2:S7-13.\u003c/li\u003e\n\u003cli\u003eJiaravuthisan MM, Sasseville D, Vender RB, Murphy F, Muhn CY. Psoriasis of the nail: anatomy, pathology, clinical presentation, and a review of the literature on therapy. Journal of the American Academy of Dermatology. 2007 Jul 1;57(1):1-27.\u003c/li\u003e\n\u003cli\u003eTreewittayapoom C, Singvahanont P, Chanprapaph K, Haneke E. The effect of different pulse durations in the treatment of nail psoriasis with 595-nm pulsed dye laser: a randomized, double-blind, intrapatient left-to-right study. Journal of the American Academy of Dermatology. 2012 May 1;66(5):807-12.\u003c/li\u003e\n\u003cli\u003eArango-Duque LC, Roncero-Riesco M, B\u0026aacute;rcena TU, \u0026Aacute;lvarez IP, L\u0026oacute;pez EF. Treatment of nail psoriasis with pulse dye laser plus calcipotriol betametasona gel vs. Nd:YAG plus calcipotriol betamethasone gel: an intrapatient left-to-right controlled study. Actas Dermo-Sifiliogr\u0026aacute;ficas. 2017 Mar 1;108(2):140-4.\u003c/li\u003e\n\u003cli\u003eKartal SP, Canpolat F, Gonul M, Ergin C, Gencturk Z. Long-pulsed Nd:YAG laser treatment for nail psoriasis. Dermatologic Surgery. 2018 Feb 1;44(2):227-33.\u003c/li\u003e\n\u003cli\u003eKhashaba SA, Gamil H, Salah R, Salah E. Efficacy of long-pulsed Nd-YAG laser in the treatment of nail psoriasis: a clinical and dermoscopic evaluation. Journal of Dermatological Treatment. 2021 May 19;32(4):446-52.\u003c/li\u003e\n\u003cli\u003eKrajewska-Włodarczyk M, Owczarczyk-Saczonek A, Placek W, Wojtkiewicz M, Wiktorowicz A, Wojtkiewicz J. Ultrasound assessment of changes in nails in psoriasis and psoriatic arthritis. BioMed research international. 2018 Sep 9;2018. \u003c/li\u003e\n\u003cli\u003eRich P, Scher RK. Nail Psoriasis Severity Index: a useful tool for evaluation of nail psoriasis. Journal of the American Academy of Dermatology. 2003 Aug 1;49(2):206-12.\u003c/li\u003e\n\u003cli\u003eHudgens S, Rich P, Geng Z, Williams D, Fleischer A, Ganguli A. Development and validation of the Physician\u0026apos;s Global Assessment of Fingernail Psoriasis. Journal of the European Academy of Dermatology and Venereology. 2021 Nov;35(11):2324-30. \u003c/li\u003e\n\u003cli\u003eWortsman X, Gutierrez M, Saavedra T, Honeyman J. The role of ultrasound in rheumatic skin and nail lesions: a multi-specialist approach. Clinical rheumatology. 2011 Jun;30:739-48.\u003c/li\u003e\n\u003cli\u003eGutierrez M, Di Geso L, Salaffi F, Bertolazzi C, Tardella M, Filosa G, Filippucci E, Grassi W. Development of a preliminary US power Doppler composite score for monitoring treatment in PsA. Rheumatology. 2012 Jul 1;51(7):1261-8. \u003c/li\u003e\n\u003cli\u003eScott J, Huskisson EC. Graphic representation of pain. pain. 1976 Jun 1;2(2):175-84. \u003c/li\u003e\n\u003cli\u003eHintze J. PASS 11. Kaysville, Utah, USA: NCSS, LLC. 2011 Sep 29. \u003c/li\u003e\n\u003cli\u003eChan YH. Biostatistics 102: quantitative data\u0026ndash;parametric \u0026amp; non-parametric tests. blood Press. 2003;140(24.08):79.\u003c/li\u003e\n\u003cli\u003eChan YH. Biostatistics 103: qualitative data-tests of independence. Singapore Med J. 2003 Oct 1;44(10):498-503.\u003c/li\u003e\n\u003cli\u003eRanganathan P, Pramesh CS, Aggarwal R. Common pitfalls in statistical analysis: Measures of agreement. Perspectives in clinical research. 2017 Oct;8(4):187.\u003c/li\u003e\n\u003cli\u003eRoter, G., Szczerkowska‐Dobosz, A., \u0026amp; Nowicki, R. J. (2022). Treatment of nail psoriasis with pulsed dye laser versus combined pulsed dye and Nd:YAG lasers\u0026mdash;An intrapatient left‐to‐right study. \u003cem\u003eLasers in Surgery and Medicine\u003c/em\u003e, \u003cem\u003e54\u003c/em\u003e(5), 688-692.\u003c/li\u003e\n\u003cli\u003eHeidenreich R, R\u0026ouml;cken M, Ghoreschi K. Angiogenesis drives psoriasis pathogenesis. International journal of experimental pathology. 2009 Jun;90(3):232-48.\u003c/li\u003e\n\u003cli\u003eOzyurt K, Colgecen E, Baykan H, Ozturk P, Ozkose M. Treatment of superficial cutaneous vascular lesions: experience with the long-pulsed 1064 nm Nd:YAG laser. The Scientific World Journal. 2012 Jan 1;2012.\u003c/li\u003e\n\u003cli\u003eTosti A, Piraccini BM. Nail disorders. Harper\u0026apos;s Textbook of Pediatric Dermatology. 2011 Jun 3;1:150.\u003c/li\u003e\n\u003cli\u003eElwan YH, Azim AA, Starace M, Abd Elhafiz HS. Nd:YAG Laser in the Treatment of Nail Psoriasis: Clinical and Dermoscopic Assessment. Dermatology Practical \u0026amp; Conceptual. 2021 Mar;11(2). \u003c/li\u003e\n\u003cli\u003eAyala F. Clinical presentation of psoriasis. Reumatismo. 2007;59(s1):40-5.\u003c/li\u003e\n\u003cli\u003eHaneke E. Nail psoriasis: clinical features, pathogenesis, differential diagnoses, and management. Psoriasis: Targets and Therapy. 2017 Oct 16:51-63.\u003c/li\u003e\n\u003cli\u003eMittal J, Mahajan BB. Intramatricial injections for nail psoriasis: an open-label comparative study of triamcinolone, methotrexate, and cyclosporine. Indian journal of dermatology, venereology and leprology. 2018 Jul 1;84:419. \u003c/li\u003e\n\u003cli\u003eAnders JJ, Lanzafame RJ, Arany PR. Low-level light/laser therapy versus photobiomodulation therapy. Photomedicine and laser surgery. 2015 Apr 4;33(4):183.\u003c/li\u003e\n\u003cli\u003eKhalkhal E, Razzaghi M, Rostami-Nejad M, Rezaei-Tavirani M, Beigvand HH, Tavirani MR. Evaluation of laser effects on the human body after laser therapy. Journal of Lasers in Medical Sciences. 2020;11(1):91.\u003c/li\u003e\n\u003cli\u003eRodrigo SM, Cunha A, Pozza DH, Blaya DS, Moraes JF, Weber JB, de Oliveira MG. Analysis of the systemic effect of red and infrared laser therapy on wound repair. Photomedicine and laser surgery. 2009 Dec 1;27(6):929-35.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"archives-of-dermatological-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Archives of Dermatological Research](https://www.springer.com/journal/403)","snPcode":"403","submissionUrl":"https://submission.nature.com/new-submission/403/3","title":"Archives of Dermatological Research","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Nd:YAG laser, ultrasonography, target NAPSI, nail psoriasis","lastPublishedDoi":"10.21203/rs.3.rs-4254041/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4254041/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBACKGROUND\u003c/h2\u003e \u003cp\u003eNail psoriasis is a chronic, inflammatory condition which is difficult to treat, linked with greater psoriasis severity, and may be associated with anxiety and significant functional impairment of the quality of life. The 1064nm Nd:YAG laser was reported to yield satisfactory results in the treatment of nail psoriasis.\u003c/p\u003e\u003ch2\u003eOBJECTIVE\u003c/h2\u003e \u003cp\u003eTo assess the clinical and ultrasonographic efficacy of long-pulsed 1064nm Nd:YAG laser in the treatment of fingernail psoriasis and compare its effect to control fingernails.\u003c/p\u003e\u003ch2\u003eMETHODS\u003c/h2\u003e \u003cp\u003eThis intra-patient randomized controlled trial analyzed 86 fingernails collected from 13 patients suffering from cutaneous and nail psoriasis. The nails were randomized into two groups. Group A was treated with Nd:YAG laser once monthly for three sessions while group B served as control. Assessment took place at baseline, 1 and 3 months after the last treatment session. For scoring, the 32-points target NAPSI scoring systems was used. Additionally, two blinded dermatologists\u0026rsquo; score of improvement, patients\u0026rsquo; pain assessment by visual analogue score and ultrasonographic assessment were all performed.\u003c/p\u003e\u003ch2\u003eRESULTS\u003c/h2\u003e \u003cp\u003eAt the end of follow up, the medians of tNAPSI score, plate definition, matrix thickness, bed thickness and bed vascularity decreased significantly in the Nd:YAG laser treated group in comparison to baseline (\u003cem\u003ep\u0026thinsp;=\u0026thinsp;0.001\u003c/em\u003e, \u003cem\u003e0.006\u003c/em\u003e, \u003cem\u003e0.039\u003c/em\u003e, \u003cem\u003e\u0026lt;\u0026thinsp;0.001\u003c/em\u003e and \u003cem\u003e0.010\u003c/em\u003e, respectively). While, there was a non-significant reduction in median tNAPSI score in the control group at last follow up, however, ultrasonography recorded a significant reduction in the medians of plate definition, bed thickness and vascularity (\u003cem\u003ep\u0026thinsp;=\u0026thinsp;0.002\u003c/em\u003e, \u003cem\u003e0.011\u003c/em\u003e and \u003cem\u003e0.033\u003c/em\u003e, respectively) from the baseline. Comparison of the Nd:YAG laser and the control groups showed no significant difference from baseline regarding the medians of tNAPSI, tNAPSI percentile improvement, pits count, blinded evaluation of photographs and ultrasonographic assessments.\u003c/p\u003e\u003ch2\u003eCONCLUSION\u003c/h2\u003e \u003cp\u003eNd:YAG laser showed clinical and ultrasonographic improvement in fingernail psoriasis. Ultrasonography is a useful noninvasive tool in diagnosing and monitoring the clinical and even the subclinical changes in nail psoriasis. Nail psoriasis although difficult to treat, may show spontaneous improvement.\u003c/p\u003e","manuscriptTitle":"Long-Pulsed Nd:YAG Laser Treatment of Nail Psoriasis: Clinical and Ultrasonographic Assessment","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-04-25 16:28:28","doi":"10.21203/rs.3.rs-4254041/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2024-04-26T16:42:12+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"194417887403788264998829810554853868323","date":"2024-04-26T16:41:43+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-04-26T16:01:12+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-04-12T11:39:37+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-04-12T11:39:36+00:00","index":"","fulltext":""},{"type":"submitted","content":"Archives of Dermatological Research","date":"2024-04-11T18:35:42+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"archives-of-dermatological-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Archives of Dermatological Research](https://www.springer.com/journal/403)","snPcode":"403","submissionUrl":"https://submission.nature.com/new-submission/403/3","title":"Archives of Dermatological Research","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"ebc6747e-fcd8-4ce3-b704-13e70cc7e561","owner":[],"postedDate":"April 25th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2024-04-26T17:20:47+00:00","versionOfRecord":[],"versionCreatedAt":"2024-04-25 16:28:28","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4254041","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4254041","identity":"rs-4254041","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}