Dermatology Online Journal
European Nail Society Meeting
EUROPEAN NAIL SOCIETY MEETING
Florence, Wednesday November 17th 2004, 8.30 - 15.00
Black Nails: Management in Children
S. Goettman, France
Longitudinal melanonychia (LM) in children is often due to lentigo or naevus (approximately 80 %). Nail melanoma during childhood is exeptional.
Nail melanoma may develop on LM present since childhood, but not before eigtheen years old, as long as we know.
We suggest that the pigmented matrix lesion should be removed if the foreseeable nail dystrophy due to surgery is non existent or acceptable ; if not, the lesion should be under medical control once a year, all life long and taken off in case of change (enlargement, change in color).
But LM in childhood, still widening over months should be surgically removed.
Mohs' Surgery in Nail Melanoma
M. Zaiac, USA
Nail unit Melanomas pose a difficult challange because of lack of surrounding tissue. Choices of wide excision with or with out amputation are not great alternatives for the Patient. Mohs surgery which by definition is microscopically controlled, allows the physician to control the margins and spare surronding tissue. Is it really an effective choice.?
Management of the Nail Apparatus Melanoma. Present and Future
M. Laporte, M. Heenen, J. Van Geertruyden, Belgium
The management of subungual melanoma is still a subject of controversy. The difficulty of defining a guideline is related to peculiar features of this type of melanoma :
its rarity (1 - 4 % of all cutaneous melanoma)
the delay in the diagnosis (mean : 30 months).
the lack of experience, leading to a variety of treatments, assumed by a variety of specialists.
The treatment remains essentially surgical. Recently the margins have been progressively reduced without significant prognostic difference between surgical resection, distal or proximal interphalangeal amputation. Even more, Moh's technique has been proposed in melanoma presenting as longitudinal melanonychie.
A further step consists of determining the necessity of an axillary or groin lymph node dissection. Two techniques are currently used in order to precise this indication : the technique of sentinel lymph node and the PET SCAN.
As a result of the poor prognosis of subungual melanoma, immunotherapy provides interesting perspectives :
In stage II b - III IFN therapy after potentially complete excision seems to improve the free survival rate after 5 years.
In stage III - IV ; peptide based vaccines as well as dendritic cells mediated vaccines have shown some promising results, with specific cytotoxic T cells in the peripheral blood.
Immunological and clinical results of vaccins using DC pulsed with MAGE peptides with or without KLH, with or without IL 2 administration will be proposed.
Redness of the lunula can be confluent or spotted. Confluent lunular dyschromias may have numerous associated causes. Spotted lunular dyschromia has been observed in patients with alopecia areata, psoriasis vulgaris and lichen planus; it has a mottled or moth-eaten appearance characterized by punctate red spots representing small, discrete lacunae or non-white plaques.
2Nail bed redness
Usually nail bed redness results mainly from chemotherapeutic agents and vascular tumours.
3Nail plate redness
Exogenous causes are responsible for the red hue.
Longitudinal erythronychia is a longitudinal streak or band in the nail plate commencing from within the matrix and running to the point of separation of the nail bed and nail plate. At this location, the distal margin of longitudinal erythronychia may be marked by a small keratosis, arising from the nail bed and adherent to the undersurface of the nail plate. Proximal to this, there may be splinter haemorrhages in the nail bed. Beyond this point the nail plate may split in line with the erythronychia, presenting a "v"-shaped nick in the free edge. When nails are long, this sign is more prominent.
Longitudinal erythronychia may present as a single or paired band in a single nail or as multiple bands in several nails. As a single band it is likely to reflect a focal matrix pathology, such as a benign or a rare malignant tumour. Multiple bands commonly represent multifocal inflammatory disease such as lichen planus, or Darier's disease. The width of isolated longitudinal erythronychia is usually less than 3 mm and seldom significantly progresses.
E. Haneke, Germany
Abstract no received
White nails are the most common chromatic abnormality of the nails and can be divided into three main types: True leukonychia (total, subtotal and partial leukonychia, and Mee's line) with involvement of nail plate that originates in the matrix;apparent leukonychia (half-and-half nails, Terry's nail, Muerchke's line, Neopolitan nails, and onycholysis) with involvement of the subungual tissue; and pseudoleukonychia (onychomycosis) with nail plate alteration for which matrix is not responsible. Most of these types are acquired, and are associated with a systemic disease, chemical exposure, trauma or infection.
We have conducted a study on nail abnormalities in 182 haemodialysis (HD) patients and 205 renal transplant recipients (RTRs). The prevalence of white nails was increased in both groups. Onychomycosis (19.2%), partial leukonychia (10.4%) and half-and-half nails (7.7%), Terry's nail (3.3%) and onycholysis (1.1%) were the types of white nails in HD patients. Among them, only onychomycosis and half-and-half nails were significantly increased in HD patients. However, since the frequencies of onychomycosis and half-and-half nails did not increase with HD duration, these nail abnormalities were likely to be related to chronic renal failure itself.
In RTRs, partial leukonychia (21.5%) was the most common type of white nail, followed by onychomycosis (12.7%), half-and-half nails (4%), Terry's nail (2.9%) and onycholysis (2%). However, among these nail abnormalities, partial leukonychia was the only type of white nail that was related to renal transplantation. The frequency of leukonychia in this group was not correlated with neither post-transplantation interval nor treatment protocol. Therefore, the increased frequency of partial leukonychia was probably linked to immunosuppressive state.
Correcting metabolic disorders in HD patients with renal transplantation greatly reduces the frequencies of some nail changes, namely half-and-half nails and splinter hemorrhage. However, partial leukonychia increases significantly after renal transplantation.
Drug-induced Nail Abnormalities
A large number of drugs may be responsible for the development of nail changes: these include cancer chemotherapeutic agents and retinoids, but only a few classes of them are consistently associated with nail symptoms.
Drug-induced nail abnormalities result from toxicity to the matrix, the nail bed, the periungual tissues or the digit blood vessels. The most common symptoms include Beau's lines, onychomadesis, melanonychia, onycholysis and periungual piogenic granulomas. Drug-induced nail changes usually involve several or all nails. In most cases nail abnormalities are asymptomatic, but sometimes cause pain and impair manual activities.
Melanoma of the Nail Bed presenting as a longitudinal Melanonychia
E. Duhard, C. Rogez (France)
A 67-year-old man presented a longitudinal pigmented streak on the nail plate of the left thumb; this streak was less than 1 mm in width, bluish at the proximal part and had an hyperkeratotic extremity. Regarding the variegated shades of pigmentation, a biopsy was decided.
Removal of the nail plate let us see a longitudinal brown black streak spreading from the distal part of the matrix to the hyponychium, that was excised.
Histologically, the epithelium of the matrix showed an increased number of melanocytes, with a lentiginous hyperplasia and some keratinocytes necrosis. The underlying dermis was fibroblastic with a lot of melanophages. The keratotic distal part showed a lentiginous and fusion nested proliferation of melanocytes with mild atypia along the epidermal junction. There were melanophages and a slight inflammatory cell infiltrate in the dermis
As the diagnosis of melanoma was highly suspected, an excision of the entire nail apparatus was performed;
This case of melanoma in situ of the nail bed is particular because of the appearance of longitudinal melanonychia.
Elastic Gauze Anchor taping Method for ingrowing Nail, Nail Loss and Onychomycosis
H. Arai, T. Arai, H. Nakajima, E. Haneke (Japan and Germany)
Taping has been a very easy and effective treatment for mild ingrowing nail.
We improved on this method by applying additional anchor tapes prior to and with usual taping, thereby strengthening attachment and push-pull dynamics bringing about pain, inflammation and granulation tissue, while protecting the surrounding soft tissue. Applied taping which pulls the bulging away from the nail allows nail growth to proceed without interference and acts as a prosthesis.
Anchor tape is available even for cases with oozing granulation tissue or when one tape is insufficient in strength. First apply anchor tape on the finger tip around the nail vertically and or longitudinally along the nail fold including granulation tissue followed by a further tape pulled and wound around. Apply a further surgical tape anchoring and fixing the tape to nail and skin. Width and length of tape and the direction depend on each case.
Taping is also effective for the treatment of onychogryphosis and for its prevention after nail avulsion or other nail loss.
The Occurrence of fungal Infection in Individuals with clinical Nail Changes
R. Maleszka, V. Ratajczak-Stefanska, M. Rozewicka, K. Turek-Urasinska (Poland)
The inquiry and mycological research comprised 208 patients, that visited dermatologist with toenail changes. Symptoms observed in the nail organs such as: yellowish and white discoloration, thickening, subungual hyperkeratosis, onycholysis, sulcation and friability of the nail plates, that are mainly connected with onychomycosis, in over 60% of cases occurred due to nonfungal nail disorders. Fungal infection was confirmed by mycological examination in only 23% of patients with nail changes of the feet. Among the cultured fungi the majority was found to be T. rubrum 61,4%, then T. mentagrophytes 27,3% and T. tonsurans in 4,5%, C. albicans in 4,5% Fusarium sp. in 2,3% of cases. A previous antimycotic treatment was observed in 46% of all examined patients, in 23% of individuals the therapy was ineffective what was proven by positive results of mycological examinations. Results of the study show an important influence of proper mycological diagnostics on the later antimycotic treatment. Diagnosing onychomycosis of the feet one cannot rely only on clinical examination because in most of patients with typical for onychomycosis nail plate changes mycological laboratory tests do not confirm the fungal infection.
Nails fungal Infections in the Region of Slupsk-Poland
I. Moszczynska, R. Nowicki (Poland)
In the available literature, there is a lack of information concerning the epidemiology of fungal infection in the Slupsk region (North Poland).This work aims to define the number of occurrences of different clinical types of fungal infection in that region and to identify the most common factors causing each disease.
Material and methods: 2040 patients reporting different forms of fungal infection of the skin and nails were treated in Slupsk between June 1999 and December 2003.On 1034 patients the clinical form was confirmed by positive results.The mycological research used a 20% KOH + DMSO solution together with Saboraud medium and the bases Mycomedium by Biomed, Poland and Mycoline by Biomrieux, France.
The greatest number of fungal infections were diagnosed as toenail onychomycosis,of which were 411 cases,that is 39,74% .Of the 1034 cases,182 were diagnosed as nail fungus on the hands that is17.6%. Toenail onychomycosis in 191 cases(46,5%) were by T. rubrum, in 52 cases were caused by C. albicans and in 50 cases by Candida sp.(24,7% together),in 66 cases(16,1%) by T. mentagrophytes var. granulosum,in 33 cases(8,1%) by Scopularopsis brevicalis, in 16 cases(3,9%) by T. interdigitale and in 3 causes(0,7%) by Aspergillus. Clinical types of toenail onychomycosis were: DLSO-51,8%, PSO - 22,9%, WSO - 9% and TDO - 16,3%.Fingernail onychomycoses were caused in 88 cases(48,4%) by C. albicans, in 34 causes(18,7%) by T. rubrum, in 37cases(20,3%) by Candida sp., in 14 causes (7,7%) by T. mentagrophytes , in 4 causes(2,2%) by Scopularopsis brevicalis, in 3 causes(1,64%) by Aspergillus sp. and in 2 causes by T. interdigitale.
The greatest number of fungal infections in the region of Slupsk were diagnosed as toenail and fingernail onychomycoses.
Onychomycosis in Bialystok Region (East Poland)
A.A. Wronski, R. Nowicki, W. Kaczmarski, L. Kaczmarska
In the years 1999-2003 there were 15365 patients from Podlaskie Voivodship treated at the Outpatient Dermatological Clinic "Dermal.
In 2140 cases dermatophyte infection was suspected and mycological diagnostics were carried out. Culture of nail scrapings was positive in 754 cases (35,23% of all examined patients), while skin lesions were present in 1386 cases (64,77% of the tested group). The medium frequency of positive nail culture results and skin lesions calculated in the examined period was 67,78% and 47,28%, respectively. In patients with nail changes fungal pathogen was cultured in 69,99% of cases, out of which 19,28% were dermatophytes, 37,14% - yeasts and 15,71% - molds. In 21,39% of patients - dual pathogen infection was found, most frequently positive yeast and mold cultures were obtained (97 cases which is 12,86% of all positive results). Mixed fungal infection caused by: dermatophytes and yeasts and dermatophytes and molds, were found in 27 and 21 cases, respectively. The most frequently cultured yeast pathogens belonged to the Candida type, namely Candida albicans and Candida tropicalis species in 89,3% and 13,1%, respectively. The most prevalent dermatophyte pathogens belonged to Trichophyton species, mainly T. rubrum and T. mentagrophytes. In the recent years there has been a noticeable increase in the frequency of mold infection of the nail, mainly with Acremonium, Aspergillus and Scopularopisis species. The latter observation applies also to skin lesions and should draw attention to this potentially important fungal pathogen group. Undoubtedly, a very interesting idea would be assessing the elimination of fungi in the process of specific pharmacotherapy treatment in the group of patients with mixed infection caused by both yeasts and molds.