Health-Related Quality of Life in Patients with Nail Disorders

Health-Related Quality of Life in Patients withNail DisordersAdam Reich and Jacek C. Szepietowski

Department of Dermatology, Venereology and Allergology, Wroclaw Medical University, Wroclaw, Poland

Contents

Abstract. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 313

1. General Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 313

2. Nail Psoriasis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 314

3. Onychomycosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 316

4. Other Nail Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 318

5. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 319

Abstract Fingernails and toenails are important organs of our body, serving as protection for the tips of fingers and

toes. Fingernails also enhance fine touching and tactile sensitivity, as well as aid in the picking up of small

objects. Healthy-looking nails are an important part of an individual’s body image, and any nail abnor-

malities may be considered by patients as a significant cosmetic problem, markedly influencing their self-

esteem. However, recent data have indicated that nail lesions are not only important because of cosmetic

disfigurement, but may be a symptom of significant morbidity. Severe nail involvement was also shown to

negatively impair social functioning and to interfere with work ability, thus markedly influencing a patient’s

well-being. Based on literature data and our own experience we conclude that nail diseases cause a marked

decrease in health-related quality of life in a substantial percentage of patients. Nail changes are an im-

portant medical concern for patients and, therefore, nail diseases should raise attention and receive proper

care from both physicians and other healthcare providers.

1. General Considerations

Both fingernails and toenails are important organs of our

body, serving as protection for the tips of fingers and toes.

Fingernails enhance fine touching and tactile sensitivity, as well

as aid in the picking up of small objects. While discussing nail

functions it should also be mentioned that nails may serve as

offensive or defensive weapons and are used during scratching.

Healthy-looking nails are an important part of an individual’s

body image, playing an important role in interpersonal relation-

ships.[1] Therefore, nail abnormalities are considered a significant

cosmetic problem, markedly influencing a person’s self-esteem.

Although little attention has been paid to nail involvement in

the past, recent data clearly indicate that nail lesions are not

only important because of cosmetic disfigurement, but may be

a symptom of significant morbidity. More severe nail psoriasis

is associated with a more severe course of psoriatic arthritis.[2]

Similarly, early nail dystrophy and loss seem to correlate with

a more rapid progression of epidermolysis bullosa.[3] Further-

more, infected nails in onychomycosis may serve as a reservoir

of pathogens, from which the infection may spread to other

body areas.[4] In addition, toenail onychomycosis facilitates the

development of bacterial cellulitis of the lower leg.[5]

Besides significant medical problems and complications,

severe nail involvement was also shown to negatively impair

social functioning and to interfere with work ability. To better

characterize the influence of various nail abnormalities on a

patient’s psychosocial well-being, we performed a literature

REVIEWARTICLEAm J Clin Dermatol 2011; 12 (5): 313-320

1175-0561/11/0005-0313/$49.95/0

ª 2011 Adis Data Information BV. All rights reserved.

review focused on the problem of health-related quality of life

(HR-QOL) in nail disorders. We searched the PubMed data-

base (last accessed March 2011) using the terms ‘quality of life’

AND ‘nail,’ as well as ‘quality of life’ AND ‘onychomycosis.’

In total, 276 articles were initially identified, of which 31 were

found suitable for the current review. In addition, in order to

make our reference list complete, we reviewed the reference lists

of the included papers, as well as all articles and abstracts not

indexed in the PubMed database that we were aware of that

focused on the various aspects of HR-QOL in nail diseases.

In total, 36 full articles, 2 book chapters and 5 abstracts were

reviewed.

2. Nail Psoriasis

Nail lesions are observed in about one-half of patients with

psoriasis, with an estimated lifetime incidence of 80–90%.[2,6,7]

Nail psoriasis occurs more often in patients with more severe

psoriasis and there is a positive correlation between the severity

of nail lesions and the severity of joint and skin symptoms.[2,8,9]

However, nail abnormalities may be the only manifestation of

psoriasis and are also frequently seen in patients with mild

disease.[2] Nail involvement may manifest as nail pitting (small

depressions in the nail plate), nail bed discoloration (‘salmon

spots’ or ‘oil drops’), subungual hyperkeratosis, nail plate

thickening and crumbling, onycholysis, splinter hemorrhages,

leukonychia, and red spots in the lunula.[2,7,10,11]

Despite its high frequency, the impact of nail psoriasis on

a patient’s functioning and well-being has not gained much

attention in the past. Nevertheless, it is clearly evident that

nail psoriasis leads to significant functional impairment, pain

and psychosocial distress, and has a negative impact on social

and work activities.[10-14] Several parameters may significantly

influence the overall impact of nail psoriasis on HR-QOL,

including a high visibility of nail lesions (especially lesions

on fingernails), limited treatment options with usually poor

to moderate efficacy, long-lasting nail disfigurements, as well

as various types of nail abnormalities (e.g. nail pitting vs

severe subungual hyperkeratosis with onycholysis and nail

dystrophy), although the latter aspect has not been well studied

so far.

Among the limited data available to date, a study by de Jong

et al.[15] is of great interest as the authors interviewed via a

mailed questionnaire more than 1700 psoriatic patients, of

whom nearly 80% had nail psoriasis. It was demonstrated that

more than 90% of these participants were concerned about the

cosmetic appearance of their nails.[15] However, the impact of

nail psoriasis was far greater than only cosmetic disfigurement,

as more than one-half of the analyzed individuals experienced

pain caused by nail changes, and nail abnormalities also signifi-

cantly restricted daily activities, housekeeping and/or work activ-

ities in 58.9%, 56.1%, and 47.9% of patients, respectively.[15]

Importantly, only 35.4% of psoriasis patients had used treat-

ment for their nail lesions, andmerely 19.3% in this group noted

a marked improvement of their nail disease during therapy,

while 35% showed little effect and 45.7% showed no improve-

ment at all.[15]

In another study of 1522 patients with psoriasis, including

40.9% with nail abnormalities, it was observed that patients

with nail involvement had significantly greater impairment of

HR-QOL assessed by the Dermatology Life Quality Index

(DLQI)[16] than those patients whose nails were normal (DLQI

in women: 9.5 – 7.1 points vs 7.6 – 6.4 points, respectively; in

men: 8.6 – 7.1 points vs 6.9 – 6.3 points, respectively; p < 0.001for both comparisons).[17] However, patients with nail in-

volvement generally also had more severe psoriasis (greater

skin area involvement, higher Psoriasis Area and Severity Index

[PASI], more frequent psoriatic arthritis, and longer duration

of psoriasis).[17] As the authors did not perform a multivariate

analysis of their data, it is difficult to assess whether the dif-

ference in HR-QOL level between compared groups was due to

significantly different psoriasis severity as a whole or was solely

related to the presence of nail lesions. Importantly, Augustin

et al.[17] also noted that patients with nail psoriasis hadmore days

off work due to psoriasis than subjects with normal nails within

a year prior to the survey (women: 8.5 – 32.1 days vs 2.4 – 12.8days, respectively; men: 6.0 – 21.9 days vs 2.9 – 17.1 days, re-

spectively; p < 0.001 for both comparisons). In another study by

the same group,[9] patients with nail psoriasis also displayed a

significantly lower HR-QOL according to the DLQI (7.2 – 6.4points vs 5.3 – 5.3 points; p< 0.001) and a poorer state of health

on the EuroQol EQ5D scale (60.1 – 21.6 points vs 67.3 – 21.0points; p< 0.001). Again, the number of days off work was

significantly higher in patients with nail psoriasis (9.8 – 42.0days vs 3.3 – 15.9 days; p < 0.001).[9]

These observations are in agreement with our data, showing

that nails are considered by 34.1% of patients as the most work-

disturbing localization of psoriasis.[18] In addition, fragility of

nails was mentioned by 18.3% of individuals as the most im-

portant symptom of psoriasis making their work difficult.[18]

Patients with nail psoriasis also displayed significantly worse

values for satisfaction with their treatment, stress, and time

expenditure due to therapy.[9] Themeannumber of consultations

was significantly higher in nail psoriasis patients, both with

dermatologists andwith orthopedic surgeons/rheumatologists.[9]

Remarkably, 36.4% of patients with psoriasis considered nail

314 Reich & Szepietowski

ª 2011 Adis Data Information BV. All rights reserved. Am J Clin Dermatol 2011; 12 (5)

abnormalities as the most bothersome symptom of the dis-

ease.[19] Only the following five psoriasis symptoms were more

commonlymentioned asmarkedly disturbing: pruritus (63.6%),

extensive skin scaling (56.4%), redness of the skin (52.7%), skin

burning (41.8%), and prominent scaling within the scalp

(38.2%).[19] Severe nail disease was also found to be associated

with functional impairment related to arthritis and more severe

nail lesions correlated with higher depression and anxiety in

patients with psoriasis.[8]

Although some authors used theDLQI to evaluateHR-QOL

in patients with nail psoriasis,[9,17] this instrument was initially

developed for assessing HR-QOL in relation to skin symp-

toms.[16] However, there are no convincing data indicating

whether this scale can also be reliably applied for assessment of

HR-QOL in diseases limited to nails.Moreover, when using the

DLQI in patients who have both skin lesions and nail abnor-

malities it is not possible to separate the influence of nail

changes on HR-QOL from the impact of skin lesions. To

overcome this problem, Ortonne et al.[20] have recently devel-

oped a new HR-QOL questionnaire designed specifically for

nail psoriasis: the Nail Psoriasis Quality of life (NPQ10) scale.

This is a ten-item unidimensional questionnaire constructed to

address the physical aspects associated with nail psoriasis, af-

fecting either fingernails, toenails, or both. The first question is

concernedwith the intensity of the pain caused by nail psoriasis,

while the remaining nine items are linked to the functional

impairment due to nail lesions. Although this scale can be used

either in fingernail or toenail disease, one item is specific for

fingernail involvement, while another one is for toenails only.

There are three possible answers for each question, scored from

0 to 2. The scores for each question are summed and converted

to percentages, based on the number of questions it was possi-

ble for a specific patient to answer. The final score may vary

between 0 (no negative impact) and 100 (the worst effect of nail

lesions on HR-QOL).[20] The NPQ10 showed very good

internal consistency (the Cronbach a coefficient was 0.88) and

good reproducibility (the intra-group coefficient of variation

was 0.82). To date, the NPQ10 was only validated in French.

The Principal Component Factor Analysis demonstrated a

unidimensional structure of the NPQ10. In addition, NPQ10

scoring discriminates patients with disease limited to the hands

or feet (mean NPQ10: 10.4 points and 12.9 points, respectively)

from those patients with both fingernails and toenails affected

(mean NPQ10: 18.8 points; p< 0.001), a finding that supports agood discriminative validity of this scale. Furthermore, NPQ10

results correlated with the DLQI scoring (R = 0.48) indicatinga good construct validity. However, as the correlation coefficient

was not very high, it was assumed by the authors that the

NPQ10 provides additional information on HR-QOL that is

not captured by the DLQI.[20] Based on the NPQ10 it was

demonstrated that women are more affected by nail psoriasis

than men (mean NPQ10: 18.3 points vs 13.4 points, respec-

tively; p < 0.05) and that HR-QOL is inversely related to the

duration of psoriasis (meanNPQ10 in £5 years vs >5 years: 22.1points vs 14.9 points, respectively; p = 0.01), while the patient’sage had no influence on NPQ10 scoring (p = 0.73).[20]

To assess HR-QOL in patients with nail psoriasis our group

has used another nail disease-specific instrument, namely the

NailQoL.[21,22] This questionnaire was originally designed by

Warshaw et al.[21] to evaluate HR-QOL in patients with ony-

chomycosis. The scale consists of 15 questions, each one with

five graded alternative responses available.[21] The higher the

final score the patient receives, the more impairment of HR-

QOL he/she has. The questions are divided into three domains:

symptoms (three items), emotions (ten items), and function

(two items). Although originally developed for onychomycosis,

the content of the scale seemed to us to also be suitable for nail

psoriasis. In comparison with the original scale, we slightly

modified the wording of the last question changing the term

‘nail fungus’ to ‘nail disease.’[23] In a pilot study of 30 subjects

we demonstrated a very good internal consistency (the Cron-

bach a coefficient was 0.88) and good reproducibility of the

NailQoL (the intraclass correlation coefficient was 0.77) in nail

psoriasis.[23] Based on theNailQoL, the most important aspects

of nail psoriasis for patients were being ashamed of, embar-

rassed about, or frustrated with the appearance of their nails,

and the worry that the nail condition may get worse.[22] Sim-

ilarly to Ortonne et al.,[20] we also observed a higher impact of

nail lesions on HR-QOL in women than in men (figure 1a).

Interestingly, in women, HR-QOL assessed with the NailQoL

questionnaire significantly correlated with nail lesion severity

evaluated by the Nail Psoriasis Severity Index (NAPSI)[24]

[R = 0.65], but no such relationship was found inmen (R= 0.03),indicating that nail abnormalities are indeed of greater im-

portance for women, while in men they play a less significant

role.[22] Moreover, psoriatic patients with joint involvement

had greater impairment of HR-QOL in relation to nail ab-

normalities than those with no psoriatic arthritis, although the

severity of nail lesions assessed by NAPSI was not markedly

different between the two groups (figure 1b).[22] We did not

observe significant relationships between HR-QOL and dura-

tion of psoriasis, duration of nail involvement, or a family

history of psoriasis. Age significantly correlated with symptom

domain scores (R = 0.36; p < 0.001), but no significant rela-

tionships were found with total scores, or emotion or function

scores.[22]

Quality of Life in Nail Diseases 315


3. Onychomycosis

Onychomycosis is the most frequently occurring nail disease

and is also probably the best studied nail condition with regard

to HR-QOL.[1,25] It accounts for about 50% of all nail changes,

with a prevalence of 3–8% of the general population according

to the available studies.[26-28] Although onychomycosis is not

considered a life-threatening disease, it cannot be handled

simply as a cosmetic problem. The disease is usually long last-

ing, even if appropriate antifungal therapy is introduced. It

causes pain and significant problems of wearing shoes in a sub-

stantial portion of subjects.[29-31] Furthermore, onychomycosis

is a risk factor for the development of bacterial cellulitis of the

lower legs and may be a reservoir of pathogens, from which the

fungal infection spreads onto other skin areas.[4,5] On rare oc-

casions it may even disseminate via blood, resulting in sepsis

and patient death.[5,32]

Due to its chronic course, problems in achieving complete

and durable clinical and mycologic cure, common relapses,

and visibility for other people, onychomycosis has a significant

influence on HR-QOL. A number of onychomycosis-specific

instruments have been developed to assess its impact on HR-

QOL (table I). Among them, the newest tools, the OnyCoE-t�and NailQoL, seem to be the best validated.[21,46] These scales

are well constructed, were properly tested for the most im-

portant psychometric variables, and demonstrate good con-

struct validity and responsiveness.

Patients with onychomycosis frequently experience reduced

self-esteem, embarrassment, and are less willing to participate

in social and leisure activities.[25] About 70% of toenail ony-

chomycosis patients considered their nail disease to be at least

a moderate problem for them.[29] Remarkably, subjects with

onychomycosis had significantly poorer ratings of general

health perception, bodily pain, mental health, social function-

ing, physical appearance, and functional limitations, if com-

pared with gender- and age-matched healthy controls.[33,34]

Based on the DLQI, only 14% of patients with onychomycosis

had normal HR-QOL, while 29.9% had slightly impaired HR-

QOL, 39.4% had moderately impaired HR-QOL, and 16.7%had severely impaired HR-QOL.[48] The mean score for all

patients was 7.2 – 5.3 points, indicating the moderate influence

of onychomycosis on HR-QOL.[48] Factors related to greater

impairment of HR-QOL due to onychomycosis were fingernail

involvement, female gender, higher education, and younger age,

while the number of infected nails had no significant impact.[48]

Comparedwith other chronic dermatoses, onychomycosis caused

comparable impairment of HR-QOL to seborrheic dermatitis,

non-melanoma skin cancers, and benign skin tumors.[21,49]

Patients with toenail onychomycosis reported various sub-

jective symptoms and emotional and social problems caused by

their nail disease, as demonstrated in several studies.[29-31] The

feeling that other people found it unpleasant to look at infected

nails was experienced by the vast majority (93%) of subjects,

fear that the disease would spread to others was observed in

31–96%, and embarrassment was noted in 44–74% of studied

patients. In addition, most of the patients with toenail ony-

chomycosis had problems wearing shoes (82%), difficulties in

cutting their nails (75–86%), and reported that they had to

spend a significant amount of money to treat their nail dis-

ease.[29-31] However, Drake et al.[29] found that more than 95%of onychomycosis subjects would be willing to pay for an

antifungal therapy with an 80% cure rate, even if their insurance

would not cover the cost. Remarkably, if the theoretical cure

90a

b

80

70

60

50

Sco

reS

core

40

30

20

10

0NAPSI NailQoL -

totalNailQoL -symptoms

NailQoL -emotions

NailQoL -function

NAPSI NailQoL -total

NailQoL -symptoms

NailQoL -emotions

NailQoL -function

90

100

80

* *

**

70

60

50

40

30

20

10

0

WomenMen

Without joint involvementWith joint involvement

Fig. 1. NailQoL scoring in nail psoriasis. (a) Comparison of health-related

quality of life (HR-QOL) measured by the NailQoL questionnaire and nail

disease severity assessed by the Nail Psoriasis Severity Index (NAPSI) in

women and men with nail psoriasis. (b) Comparison of HR-QOL and nail

disease severity in patients with psoriasis with and without joint involvement.* p < 0.05.



rate dropped to 35%, 57% of patients were still eager to pay for

their own treatment.[29]

Pain within the toes was present in 41–60% of studied subjects

and nearly one-fifth of patients avoided various social activities

due to onychomycosis.[29-31] Other sensations related to ony-

chomycosis included tingling, burning, numbness, pressure,

or discomfort.[29] According to the Achilles Foot-Screening

Project, 51% of patients with onychomycosis had discomfort on

walking, 33% had foot pain, 28% were embarrassed by the nail

condition, and 13% were limited in work or other activities

because of the toenail infection.[50]

A significant portion of patients feel unattractive and stig-

matized by onychomycosis, indicating that other people stare at

the changed nails and consider their disease as contagious.[51]

Remarkably, antimycotic therapy resulted in a significant re-

duction of stigmatization by about 60% from the baseline

level.[51]

A number of demographic and disease-related parameters

may influence the impairment of HR-QOL by onychomycosis.

Usually, women had greater impairment of HR-QOL due to

onychomycosis than men.[29,39-41,48,52] Onychomycosis is also

more likely to cause embarrassment in women than in men.[29]

Furthermore, younger people seem to be more affected emo-

tionally by the fungal nail infection as their appearance is of

greater importance for them in interpersonal relationships,[30]

while older counterparts experienced more symptoms and so-

cial isolation due to onychomycosis.[39,41] Some variations of

HR-QOL can also be noted between different nations, as

patients from Germany and the US were more affected than

people living in France or Italy.[41] A replication of the Achilles

Table I. A short description of the onychomycosis-specific health-related quality-of-life instruments

Questionnaire Short description

Onychomycosis interview questionnaire by Lubeck

et al.[33,34]A questionnaire consisting of generic and disease-specific items. The generic part is based on the

Medical OutcomesStudy Functioning andWell-Being Profile[35] and the Fleming Self-EsteemScale.[36]

Disease-specific components measure problems with physical appearance, activity limitation, and

disease symptoms

Questionnaire by Whittam and Hay[37] A nine-item questionnaire developed by the authors based on the social, psychological, and economic

problems described by the patients. The instrument assesses nuisance and bothersomeness of

onychomycosis, the amount of money spent on treating this disease, and the number of doctor visits

during the previous year

Toenail onychomycosis patient self-assessment

survey instrument by Elewski[31]A 15-item questionnaire assessing demographic (four items), physical (five items), and psychosocial

(six items) dimensions, with binary ‘yes’/‘no’ responses, making the questionnaire easy to administer

and interpret

Questionnaire by Drake et al.[29,38] A 57-item questionnaire divided into physical, functional, psychosocial, and economic domains. The

questionnaire was developed on the basis of the authors’ experience and the instrument developed by

Lubeck et al.[33]

Onychomycosis quality-of-life questionnaire by

Lubeck et al.[39,40]An instrument consisting of generic (general health perceptions, health transition, pain, overall

problems, social functioning, mental health, health distress, and physical function) and disease-specific

(toenail symptoms, appearance problems, physical activity problems, stigma, and treatment

satisfaction) components. The questionnaire was based on previous scales[33,34]

International onychomycosis-specific questionnaire

by Drake et al.[41]Available in several languages, this instrument was constructed separately for fingernail (24 items) and

toenail (17 items) onychomycosis. Questions are subdivided into three categories: emotional, social,

and symptom components. The instrument also contains generic elements including the 12-Item Short

Form health survey[42] and the Psychological General Well-Being index[43]

Onychomycosis Disease-Specific Questionnaire

(ODSQ)[44]A questionnaire developed for both fingernail and toenail onychomycosis based on the instrument

described by Lubeck et al.[39] and consisting of questions related to general health status and well-

being, onychomycosis symptom distress, onychomycosis problems, and social stigma

Toenail onychomycosis quality-of-life questionnaire

by Firooz et al.[45]A 13-item questionnaire for toenail onychomycosis based on the questionnaire by Drake et al.[41]

OnyCOE-t� questionnaire[46] A toenail onychomycosis-specific questionnaire adapted from instruments described by Lubeck

et al.[33,39] It consists of 33 items considering overall problems, symptoms, appearance problems,

physical activity problems, stigma, and treatment satisfaction

NailQoL[21] A questionnaire based on the Skindex-29[47] with ten additional items validated in the pilot study. The

final version consists of 15 items assessing symptoms, emotions, and function



Foot-Screening Project in Asia revealed that the impact of toenail

onychomycosis on HR-QOL was smaller than that reported in

European countries, although identified problemswere similar.[53]

In addition, patients living in towns or big cities, as well as those

having a higher education level were more emotionally and so-

cially affected by onychomycosis, while subjects in the countryside

or with a poorer education more often emphasized problems

connected to physical symptoms of the disease.[30,48]

Regarding disease-related parameters, Elewski[31] observed

that patients with onychomycosis for 10 years or longer had

more psychosocially than physically impaired HR-QOL, and

the psychosocial ramifications were directly related to the

number of toenails involved, i.e. patients with five or more

infected toenails experienced more psychosocial effects than

those with four or fewer infected toenails. Drake et al.[29] noted

that patients having whole-nail onychomycosis were sig-

nificantly more emotionally, socially, and physically affected

by the disease than patients who had half-nail involvement. A

long duration of toenail onychomycosis and involvement of

five or more toenails significantly impaired emotional and

physical domains, but not social scoring of HR-QOL assess-

ment.[41] Coexisting fingernail involvement was another im-

portant parameter significantly altering HR-QOL, as these

patients demonstrated a greater reduction in HR-QOL in all

dimensions compared with subjects having only toenail ony-

chomycosis.[48] Interestingly, the clinical type of onychomy-

cosis and the family history of fungal nail infection seemed to be

less important for the level of HR-QOL.[30]

Improvement in the level of HR-QOL was shown to be

strictly connected with improvement or cure of infected

nails.[21,39,40,44,45] Accordingly, patients satisfied with the

treatment had better HR-QOL.[41] However, subjects with re-

current disease had significantly poorer HR-QOL than patients

who had the disease for the first time and had not previously

been treated for onychomycosis.[30]

Taken altogether, onychomycosis is far more than a cos-

metic problem.[54] Patients with onychomycosis demonstrate

impairment of HR-QOL in all dimensions, including physical,

mental, and social functioning. Nail pressure and painmay lead

to an inability to wear shoes, and the infection of fingernails

may impair the ability to do jobs, accounting for absence from

work.[54] Thus, onychomycosis should be considered as an im-

portant medical problem that needs careful attention and care.

4. Other Nail Conditions

Data on the influence of nail diseases other than nail psori-

asis or onychomycosis on HR-QOL are very limited. Tabolli

et al.[55] analyzed HR-QOL in 114 patients with nail problems,

of whom 48 (42.1%) had nail conditions other than onycho-

mycosis. Using the Skindex-29, they have shown that 17% of

patients answered ‘‘all the time’’ to the item ‘‘I worry that my

skin condition may get worse,’’ 15% answered ‘‘I am annoyed

by my skin condition,’’ 12% answered ‘‘I am ashamed of my

skin condition,’’ and almost 10% reported ‘‘My skin hurts.’’[55]

A longer duration of nail disease was related to greater im-

pairment of HR-QOL. On the other hand, no significant dif-

ferences were observed between men and women, or between

different age groups using the Skindex-29. Although these ob-

servations are of some interest, there are several limitations that

restrict the generalization of the data to other nail conditions.

First of all, the authors did not provide detailed information on

which nail diseases other than onychomycosis were analyzed.

Furthermore, patients with onychomycosis had higher values

in all Skindex-29 scales, and it is not exactly clear whether all

patients with the most affected HR-QOL belonged to the

onychomycosis group or had other nail conditions. Finally,

HR-QOL was assessed using generic scales (Short Form-36,

General Health Questionnaire [GHQ]) and with the Skindex-

29, i.e. with instruments not specific for nail problems. Thus,

the impact of nail diseases on HR-QOL in this study might be

substantially underestimated.[55]

Various nail lesions may occur during chemotherapy in

cancer patients.[56] A number of chemotherapeutics were shown

to induce nail abnormalities, but taxanes and anthracyclines are

most commonly implicated as causative antineoplastics.[56,57]

Nail toxicities can be asymptomatic and limited to cosmetic

concerns, but may also be quite severe, causing considerable

pain and discomfort.[56,58] In a study by Winther et al.,[58] 60%of patients with fingernail lesions and 37.2% of patients with

toenail involvement induced by docetaxel reported various

degrees of cosmetic nuisance because of nail abnormalities.[58]

Evenmore importantly, more than 40% of analyzed individuals

experienced various degrees of functional problems (house-

keeping, writing, sewing) due to docetaxel-induced nail lesions,

up to 37% had problems finding proper footwear, and nearly

one-third declared difficulties in walking.[58]

Brittle nail syndrome, defined as an increased fragility of the

nail plates, is another important nail condition that may cause

significant cosmetic concerns, thus lowering a patient’s self-

esteem.[59] Although the impact of brittle nails onHR-QOL has

not been specifically evaluated so far, the vast majority of

patients experience brittle nails as a significant cosmetic prob-

lem and a substantial number of patients indicated that these

nail abnormalities are painful, impair daily activities, and have

a negative influence on occupational abilities.[59,60]



5. Conclusions

Nail abnormalities are a common clinical problem with a

significant influence on a patient’s well-being. Based on liter-

ature data and our own experience, we conclude that nail

diseases cause marked impairment of HR-QOL in a substantial

percentage of patients. HR-QOL studies clearly showed that

nail involvement is an important medical concern for the

patients, and therefore nail diseases should raise attention

and receive proper care from physicians and other healthcare

providers.

Acknowledgments

This work was supported by the educational grant ST-374 of Wroclaw

Medical University. The authors have no conflicts of interest that are

directly relevant to the content of this review.

References1. Reich A, Szepietowski JC. Quality of life in toenail onychomycosis. In:

Preedy VR, Watson RR, editors. Handbook of disease burdens and quality

of life measures. New York (NY): Springer, 2010: 3837-50

2. Reich K. Approach to managing patients with nail psoriasis. J Eur Acad

Dermatol Venereol 2009 Sep; 23 Suppl. 1: 15-21

3. Moss C, Wong A, Davies P. The Birmingham Epidermolysis Bullosa Severity

score: development and validation. Br J Dermatol 2009May; 160 (5): 1057-65

4. Szepietowski JC, Reich A, Gar"owska E, et al. Factors influencing coexistenceof toenail onychomycosis with tinea pedis and other dermatomycoses: a

survey of 2761 patients. Arch Dermatol 2006 Oct; 142 (10): 1279-84

5. ReichA, SchwartzRA, Szepietowski JC. Complications of superficial mycoses.

In: Fratamico PM, Smith JL, Brogden KA, editors. Sequelae and long-term

consequences of infectious diseases. Washington, DC: ASM Press, 2009:

407-13

6. Jiaravuthisan MM, Sasseville D, Vender RB, et al. Psoriasis of the nail: anat-

omy, pathology, clinical presentation, and a review of the literature on ther-

apy. J Am Acad Dermatol 2007 Jul; 57 (1): 1-27

7. Edwards F, de Berker D. Nail psoriasis: clinical presentation and best practice

recommendations. Drugs 2009; 69 (17): 2351-61

8. Williamson L, Dalbeth N, Dockerty JL, et al. Extended report: nail disease in

psoriatic arthritis: clinically important, potentially treatable and often over-

looked. Rheumatology (Oxford) 2004 Jun; 43 (6): 790-4

9. Radtke MA, Langenbruch AK, Schafer I, et al. Nail psoriasis as a severity in-

dicator: results from the PsoReal study. Patient Relat OutcomeMeas 2011; 2: 1-6

10. Baran R. The burden of nail psoriasis: an introduction. Dermatology 2010;

221 Suppl. 1: 1-5

11. Salomon J, Szepietowski JC, Proniewicz A. Psoriatic nails: a prospective

clinical study. J Cutan Med Surg 2003 Jul-Aug; 7 (4): 317-21

12. Lawry M. Biological therapy and nail psoriasis. Dermatol Ther 2007 Jan-Feb;

20 (1): 60-7

13. Hussain W, Coulson I, Owen C. Severe recalcitrant nail psoriasis responding

dramatically to infliximab: report of two patients. Clin Exp Dermatol 2008

Jul; 33 (4): 520-2

14. Gupta AK, Cooper EA. Psoriatic nail disease: quality of life and treatment.

J Cutan Med Surg 2009 Sep-Oct; 13 Suppl. 2: S102-6

15. de Jong EM, Seegers BA, Gulinck MK, et al. Psoriasis of the nails associated

with disability in a large number of patients: results of a recent interview with

1,728 patients. Dermatology 1996; 193 (4): 300-3

16. Finlay AY, Khan GK. Dermatology Life Quality Index (DLQI): a simple

practical measure for routine clinical use. Clin Exp Dermatol 1994 May;

19 (3): 210-6

17. AugustinM, Reich K, Blome C, et al. Nail psoriasis in Germany: epidemiology

and burden of disease. Br J Dermatol 2010 Sep; 163 (3): 580-5

18. Zimolag I, Reich A, Szepietowski JC. Influence of psoriasis on the ability to

work [abstract no. OP76 plus oral presentation]. Acta Derm Venereol 2009

Sep; 89 (5): 575-6

19. Rams Ł, Reich A. Psoriasis in a view of patients: a questionnaire study

[in Polish, abstract no. 113]. XIVth Nationwide Conference of Student

Scientific Circles of Medical Universities; 2009 Apr 17-18; Wroclaw

20. Ortonne JP, Baran R, Corvest M, et al. Development and validation of nail

psoriasis quality of life scale (NPQ10). J Eur Acad Dermatol Venereol 2010

Jan; 24 (1): 22-7

21. Warshaw EM, Foster JK, Cham PM, et al. NailQoL: a quality-of-life instru-

ment for onychomycosis. Int J Dermatol 2007 Dec; 46 (12): 1279-86

22. Zdrojowy M, Szepietowski J, Zazulak N, et al. Quality of life in nail psoriasis

[abstract no. OP25 plus oral presentation]. Acta Derm Venereol 2009 Sep;

89 (5): 561

23. Zdrojowy M, Szepietowski J, Zazulak N, et al. Creation and validation of

Polish version of NailQoL questionnaire [abstract no. OP45]. Acta Derm

Venereol 2009 Sep; 89 (5): 566-7

24. Rich P, Scher RK. Nail Psoriasis Severity Index: a useful tool for evaluation of

nail psoriasis. J Am Acad Dermatol 2003 Aug; 49 (2): 206-12

25. Szepietowski JC, Reich A. Onychomycosis and quality of life. Eur Dermatol

2009; 4 (1): 85-7

26. Roberts DT. Prevalence of dermatophyte onychomycosis in the United

Kingdom: results of an omnibus survey. Br J Dermatol 1992 Feb; 126 Suppl.

39: 23-7

27. Heikkila H, Stubb S. The prevalence of onychomycosis in Finland. Br J Der-

matol 1995 Nov; 133 (5): 699-703

28. Gupta AK, Jain HC, Lynde CW, et al. Prevalence and epidemiology of un-

suspected onychomycosis in patients visiting dermatologists’ offices in

Ontario, Canada: a multicenter survey of 2001 patients. Int J Dermatol 1997

Oct; 36 (10): 783-7

29. Drake LA, Scher RK, Smith EB, et al. Effect of onychomycosis on quality of

life. J Am Acad Dermatol 1998 May; 38 (5 Pt 1): 702-4

30. Szepietowski JC, Reich A, Pacan P, et al. Evaluation of quality of life in

patients with toenail onychomycosis by Polish version of an international

onychomycosis-specific questionnaire. J Eur Acad Dermatol Venerol 2007

Apr; 21 (4): 491-6

31. Elewski BE. The effect of toenail onychomycosis on patient quality of life.

Int J Dermatol 1997 Oct; 36 (10): 754-6

32. Arrese JE, Pierard-Franchimont C, Pierard GE. Fatal hyalohyphomycosis

following Fusarium onychomycosis in an immunocompromised patient. Am

J Dermatopathol 1996 Apr; 18 (2): 196-8

33. Lubeck DP, Patrick DL, McNulty P, et al. Quality of life of persons with

onychomycosis. Qual Life Res 1993 Oct; 2 (5): 341-8

34. Lubeck DP. Measuring health-related quality of life in onychomycosis. J Am

Acad Dermatol 1998 May; 38 (5 Pt 3): S64-8

35. Stewart AL, Ware JE. Measuring functioning and well-being: the Medical

Outcomes Study approach. Durham (NC): Duke University Press, 1992

36. Fleming JS, Courtney BE. The dimensionality of self-esteem II: hierarchical

facet model for revised measurement scales. J Pers Soc Psychol 1984; 46:

404-21

37. Whittam LR, Hay RJ. The impact of onychomycosis on quality of life. Clin

Exp Dermatol 1997 Mar; 22 (2): 87-9

38. Drake L. Qualify of life issues with patients with fungal nail infections. AIDS

Patient Care 1995; 9 Suppl. 1: S15-7



39. Lubeck DP, Gause D, Schein JR, et al. A health-related quality of life measure

for use in patients with onychomycosis: a validation study. Qual Life Res

1999; 8 (1-2): 121-9

40. Lubeck DP, Schein JR, Gause D, et al. Health-related quality of life in patients

with toenail onychomycosis: data from 9-month observational study. J Clin

Outcomes Manage 1999; 6: 37-42

41. Drake LA, Patrick DL, Fleckman P, et al. The impact of onychomycosis on

quality of life: development of an international onychomycosis-specific

questionnaire to measure patient quality of life. J Am Acad Dermatol 1999

Aug; 41 (2 Pt 1): 189-96

42. Ware Jr J, Kosinski M, Keller SD. A 12-Item Short-Form Health Survey:

construction of scales and preliminary tests of reliability and validity. Med

Care 1996 Mar; 34 (3): 220-33

43. Dupuy HJ. The Psychological General Well-Being index (PGWB). In: Wenger

NK,MattsonME, Furberg CD, et al., editors. Assessment of quality of life in

clinical trials of cardiovascular therapies. New York (NY): Le Jacq Publish-

ing, 1984: 170-83

44. Turner RR, Testa MA. Measuring the impact of onychomycosis on patient

quality of life. Qual Life Res 2000 Feb; 9 (1): 39-53

45. Firooz A, Khamesipour A, Dowlati Y. Itraconazole pulse therapy improves

the quality of life of patients with toenail onychomycosis. J Dermatol Treat

2003 Jun; 14 (2): 95-8

46. Potter LP, Mathias SD, Raut M, et al. The OnyCOE-t questionnaire: re-

sponsiveness and clinical meaningfulness of a patient-reported outcomes ques-

tionnaire for toenail onychomycosis. Health Qual Life Outcomes 2006 Aug; 4: 50

47. Chren MM, Lasek RJ, Flocke SA, et al. Improved discriminative and eval-

uative capability of a refined version of Skindex, a quality-of-life instrument

for patients with skin diseases. Arch Dermatol 1997 Nov; 133 (11): 1433-40

48. Szepietowski JC, Reich A, Wozniak M, et al. Evaluation of quality of life in

patients with onychomycosis using the Polish version of Dermatology Life

Quality Index. Mikol Lek 2006; 13 (3): 193-8

49. Szepietowski JC, Reich A,Weso"owska-Szepietowska E, et al. Quality of life in

patients suffering from seborrheic dermatitis: influence of age, gender and

education level. Mycoses 2009; 52 (4): 357-63

50. Katsambas A, Abeck D, Haneke E, et al. The effects of foot disease on quality

of life: results of the Achilles Project. J Eur Acad Dermatol Venereol 2005

Mar; 19 (2): 191-5

51. Szepietowski JC, Reich A; for the National Quality of Life in Dermatology

Group. Stigmatisation in onychomycosis patients: a population-based study.

Mycoses 2008; 52 (4): 343-9

52. Kowalczuk-Zieleniec E, Nowicki E, Majkowicz M. Onychomycosis changes

quality of life [abstract no. P23-20]. J Eur Acad Dermatol Venereol 2002;

16 Suppl. 1: 248

53. Millikan LE, Powell DW, Drake LA. Quality of life for patients with ony-

chomycosis. Int J Dermatol 1999 Sep; 38 Suppl. 2: 13-6

54. Lateur N. Onychomycosis: beyond cosmetic distress. J Cosmet Dermatol 2006

Jun; 5 (2): 171-7

55. Tabolli S, Alessandroni L, Gaido J, et al. Health-related quality of life and nail

disorders. Acta Derm Venereol 2007; 87 (3): 255-9

56. Gilbar P, Hain A, Peereboom VM. Nail toxicity induced by cancer chemo-

therapy. J Oncol Pharm Pract 2009 Sep; 15 (3): 143-55

57. Hong J, Park SH, Choi SJ, et al. Nail toxicity after treatment with docetaxel:

a prospective analysis in patients with advanced non-small cell lung cancer.

Jpn J Clin Oncol 2007 Jun; 37 (6): 424-8

58. Winther D, Saunte DM, Knap M, et al. Nail changes due to docetaxel: a

neglected side effect and nuisance for the patient. Support Care Cancer 2007

Oct; 15 (10): 1191-7

59. van de Kerkhof PC, Pasch MC, Scher RK, et al. Brittle nail syndrome: a

pathogenesis-based approach with a proposed grading system. J Am Acad

Dermatol 2005 Oct; 53 (4): 644-51

60. Scher RK. Brittle nails. Int J Dermatol 1989 Oct; 28 (8): 515-6

Correspondence: Prof. Jacek C. Szepietowski, Department of Dermatol-

ogy, Venereology and Allergology, Wroclaw Medical University, Ul.

Chalubinskiego, 1 50-368 Wroclaw, Poland.

E-mail: [email protected]



Documents

Health-Related Quality of Life in Patients with Nail Disorders