Dermatology Online Journal

Abstracts of the Sixth Meeting of the European Nail Society
Barcelona, Wednesday October 15th 2003, 9.00 - 16.00

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IS TREATING YELLOW NAIL SYNDROME WORTHWILE?
Josette ANDRÉ, CHU Saint-Pierre, Free University of Brussels, Brussels, Belgium

History1

The combination of slow growing discoloured nails and oedema was named the “yellow nail” syndrome by Samman and White in 19642. In 1966, the full triad of yellow nails, lymphoedema and pleural effusions was described for the first time by Emerson3.

Definition

Yellow nail syndrome (YNS) is a rather rare condition characterized by a triad of yellow nails, lymphoedema and respiratory tract involvement, with or without sinusitis. However, these three alterations are simultaneously present in only 27 % of cases.4

In a series of 97 patients reviewed by Nordkild1 in 1986, the yellow nails were present in 99% of the cases and were the first symptom in 37 %. The lymphoedema was present in 80%, being the first symptom in 34% and a respiratory tract involvement (mainly recurrent attacks of chronic bronchitis occasionally associated with bronchiectases, chronic sinusitis, pneumonia or pleuritis) was present in 63%, being the first symptom in 29%. YNS is most often seen in middle-aged individuals with a male/female ratio of 1/1.6.

Nails

The nail clinical aspect is characteristic: the yellow/green nails are thickened and hardened, with both transverse and longitudinal overcurvature. There may be chronic paronychia, accompanied by loss of the cuticle, onycholysis and transverse ridging. The linear nail growth is markedly reduced5.

Associations

In addition to lymphoedema and respiratory symptoms, the typical nail changes and slowed growth have been observed in association with thyroid disease, rheumatoid arthritis, the nephrotic syndrome, malignancies and immune deficiencies.6

Physiopathology

The physiopathology is not fully understood. A lymphatic functional defect, rather than an anatomic defect is now considered to be an underlying abnormality in YNS.7 An inflammatory component, which could alter both blood flow and capillary permeability would also play a role, by provoking a lymphatic overload.

As for the nails, a nail matrix biopsy was performed by De Coste8 in one case of YNS. Light microscopy revealed numerous ectatic capillaries within a sclerotic stroma. This observation has not been further confirmed and, in our opinion, it is hard to understand how this sclerosis could have spontaneously resolved. Ohkuma9 stated that the yellow nail colour was caused, partly by thickening of the nail plate and partly by deposit of a yellow substance while Reynes10 did not find any abnormal pigment by chromatographic studies. Lipofuschin accumulation in the nail plate was also advocated6 but we did not observed any lipofuschin in one of our case11. The coloration would only be caused by the dystrophic nail growth, responsible for nail thickening and structural alteration10. In 2000, Moffit and de Bercker12 showed that longitudinal growth was half the normal value, that nail thickness was double and that the number of cells in the dorso-ventral axis was greater by a factor of 1.5. They suggested that rate of nail production by the matrix was the same in affected and normal nail but that some factor produced an altered orientation of nail growth.

Treatment: Is treating YNS worthwile?

It definitely is, because yellow nails cause pain, impairment of the digital function and cosmetic discomfort13, because spontaneous regression is only observed in about 10% of the cases6 and because there are several reports of nail cure following treatments devoid of serious side effects.

Treatment modalities are however, difficult to evaluate because double-blind studies on a large number of patients is not possible in this rather rare condition. Moreover, yellow nails may have a fluctuating course and may show spontaneous improvement.

Associated pathologies, specially respiratory tract involvement but also thyroiditis, rheumatoid arthritis, nephrotic syndrome, immune deficiencies and neoplasm’s should be looked for and treated. This is important for the patient’s health and can lead to the cure of the nails.14-19 The relation between YNS and rheumatoid arthritis is more complex. Total resolution of yellow nails was reported after chrysotherapy20 while, in seven patients, resolution of yellow nails was reported after D-Penicillamine or other thiol compound treatment was stopped.21

Concerning the nails, local treatments have occasionally been reported to be effective including intralesionnal steroids (five of 10 patients)22 and topical Vitamine E23, but oral Vitamin E at a daily dosage of 800 to 1200 IU for several months, seems to be the most effective treatment 6,24-26 although not with good results in all patients.18,25 The efficacy of the drug is probably linked to its antioxidative properties.23 Zinc sulphate which is a free-radical scavenger like Vitamine E, might be an alternative.27

If an onychomycosis super infection is demonstrated, which however is a rare occurrence, it should be treated by the new oral antimycotics, specially itraconazole pulse therapy11. The latter as well as fluconazole have been shown to increase linear nail growth rate and to give some results in YNS.5,13

When there is no onychomycosis, azoles should not be prescribed on a regular basis, mainly because they are expensive.13 However, they could be tried as a last attempt, in willing patients, when everything else has failed.

References

1. Nordkild P, Kromann-Andersen H, Struve-Christensen E. Yellow nail syndrome – the triad of yellow nails, lymphedema and pleural effusions. Acta Med Scand 1986; 219: 221-7.

2. Samman PD, White WF. The “yellow nail” syndrome. Br J Dermatol 1964; 76:153-7.

3. Emerson PA. Yellow nails, lymphoedema, and pleural effusions. Thorax 1966; 21: 247-53.

4. Gupta AK, Davies GM, Haberman HF. Yellow nail syndrome. Cutis 1986; 37: 371-4.

5. Baran R. The new oral antifungal drugs in the treatment of the yellow nail syndrome. Br J Dermatol 2002; 147: 189-91.

6. Norton L. Further observations on the yellow nail syndrome with therapeutic effects of oral alpha-tocopherol. Cutis 1985; 36: 457-62.

7. Bull RH, Fenton DA, Mortimer PS. Lymphatic function in the yellow nail syndrome. Br J Dermatol 1996; 13: 307-12.

8. De Coste SD, Imber MJ, Baden HP. Yellow nail syndrome. J Am Acad Dermatol 1990; 22: 608-11.

9. Ohkuma M. Studies on yellow nail syndrome. In : Proceedings of the XVIth International Congress of Dermatology (A. Kukita & M. Seiji. Eds) Tokyo, University of Tokyo Press 1983, p775.

10. Reynes J, Bernard E, Dellamonica P et al. Un cas de syndrome des ongles jaunes. Ann Dermatol Venereol 1984; 111: 273-5.

11. Luyten C, André J, Walraevens C, De Doncker P. Yellow nail syndrome. Experience with itraconazole pulse therapy combined with vitamin E. Dermatology 1996; 192: 406-8.

12. Moffitt DL, de Berker DAR. Yellow nail syndrome: the nail that grows half as fast grows twice as thick. Clin Exp Dermatol 2000; 25: 21-3.

13. Tosti A, Piraccini BM, Iorizzo M. Systemic itraconazole in the yellow nail syndrome. Br J Dermatol 2002; 146: 1064-7.

14. Pang SM. Yellow nail syndrome resolution following treatment of pulmonary tuberculosis. Int J Dermatol 1993; 32: 605-6.

15. Pavlidakey GP, Hashimoto K, Blum D. Yellow nail syndrome. J Am Acad Dermatol 1984; 11: 509-12.

16. Cockram CS, Richards P. Yellow nails and nephrotic syndrome. Br J Dermatol 1979; 101: 707-9.

17. Danenberg HD, Eliashar R, Flusser G et al. Yellow nail syndrome and xanthogranulomatous pyelonephritis. Postgraduate Medical J 1995; 71: 110-1.

18. Guin JD, Elleman JH. Yellow nail syndrome. Arch Dermatol 1979; 115: 734-5.

19. Iqbal M, Rossoff LJ, Marzouk KA et al. Yellow nail syndrome. Resolution of yellow nails after successful treatment of breast cancer. Chest 2000; 117: 1516-8.

20. Launay D, Hebbar M, Louyot J et al. Syndrome des ongles jaunes associé à une polyarthrite rhumatoïde. Régression sous chrysothérapie. Rev Méd Interne 1997; 18: 494-6.

21. Lehuédé G, Toussirot E, Despaux J et al. Yellow nail syndrome associated with thiol compound therapy for rheumatoid arthritis. Two case reports. Joint Bone Spine 2002; 69: 406-8.

22. Abell E, Samman PD. Intradermal triamcinolone acetonide injection in the yellow nail syndrome. Trans St John’s Hosp Dermatol Soc 1973; 59: 114-7

23. Williams HC, Buffham R, du Vivier A. Successful use of topical vitamin E solution in the treatment of nail changes in yellow nail syndrome. Arch Dermatol 1991; 127:1023-8.

24. Ayres S, Mihan R. Yellow nail syndrome. Response to vitamin E. Arch Dermatol 1973; 108: 267-8.

25. Venencie PY, Dicken CH. Yellow nail syndrome: report of five cases. J Am Acad Dermatol 1984; 10, 187-92.

26. Rommel A, Havet M, Ball M et al. Syndrome des ongles jaunes : réponse à la vitamine E. Ann Dermatol Venereol 1985; 112: 625-7.

27. Arroyo JF, Cohen ML. Improvement of yellow nail syndrome with oral zinc supplementation. Clin Exp Dermatol 1993; 18: 62-4.

TREATMENT OF ONYCHOMYCOSIS : THE FUTURE
Bianca Maria Piraccini , Silvia Mantovani, Matilde Iorizzo, Antonella Tosti
Department of Dermatology University of Bologna, Italy

Dermatophytes account for more than 85% of onychomycosis, with T.rubrum being the most common pathogen. They may produce 4 different clinical types of onychomycosis, depending on the modality of nail invasion by the fungus.

Distal subungual onychomycosis

In distal subungual onychomycosis, dermatophytes reach the nail bed horny layer through the hyponychium. The affected nails show subungual hyperkeratosis, onycholysis and yellow discoloration. Distal subungual onychomycosis affects toenails more frequently than fingernails. Since the skin of the palms and soles is the primary site of infection, distal subungual onychomycosis is usually associated with tinea manum or tinea pedis.

Proximal subungual onychomycosis

Proximal subungual onychomycosis is characterized by a primitive invasion of the nail matrix keratogenous zone through the proximal nail fold horny layer. Fungal elements are typically located in the ventral nail plate with minimal inflammatory reaction. The affected nail shows proximal leukonychia that progresses distally with nail growth.

White superficial onychomycosis

In white superficial onychomycosis dermatophytes colonize the most superficial layers of the nail plate without penetrating it. The affected nail presents multiple friable white opaque spots that can be easily scraped away.

Deep white superficial onychomycosis from T:rubrum can occur in children and HIV patients

Endonyx onychomycosis

Endonyx onychomycosis is characterized by massive nail plate parasitation in the absence of nail bed inflammatory changes. The affected nail is milky-white in color. The nail plate is firmly attached to the nail bed and there is no nail bed hyperkeratosis or onycholysis.

TREATMENT

The treatment choice depends on the clinical type of the onychomycosis, the number of affected nails and the severity of nail involvement.

Topical treatment

Penetration of a topical antifungal through the nail plate requires a vehicle that is specifically formulated for transungual delivery. Two transungual delivery systems are currently available in most European countries: amorolfine 5% nail lacquer and cyclopirox 8% nail lacquer. Amorolfine nail lacquer is applied once a week, whereas cyclopirox nail lacquer is applied daily.

Nail lacquers are effective as monotherapy in the treatment of white superficial onychomycosis and of distal subungual onychomycosis limited to the distal nail of a few digits. Treatment should be prolonged for 6 to 12 months. Nail lacquers are also utilized in severe onychomycosis in combination with systemic antifungals to reduce duration of treatment and increase cure rate.

Weekly application of a nail lacquer may also prevent relapses of onychomycosis after successful treatment.

Systemic treatment

Distal subungual onychomycosis extending to the proximal nail, endonyx onychomycosis and proximal subungual onychomycosis always require a systemic treatment. Systemic treatment with terbinafine or itraconazole produces mycological cure in more than 90% of fingernail infections and in about 80% of toenail infections. These success rates can be increased by associating a topical treatment with a nail lacquer to the systemic treatment. Terbinafine is administered at the dosage of 250 mg daily or as “pulse therapy” at the dosage of 500 mg daily for 1 week a month. Itraconazole is administered as pulse therapy at the dosage of 400 mg daily for one week a month. Treatment duration is 2 months for fingernails and 3 to 4 months for toenails.

Data about efficacy of fluconazole in the treatment of onychomycosis are recent and require additional studies to definitely establish optimal dosages and treatment duration. The approved dosage of fluconazole is 150 mg/once a week, but higher dosages (300 mg/once a week) are probably more effective. Treatment should be prolonged for at least 6 months.

Chemical or surgical nail avulsion can be used in association with oral antifungals in order to remove localized fungal masses in total onychomycosis and dermatophytoma. Sequential treatment with itraconazole and terbinafine has been utilized to increase cure rates: the suggested regimen is 2 pulses if itraconazole 400 mg/day for 1 week a month followed by 1 or 2 pulses of terbinafine 500 mg/day for 1 week a month. Mycological cure can be evaluated at the end of treatment. Evaluation of clinical response, on the other hand, requires several months due to the slow growth rate of the nail. Recurrences and reinfection are not uncommon (up to 20% of cured patients). They may be prevented by the regular application of nail lacquers on the previously affected nails and topical antifungals on soles and toewebs.

Onychomycosis due to moulds is becoming increasingly common worldwide

Non-dermatophytic moulds account for up to 15% of nail infections in Bologna. Moulds that are responsible for onychomycosis include: Scopulariopsis brevicaulis, Acremonium sp., Aspergillus sp., Fusarium sp., Scytalidium sp., Onychocola canadensis and Alternaria sp.

Mould onychomycosis can often be clinically suspected due to the presence of periungual inflammation.

Treatment with systemic antifungals is very effective in onychomycosis due to Aspergillus sp. Scopulariopsis brevicaulis, and Fusarium sp. infection are difficult to eradicate and treatment with systemic antifungals should always be associated with topical treatment with nail lacquers.

Candida onychomycosis is always a sign of immunodepression. Systemic treatment with itraconazole or fluconazole is usually effective, but relapses are very common.

The Nail In Forensics
C Ralph Daniel, Melissa P Daniel, F. Emily Bell, Jonathan G Daniel

The nail plate may act as a window into the body primarily due to its close approximation to the nail vascular bed and the nail matrix.It may be analyzed for DNA source, metamphetamines,sodium and potassium levels in cystic fibrosis, copper in Wilson's Disease, and heavy metals.

We briefly report 3 cases that the apprearance of Mees's lines then the nails subsequent analysis for arsenic helped solve 3 murder cases.

For heavy metals especially, the great toenail is best to analyze because it is less exposed to the environment and takes about a year or longer to grow out. Gas chromatography, mass spectometry, and atomic absorption and emission may be utilized for analysis.

Arsenic is considered a "general protoplasmic poisoning agent".It has an affinity for sulfhydroxyl groups and may inhibit oxidative phosphorylation.Elemental arsenic is not as toxic as As3 or As5.

We are exposed to arsenic daily in water, foods, air, byproducts of mining and smelting, pesticides, herbicides, etc.

nails or hair containing more than 3 micrograms per gram are considered diagnostic of arsenic poisoning.

Other than Mees's lines, the nails may also exhibit in arsenic poisoning: slower growth, Beau's lines, onychomadesis, discoloration,etc.

Significantly elevated mercury levels may be associated with increased risk of MI.

Don't forget, always examine the nails!

THE HAIR IN FORENSIC MEDICINE
Antonella Tosti
Department of Dermatology, University of Bologna, Italy

Some cases of drug abuse and poisoning can be suggested by examination of hair and be confirmed by analysis of hair clippings.

Hair analysis is also very useful to identify doping practice in professional athletes. Doping substances that can be detected in hair include clenbuterol, corticosteroids, ephedrine, methenolone, nandrolone metabolites, salbutamol, stanozolol and testosterone.

The storage of both nandrolone and its metabolites (norandrosterone and noretiocholanolone) in hair samples permit to discriminate between intake of doping agents and intake of other 19-norsteroids such as norandrostenedione and norandrostenediol which are available in over the counter vitamin supplementations

Hair samples may be very useful in cases of drug abuse since the detection of the drug together with its metabolites in these tissues may confirm intake of the incriminated substance followed by metabolism 4. Exogenous exposure to substances is excluded by the presence of its metabolites.

Hair analysis is useful for monitoring treatment compliance in psychiatric, epileptic and HIV patients .

Hair exposure to chemicals may produce hair discoloration as in the case of green hair (copper from water or cosmetics) or blue hair (cobalt workers).

Hair loss is an evident symptom of some poisoning which may lead to the diagnosis Poisoning can also be diagnosed from hair analysis. Poison from heavy metals is characteristically associated with hair loss. Arsenic and thallium produce hair loss and poisoning may be diagnosed by dosing the metals in hair sampling. Thallium poisoning causes a very acute and severe anagen effluvium with involvement of scalp, eyelashes, the lateral portion of eyebrows and body hairs. Hair loss starts 2 weeks after poisoning. Hair loss is a diagnostic sigh of mercury poisoning. Other symptoms include hair loss, stomatitis, neurological and mood disturbances, nail pigmentation

A large number of trace elements can be detected in hair samples, but the vast majority comes from the environment, for example from pollution and cosmetics. For this reason hair samples can be utilized to evaluate environmental exposure to pollutants (lead, nicotine).

DNA typing can be easily performed on plucked hair and dandruff scales .

Dosage of androgens in terminal scalp hair may provide a basis for predicting baldness: the ratio of testosterone-epitestosterone being significantly greater in the hair of balding fathers and their sons than in the hair of non balding control subjects .

References

1. Pichini S, Altieri I, Zuccaro P, Pacifici R. Drug monitoring in nonconventional biological fluids and matrices. Clin Pharmacokinet 1996; 30:222-8.

2. Jurado C, Kintz P, Mendez M, Repetto M. Influence of the cosmetic treatment of hair on drug testing. It J Legal Med 1997; 110:159-63.

3. Kintz P, Cirimele V, Ludes B. Discrimination of the nature of doping with 19-norsteroids through hair analysis. Clin Chem 2000; 46:2020-2.

4. Tromme I, Van Neste D, Dobbelaere F et al. Skin signs in the diagnosis of thallium poisoning. Br J Dermatol 1998; 138:321-5.

5. Hubler WR. Hair loss as a symptom of chronic thallotoxicosis. South Med J 1966; 59:436-42.

6. Lorente M, Entrala C, Lorente JA et al. Dandruff as a potential source of DNA in forensic casework. J Forensic Sci 1998;43:901-2.

7. Herber B, Herold K. DNA typing of human dandruff. J Forensic Sci 1998;43:648-56.

8. Choi MH, Kim KR, Kim YT, Chung BC. Increased polyamine concentrations in the hair of cancer patients. Clin Chem 2001; 47:143-4.

9. Bernard L, Vuagnat A, Peitavin G et al. Relationship between levels of indinavir in hair and virologic response to highly active antiretroviral therapy. Ann Intern Med 2002; 137:656-9.

10. Choi HM, Yoo YS, Chung BC. Biochemical roles of testosterone and epitestosterone to 5α-reductase as indicators of male pattern baldness. J Invest Dermatol 2001; 116:57-61.

11 Daniel III C R, , Piraccini B M , Tosti A, The nail and hair in forensic medicine J Am Acad Dermatol (in press)

LONGITUDINAL MELANONYCHIA
Veronique BLATIÈRE.
Department of Dermatology, Saint Eloi University Hospital, Montpellier, France

To (“punch”) biopsy or to excise: that is the question!

But, why?

Because, a pigmented nail presents a diagnostic challenge for both dermatologists and pathologists.

• The first concern with a pigmented streak is life threatening: it can represent an early melanoma. Nail melanoma is a rare form of coetaneous melanoma with a poor prognosis.

• The second concern is that an accurate histological diagnosis of nail melanoma is difficult, and dependent on an adequate and representative biopsy specimen. (4).

• At last but not the least, is the concern of scarring: there is a risk of permanent dystrophy if the nail matrix excision is wider than 3 mm which is not acceptable for benign lesions which are the most frequent, and especially, in young children.

Clinical presentation. The causes of longitudinal melanonychia are numerous and often impossible to differentiate clinically from one another. Careful examination of the lesion, general physical examination, history (racial origins, family history, drug ingestion hobbies…) must be evaluated. (1, 2, 3, 4).The “ABC” rule for clinical detection of subungual melanoma (5) are clinical steps to be kept in mind when examining a longitudinal melanonychia.

A Age PEAK: 5TH-7TH DECADES

RACE : AFRICAN-AMERICAN, NATIVE AMERICAN, ASIAN

B BAND

BREADTH

BORDER Brown, Black (pigment)

≥ 3mm

irregular/ blurred

C CHANGE Rapid increase

D DIGIT Involved: Thumb > Hallux > Index digit

Single digit > multiple digits

Dominant hand

E EXTENSION Extension of the pigment to involve proximal or lateral nail fold (Hutchinson sign) or free edge of nail plate

F FAMILY Or personal history of previous melanoma or dysplastic nevus syndrome

Dermoscopic examination. (6, 7)This non invasive diagnostic technique provides useful information that could help the clinician. It allows better management of nail pigmentation distinguishing first non melanic (haematoma is very common) from melanic pigmentation. Some criteria are provided to separate melanocyte activation from proliferation. Dermoscopy can give additional information for early melanoma diagnosis and allows the dermatologist to more accurately decide if an invasive procedure should be performed. But good training is necessary.

Clinician judgement/Patient information

The clinician has to decide on whether to biopsy or not, to perform surgery or follow-up, such as in any cutaneous pigmented lesion. In children, nail melanoma risk is very low but not zero (10, 11, 12, 13). The remote chance of discovering a nail melanoma must be weighted against the risk of general anaesthesia and the potential permanent cosmetic damage. The patient (or the parents) should be informed of what to deal with as it was proposed, in the last ENS meeting, by David De Berker:

• wait and see: annual and permanent follow-up
• partial biopsy and follow-up for the persistent band. This may lead to another biopsy in case of further modifications. There is, however, a risk of dystrophy and to develop a nail melanoma because clinical and histological diagnosis is more difficult in this case.
• Complete excision which leads to a dystrophy or the nail loss but an optimal diagnosis.

Tissue diagnostic is required in adults, when a combination of clinical features is present (4, 5). Diagnostic may be delayed because biopsy specimens are small, fragmented, difficult to orientate and often infected (14). The melanocytes of the nail matrix are frequently found irregularly distributed in a suprabasal or basal position either as single cells or clustered in small groups of three or four cells. This upward scatter of nail melanocytes which is especially prominent in the proximal matrix can make the diagnosis of in situ melanoma difficult and lead to overdiagnosis. Melanocytes are also present in nail bed but fewer in number compared with those of the nail matrix. Adjacent, apparently normal skin is of great importance for the diagnosis of nail melanoma, and, to preclude recurrence.

The biopsy method which is finally selected depends on: (3)

• the clinical index of suspicion for a nail melanoma,
• the need to select a procedure that will minimize dystrophy,
• the band location (lateral or medial),
• the band width,
• the matrix origin (proximal or distal). By cutting the free edge of the plate, the location of the melanin (Fontana-Masson staining) is revealed. If the pigment is dorsal, then the lesion is located in proximal matrix; if it is ventral, it is in the distal matrix which is the most common.

The lateral longitudinal biopsy is for many authors the gold standard and is indicated when the streak involves the lateral fold. The cosmetic result is excellent with a narrowed nail and a light deviation of the nail towards to the side of the biopsy. (9, 14, 15)

• The punch biopsy: is indicated when: the band is less than 3mm, (because the risk of melanoma is very low) the band is located on the mid portion of the nail bed or on the lateral third (3). The main criticism is that the specimen is often incomplete and the plate often missing. Thai (14) pointed out that, with the punch biopsy method, if the histologic report comes back as normal, is it a false negative, and the biopsy site missed, with a potential of missing the malignant focus?
• The transverse elliptic excision is indicated when the band is 3-6mm wide. There is a risk of dystrophy wherever the lesion is located: on the two distal thirds or on the proximal matrix. The releasing flap method of Schernberg and Amiel is indicated in the latter.
• The “en bloc” excision is highly recommended when the band is wider than 6mm. The underlying disease process is unlikely benign. To delay the reconstruction procedure is recommended.

Scarring. It is unlikely to occur when the distal matrix is involved, when the band is located in the lateral third of the nail plate, when the band is thin. Dystrophy (split) and pterygium are common. The appearance is less crucial in the toes than in the fingers. Women are more affected about it than men. In elderly patients, it is of less concern. Function integrity is essential in the fingers. (3)

Conclusion. Accurate diagnosis needs adequate and oriented specimens to allow multiple sections. Partial biopsy should be avoided: it leads to misdiagnosis and tough follow-up Though, the punch biopsy method should be only indicated when it realizes a complete excision of the longitudinal melanonychia.

References

1. Baran R, Kechijian P. Longitudinal melanonychia (melanonychia striata) : diagnosis and management. J Am Acad Dermatol. 1989 ; 21 : 1165-1175.

2. Baran R, Kechijian P. Hutchinson’s sign : a reappraisal. J Am Acad Dermatol. 1996 ; 34 : 87-90.

3. Baran R, Dawber Rp. Diseases of the nails and their management. Oxford:BlackwellScientific Publications, 2001: 1-644

4. Banfield CC, Dawber RP. Nail melanoma : a review of the litterature with recommendations to improve patient management. Br J Dermatol. 1999 ; 141 : 628-632

5. Levit EK, Kagen MH, Scher RK, Grossman M, Altman E. The ABC rule for clinical detection of subungual malignant melanoma. J Am Acad Dermatol. 2000 ; 42 (2,pt1) : 269-27

6. Ronger S, Touzet S, Ligeron C, Balme B, Viallard AM, Barrut D, Co Thomas L. Dermoscopic examination of nail pigmentation. Arch Dermatol. 2002 Oct ; 138 (10) : 1327-33

7. TostiA: Dermoscopy allows better management of nail pigmentation .Arch Dermatol 2002;138:1369-70

8. Bali D, Casanova D, Aharoni C, Mutaftschiev N, Cilirie K, Legre R. Longitudinal melanic nail bands (melanonychia): report of 2 cases. Chir. Main. 2002 ; Jul ; 21(4) : 225-34

9. De Berker DAR:Lateral longitudinal nail biopsy. Australas J Dermatol 2001;42, 142-144

10. Goettmann S, André J. Longitudinal melanonychia in children, a clinical and histological study of 40 cases.J Am AcadDermatol 1999;41:17-22.

11. Goettmann S. Nail pathology in children. Rev Prat. 200 Dec 15 ; 50 (20) : 2256-61

12. Goettmann S. Pigmented lesions of the nail apparatus. Rev Prat. 2000 Dec 15 ; 50 (20) : 2246-50

13. Tosti A, Baran R, Piraccini BM, Cameli N, Fanti PA. Nail matrix nevi : a clinical and histopathologic study of twenty-two patients. J Am Acad Dermatol. 1996 ; 34 (5, pt 1) : 765-771.

14. Thai KE, Young R, Sinclair RD. Nail apparatus melanoma. Australas J Dermatol. 2001 May ; 42 (2) : 71-81 ; quiz 82-3

15. Marin Braun F, Lorea P, Ameziane L, Dury M. Wedge excision : a new reconstructive technique after longitudinal nail biopsy. Chir. Main. 2002 Oct ; 20 (5) : 337-41

16. Bali D, Casanova D, Aharoni C, Mutaftschiev N, Cilirie K, Legre R. Longitudinal melanic nail bands (melanonychia) : report of 2 cases. Chir. Main. 2002 ; Jul ; 21(4) : 225-34

E-NAIL CLINICS A TERTIARY REFERRAL PROCESS FOR NAIL DISEASE
David de Berker
Bristol Dermatology Centre, Bristol Royal Infirmary, Bristol, UK

Members of the European Nail Society are able to share images and thoughts on unusual or challenging cases of nail diseases using e-nail. This is a network of colleagues who communicate using a proforma for summarising patient history, signs and investigations which can be attached to an e-mail alongside a digital image. Details of this process and access to it are through membership of the European Nail Society as outlined on the society web site. http://www.euronails.org/

The interactive presentation takes the audience through a range of cases that have been exchanged through the year and aims to highlight the variety of diagnostic and therapeutic choices made by experienced nail clinicians.

PAIN CONTROL IN NAIL SURGERY
Philippe ABIMELEC M.D
Hôpital Saint-Louis, Paris, France, abimelec@noos. fr

Since nail surgery can be extremely painful, pain control is an important issue. In the absence of complications, post-op pain may last up to 48 hours. Pain management requires pre, peri and post-operative intervention. Pre-operative measures include the use of anxiolysis with Midazolam. The use of anesthetic creams prior to distal digital anesthesia is valuable for children. The use of nerve blockades with long acting anesthetics enhance post-operative analgesia for up to 24 hours after the surgery. Finally, post-operative measures rely on a pharmacological intervention, the prescribed analgesic should be chosen according to the anticipated level of pain.

Preoperative anxiolysis is not mandatory but offers numerous advantages. Benzodiazepines are the most widely used medication for relief of anxiety. Midazolam is favoured because of its higher potency and shorter duration. Short-acting midazolam offers hypnotic, anxiolytic, and anterograde amnestic properties which are advantageous because patients often do not remember the pain associated with local nerve blocks. Pre-operative children local anesthesia includes the use of anesthetic creams before local anesthetic injections. Topical anesthesia with an anesthetic cream is effective for the pain associated with the needle prick. We recommend its use over the proximal nail fold before a distal digital anesthesia with lidocaine. Local anesthesia through the proximal nail fold will then act as a field block to anesthetize the proximal digit before painful matrical or lateral distal digital infiltrations. The proximal nail fold skin injection may be done one hour after EMLA cream has been placed over it and the lateral digit under occlusion. The cream should be applied in sufficient quantity; a three mm layer is usually preferred. We only infiltrate the skin over the PNF and the lateral digit with less than one milliliter of 2% lidocaine. We wait ten minutes before deep lateral digital and/or matrical infiltrations with plain 1% lidocaine may be done. The use of nerve blockades with long acting anesthetics enhances post-operative analgesia for up to 24 hours after the surgery. These procedures are used when post-operative pain is anticipated as for latero-longitudinal excision, flaps or total nail unit excision. Transthecal digital anesthesia and axillary blocks may be performed either Bupivacaine or the more recent Ropivacaïne. Ropivacaine is a long-acting, amide local anesthetic. The drug is less cardiotoxic than bupivacaine but more so than lidocaine.

Peri-operative measures to alleviate post-op pain include wound tension control. Wound tension should be kept as minimal as possible. Undermining should be done when necessary and the wound should be closed with a limited number of stitches to facilitate drainage. When the avulsed nail plate is put back in place, openings should be made at the base, extremity or laterally to insure drainage. In case of matrix surgery, the proximal avulsed nail plate may be put back in place after a transversal recut which offers the necessary opening drainage. Larger nail bed fusiform excisions may require large undermining and contro-lateral incisions in the lateral sulci. The nail plate is put back in place after an anterior triangular and lateral nail plate operation, recuts are done to facilitate post-operative drainage. The nail plate may then be sutured to the hyponychial skin.

Post-operative measures rely on a pharmacological intervention. The analgesic should be chosen according to the anticipated level of pain that we will review. Initiation of therapy requires titration of the chosen analgesic to optimal dose and interval with a nyctohemeral drug delivery. The analgesic should be given at regular intervals depending on the drug elimination half life and before the reappearance of the pain. Adaptation of doses and analgesic strength levels is necessary. In the absence of sedation, the physician should not hesitate to repeat the initial dose or to increase the analgesic level to achieve satisfactory pain relief. Pain level associated with nail surgery is variable. In my experience, surgical techniques that induce an intense level of pain are latero-longitudinal excisions, Shernberg ’s flap and total nail unit removal. Simple excisions and biopsies are moderately painful whereas avulsions and segmental matricectomies generate a low level of pain.

Initial drug choice depends on the expected level of pain. Painful procedures require step 2 or step 3 levels of analgesia from the onset. Step 1 refers to a low to moderate level of pain for which acetaminophen or non steroidal anti-inflammatory drugs are used. Step 2 refers to a moderate level of pain. Mild opioid narcotic analgesics are recommended at this step. They include: dextropropoxyphen, tramalol, dihydrocodein and opioid cyclooygenase combinations such as acetaminophen + codein and dextropropoxyphen and codein.

Step 3: refers to intense pain that is not alleviated by step 2 measures. Narcotic analgesics used are morphine and morphine derivatives such as buprenorphine.

Philippe Abimelec M. D: 129, rue Caulaincourt, 75018 Paris, France and Hôpital

Saint-Louis, policlinique de dermatologie 1, avenue claude vellefaux, 75475 paris cedex 10. France. abimelec@noos. fr

How to avoid bleeding in nail surgery
L.Plusjé
Leiden University Medical Centre, The Netherlands

Surgery of the nail unit causes inevitable bleeding because it involves highly vascularised tissue (1). Careful preoperative planning as well as intra- and postoperative precautions contribute to minimize bleeding, promote healing and facilitate the surgical procedure.

A pre-operative interview provides valuable information to the presence of e.g. neurovascular diseases, intoxications, coagulation disorders and the use of anticoagulants which may alter peripheral blood flow and bleeding time. Especially aspirin and warfarin are being frequently prescribed to patients with a history of cardiovascular, cerebrovascular and thromboembolic events. Also non-steroidal anti-inflammatory drugs interfere with blood clotting. Recent studies have shown that continuation of these drugs although they may cause more profuse and prolonged bleeding during the operation, do not influence the final result nor increase the risk of complications (2). If to the patient the risk of discontinuation is too great, it is advised to continue aspirin or reduce the warfarin dosage three days prior to surgery. As a guide line the INR (International Normalized Ratio) should be below 2.5. This decision however has to be made in every individual case (2,3,4).

Also the indication for nail surgery has to be taken into account. In case of a highly vascularised subungual or periungual tumours or inflamed tissue one should be prepared for more profuse bleeding.

During the operation bleeding can be kept to a minimum by applying a tourniquet of some sort or having the patient put on a sterile glove of which the tip is cut of and the finger rolled down to the base of the treated digit. The digital nerve bloc most often used, causes some compression of the digital arteries but this effect is more profound with a distal wing bloc. If several digits on the same extremity have to be operated on an intravenous regional anaesthesia could be useful, because in this technique all blood is being evacuated from the limb (5). One should avoided unnecessary tissue damage. No electro coagulation on nail tissue, only bipolar coagulation on surrounding soft tissue in case of flap reconstruction if needed. In specific cases a carbon dioxide laser can be used, thereby simultaneously reducing blood loss even further (6).

Post-operative a bulky compressive bandage reduces blood loss, absorbs blood that exudes from the wound and protects against inadvertent trauma. Patients have to be advised to keep the limb elevated for 24 to 48 hours. This reduces bleeding, swelling and pain and promotes rapid healing.

If post-operative bleeding nevertheless does occur it hardly ever leads to any serious complications even when grafts are used. Small haematomas will be absorbed spontaneously; large haematomas should be evacuated in order to decompress the tissue and reduce the risk of inflammation.

Paying attention to the measures and considerations mentioned will contribute to achieving better results in nail surgery

References

1. Baran R, Dawber RPR: Diseases of the Nails and their Management. 2e edition Blackwell Science.

2. Alcalay J. Cutaneous Surgery in Patients Receiving Warfarin Therapy. Dermatol Surg. 2001;27:756-8.

3. Kovich O, Otley CC. Thrombotic complications related to discontinuation of warfarin and aspirin therapy perioperatively for cutaneous operations. J Am Acad Dermatol 2003;48:233-7

4. Stables G, Lawrence CM. Management of patients taking anticoagulant, aspirin, non-steroidal anti-inflammatory and other anti-platelet drugs undergoing dermatologic surgery. Clin Exp Dermatol 2002;27:432-5.

5. Blaheta HJ, Deuasch H, Rassner G et.al. Intravenous regional anesthesia (Bier’s block) is superior to a peripheral nerve block for painless treatment of plantar hyperhidrosis with botulinum toxin. J Am Acad Dermatol 2003;48:301-2.

6. Berlin AL, Billich RC. Use of CO2 laser in the treatment of periungual fibroma’s associated with tuberous sclerosis. Dermatol Surg. 2002; 28(5):454-6.

PHENOL. HOW AND WHEN.
VICENTE DELGADO FLORENCIO, FRANCISCO MENDOZA GUIL, FJ DELGADO CEBALLOS
FACULTAD DE MEDICINA. HOSPITAL UNIVERSITARIO. UNIVERSIDAD DE GRANADA. ESPAÑA.

INTRODUCCIÓN.

Phenol is used as an ungual treatment since decades, specially in total and partial matricectomy, among the destruction of tissue that makes it application. Finding among its indications some types of ingrown toenails, onychogryphosis and pincer nail.

We comment the materials, the technique, the indications, contraindications and we finish making personal comments on the technique.

Phenolization is presented as an outstanding alternative between the different techniques guided to destroy the nail matrix (4).

MATERIAL AND METHOD:

Indications: it can be can use when we want to produce a partial or total matricectomy. Therefore its indications can be: Onychocriptosis: stage III, stage I when medical care failure and stage II according to some authors. Onychogryphosis. Pincer nail. And, some onychomycosis with nail hipertrophy and not respond to medical treatment.

Instruments: holed clothing, sterile cloth, absorbent cloth , 2% mepivacain, insulin syringe, insulin needle, hemostats, Kocher pincers, Freer septum elevator, handle of scalpel small with nº 15 blade, straight scissors with fine tip, Penrose drains or cutted sterile glove, 85% liquefied phenol, cotton swabs, non-adherent, gauze and gelfoam pads, finger bandage, sticking plaster.

Technique: field Preparation: patient in supine position, we place the absorbent cloth behind the feet and proceed to brush with a topical antiseptic (povidone iodine), sterile cloth under and proximal to the foot. We cover the rest of the foot with a sterile holed clothing, only leaving to the overdraft the finger to treat. Anesthesia: we use the proximal digital block, injecting, about 4 ml of 2% mepivacain. We massage the toe and wait for 5 minutes approximately. In specially anxious patients it is useful giving them a short/half-life benzodiazepin 30 minutes before starting.

Total matricectomy: Suitable in pincer nail, onychogriphosis and exceptionally in recalcitrant onychomycosis. The Freer elevator is introduced under the free edge of the nail plate and pushed proximally, then is pulled or rocked from side to side until the entire nail is freed. Next the nail plate is secured with the Kocher pincers and easily removed with a rolling motion.

We make 2 cuts with the nº 15 scalpel along the proximal side of the lateral nail plate. we obtain this way a flap that leaves to the overdraft the proximal matrix. We lift the torn piece back, holding it with two stitches.

Now an exanguinating tourniquet is applied in the proximal part of the toe for avoid bleeding that inactives phenol and proceed to apply it with enough pressure for about 45 seconds, repeating twice. We will put special emphasis in the lateral borders and in the proximal matrix. In order to avoid surrounding tissue damage we apply paraffin. One way to check the effectiveness of phenol is watching the tissue color turning that changes from white to a bluish hue. We move away the tourniquet and the 2 clamp suture stitches and proceed to replace the flap trough one ore two stitches each side.

Segmental matricectomy. It is used in onychocriptosis. Here we only cut a longitudinal nail band. With some pointed scissors or else the scalpel, we carry out a cut following the axis of the toe trough the nail fold. We should continue the incision proximal to facilitate the later boarding of the proximal matrix. With object of softening the fingernail is convenient that, previous to the intervention, the patient has in soaking the foot during about 20 minutes. We introduce the Freer elevator among the main distal and the plate located externally to the cut, we separate it and we move away with Kocher pincers. Phenol solution is applied as described up in total matricectomy.

In both techniques we clean con sterile saline, brush with povidone iodine and and proceed to cover with clotting agent to avoid bleeding, covering with non-adherent pad, gauze pads and 5 cm wide bandage. Relative rest is indicated and oral analgesia is recommended.

We carry out revisions, an initial to the second day where the bandage is retired and povidone iodine, covering with sterile dressings is applied. In the following revisions eschares are retired, any significant granulation tissue is corrected with silver nitrate stick and bacterial cultures are taken if any sign of infection is seen. Wound healing takes place in about 15 days. We seek advice a normal life according to symptoms, only bathing in swimming-pool and sea is forbidden until the complete healing.

In the moment of the discharge it is recommended: wide and well aired footwear, use rational of the sport shoes and cut the nails straight across leaving the corners reach out from the toe. To the 3 months of the last one visit another it is carried out a control revision to check that there is not relapse.

DISCUSSION

It exists in the literature about nail matrix phenolization great number of opinions in relation to indications, technique and results.

In general the following indications are accepted.: painful onychogriphosis and ingrowing toenail in advanced stages or when medical care is failure (16). Some authors include: paronychia (14), onichausis (11), chronic painful, distorted nail conditions, onychomycosis (15).

As contraindications (when making studies) are included: distal perfusion anomalies, diabetes, history of autoinmune disease, inmunosupressive drugs, current anti-inflamatory, antimalarial, cytotoxic, beta blocker, anticoagulant drug therapy, iron deficiency anemia, vitamin deficiency or malnourishment disorders (5). For other they don't suppose contraindication. (8)

All the authors avoid adrenalin as a vasoconstrictor and use complete digital block with 1-2% lidocain, 5% marcain (9).

Most prefers to place the tourniquet after the anesthesia. using a Penrose drain or else a piece of glove, there also who carries out a previous compression to leave bloodless the toe. It can also be applied manual pressure in the moment of the phenolization (3). The time of isquemia should not overcome 15 minutes to reduce the liberation of toxic metabolits and the postintervention pain . This is the reason we prefer aplying the tourniquet just before phenolization. The importance of the isquemia resides in that phenol inactive blood.

To protect the rest of tissues of the clotting that produces the phenol, paraffin is used. We don't believe that the agent has importance, but if the protection. Liquefied phenol used varies from 80% to 88%.

The time of phenol application is very variable according to the author. It is of importance to apply it with pressure on the tissues then this bears a great reduction of the process. It goes from 30 seconds to 5 minutes. (3). It can be helpful watch the color change of the tissue when phenol reaches its effectiveness, that turns from pink to white-grayish. Most of the works emphasize the proximal and lateral fold without forgetting that the roof that also is nail plate synthesizer.

Not all the authors defend the inactivation of the phenol excess (3). Among the used agents the alcohol , 20% ferric chloride(1) and sterile saline highlights. We don't carry out neutralization in a deliberate way, because we don't believe that it is necessary, however we clean the blood and paraffin remains from the toe with sterile saline when finishing.

Postoperative wound healing can be made by diverse methods: povidone iodine, amorphous hydrogel dressing, paraffin gauze don’t enhance the rate of healing or decrease infection rates, but with amorphous hydrogel dressing develops acute hypergranulation tissue (5). In our experience we apply non-adherent and gelfoam pads and cover with gauzes and bandage, in the following cures we apply povidone iodine and non-adherent pad and gauzes and bandage. When granulation tissue appears we use silver nitrate stick in order to reduce it. Debridament may be necessary when eschar is found. We advise patients to stay with the toe exposed as more as possible.

Cheat of healing is variable, more than by the technique by the including. Our time of “cure” it is located around the 15 days, and we consider as such when the patient can return to his daily tasks.

Some authors take wound cultures, S. aureus is the most frequently identified organism, others are E. coli, S. epidermidis, S. faecalis, pseudomonas species. They are found in more than 85% of the cases (14).

The results of this technique are very variables. They go from the absence of relapses to 25% (6). In general they are smaller to those of other techniques than don't include the destruction of the matrix (10,13). Avoiding the relapses depends more than the degree of training that of the technique (6).

As advantages on other techniques highlight: the pain absence that comes given by the anesthesia that phenol produces on the nervous terminations, the possibility to walk and to develop an almost normal life from the beginning, smaller persistence of symptoms and higher degree of satisfaction (2). It doesn't also require specialized team, the necessary time of operation it is scarce and one can even make on infected fingernails(12). As disadvantage we found that the time of cure is longer than with other techniques. Other authors don't find differences (7).

Personal comments to the phenolization:

1- These techniques can be done sat down by what it is of utility having a stool

2- The introduction of the foot in lukewarm water during 20 minutes facilitates the extraction and court of the fingernail

3- Great part of the postoperative pain is due to an excessive time of permanency of the tourniquet. For this reason we prefer to only place it during the application of the phenol.

4- When bleeding takes place after the retreat of the tourniquet you can place gelfoam pad dressing. We prefer to make the postoperative cure dries off, only applying povidone iodine. Wound healing is faster and creation of granulation tissue is reduced. In the total matricectomy we apply after the intervention antibiotic ointment, continuing later since with povidone because the risk of granulation tissue is smaller

5- In the successive revisions after partial matricectomy can be necessary the application of silver nitrate to avoid the formation of granulation tissue.

References

1. Aksakal AB, Atahan C, Oztas P, Oruk S. Minimizing postoperative drainage with 20% ferric chloride after chemical matricectomy with phenol. Dermatol Surg 2001. 27: 158-160

2. Beaton DF, Kriss SM. Ingrowing toenails: a patient evaluation o phenolisation versus wedge excision. Chiropodist 62-64

3. Dagnail JC. The history, development and current status of nail matrix phenolisation. Chiropodist 1981; 36:315-324

4. Delgado Florencio V, Fernández Pugnaire MA. Tratamiento quirúrgico de las onicopatías. In dir Serrano Ortega S, Soto de Delás J, Moreno Giménez JC. Dermatología Cosmética. Ed Aula Médica. 2002. Madrid. Pag 669-682.

5. Dovison R, Keenan AM. Wound Healing and infection in nail matrix phenolization wounds. Does topical medication make a diference?. J Am Podiatr Med Assoc. 2001; 91:230-233

6. Fulton GJ, O´Donohoe MK, Reynolds JV, Keane FBV, Tanner WA. British Journal of Surgery 1994; 81:1074-1075.

7. Gerritsma-Bleeker CL, Klaase JM, Geelkerken RH, Hermans J, van Det RJ. Partial matrix excision or segmental phenolization for ingrowing toenails. Arch Surg 2002. 137:320-325

8. Gialcalone VF. Phenol matricectomy in patients with diabetes. J foot ankle surg. 1997. 36:464-5

9. Greig JD, Anderson JH, Ireland AJ, Anderson JR. The surgical treatment of ingrowing toenails. J Bone Joint Surg. 1991; 73:131-3

10. Herold N, Houshian S, Riegels-Nielsen P. A prospective comparison of wedge matrix resection with nail matrix phenolization for treatment of ingrown toenail. J foot ankle sur 2001. 40:390-395.

11. Johnson DB, Ceilley RI. A revised Technique for ablation of the matrix of a nail. J Dermatol Surg Oncol 1979; 5:642

12. Kimata Y, Uetake M, Tsukada S, Harii K. Follow-up study of patients treated for ingrown nails with the nail matrix phenolization method. Plast reconstr surg 1995. 95:719-724

13. Légaré F, Dubé S, Naud A, Laperrière L, Turcot L. Récideives et niveau de satisfaction post-onysectomie avec ou sans phénolisation. Can Fam Physician . 1999; 45:926-931.

14. Rinaldi R, Sabia M, Gross J. The treatment and prevention of infection in Phenol Alcohol Matricectomies. Journal of the American Podiatry Association. 1982; 72:453-457.

15. Salasche Stuart J. Surgery. In dir Scher RK, Daniel CR. Nails: therapy, diagnosis, surgery. Ed W.B. Saunders Company. Phyladelphia 1997.

16. Zuber TJ, Pfenninger JL. Management of ingrown toenails. American Family Physician. 1995;52:181-188

ANESTHESIA OF THE NAIL APPARATUS: TECHNIQUES AND TIPS
B. Richert, MD, PhD
Dermatology Department, University of Liège, Belgium

A good knowledge of the techniques of anesthesia of the nail apparatus is mandatory in order to have surgery at that site comfortable, both for the patient and surgeon. If pain occurs it may complicate or hinder the correct surgical procedure.

First, one should remember the nerve anatomy of the digits. Paired palmar and plantar nerves lie at the sides of the flexor tendon sheath and proper digital arteries. These digital nerves divide into three main branches just distal to the distal interphalangeal joint. One branch goes to the nail bed, one to the tip of the digit and the other onto the pulp (1).

Always check for a history of allergy to lidocaine or carbocaine or parabens (contained in both as preservative). Local anesthetics may be contraindicated in patients with cardiac disease such as heart block (2).

PREMEDICATION:

For post people, nail surgery is an emotional experience. As the visit to the dentist, patients are more often more apprehensive about the needle stick than the actual procedure (3). Premediction may be useful in anxious patients. Short action molecules should be preferred: hydroxyzine, diazepines, orally or sublingually, the latter being quicker. The combination of hydroxyzine 25 mg the night before operation with lorazepam sublingually one hour prior to surgery is very efficient. The use of EMLA in children or adults is still debated. For some authors, its application at least one hour prior to local anaesthesia alleviate the pain caused by needle insertion and deposition of the local anaesthetic (4). For others, pain occurs during the infiltration step secondary to swelling and is not reduced by application of EMLA cream prior to digital block (5).

MATERIAL:

As all types of anesthesia at that location are high resistance injections (weak dilatation of tissues), the use of Luer-Lock syringe is mandatory.

The use of very thin needles (30 G for fingers, 27 G for toes, 30 G for children in all instances) is twofold: thinness of the needle decreases pain from puncture and limits the anaesthetic flow thus performing a very progressive swelling of the soft tissues. It is common for the physician to spend more time administering the anaesthetic than performing the surgical procedure.

ANAESTHETIC PRODUCTS:

Several products are available for regional blocks. Plain lidocaine 1 or 2 % is the reference local anaesthetic. Lidocaine is acid. Its alkalinisation reduces pain during infusion (6). Addition of too much sodium bicarbonate will result in a milky solution secondary to flocculation. This may impair the flow through the needle that may even become obstructed.

Lidocaine is a known smooth muscle relaxer and vasodilatator (7). Local anaesthesia with adrenaline containing anaesthetics is currently widely used for palmar and dorsal hand surgery but there remains a very deeply ingrained resistance to its use for digital anaesthesia. It is widely thought that this will lead to irreversible digital artery vasospasm (8). Many textbooks discourage the use of epinephrine in the extremities due to the theoretical risk of ischemia. However, adrenaline containing anaesthetics are commonly used at other end-arterial sites such as teeth, nipples, ears, nasal tips and even the penis (8). Multiple studies involving thousands of patients support the premise that the use of lidocaine with epinephrine is safe in the digits. An extensive review of the literature failed to provide consistent evidence that current preparations of local anaesthesia with epinephrine cause digital necrosis, although not all complications are necessarily reported. A total of 48 cases of digital gangrene after anaesthetic block (mostly using old anaesthetics such as cocaine and procaine) have been reported in the literature. The majority of them occurred more than 50 years ago when adrenaline became widely available and was used in an uncontrolled manner. Only 21 cases involved the use of epinephrine; 17 involved an unknown concentration of epinephrine based on manual dilution. Multiple other concurrent conditions (injection of large amount, hot soaks, tight tourniquets and infection) existed in these case reports, making it difficult to determine the exact cause of the tissue insult. There have been no case reports of digital gangrene using commercial lidocaine with epinephrine since its introduction in 1948 (9). A recent study used duplex scanner and Doppler probe to measure actual changes of digital artery flow consecutive to digital block with 2% lidocaine with epinephrine (1:80 000). A dramatic decrease of 50% of the arterial flow was noted after 5 minutes but returned to normal by 60 minutes (7). As the temporary vasoconstrictor effect is reversible, the threat of complication from vasoconstrictor-induced ischemia is theoretical (10). Epinephrine prolongs lidocaine’s duration of action fourfold: 2% plain lidocaine gives up to one hour of complete analgesia and an extra 30 minutes of partial anaesthesia; 2% lidocaine with 1:80 000 adrenaline gives 4 to 8 hours of complete anesthesia and a further 4 to 6 hours of partial anaesthesia (8). The use of lidocaine with epinephrine has clear advantages such as quicker onset, fewer reinforcement doses, less need for special bleeding manoeuvres and better total time of post-operative analgesia (11). It is however recommended not to use epinephrine in patients with vasospastic, thrombotic or extreme medical conditions. Prolonged ischemia may be reversed with nitroglycerin ointment or phentolamine injection (9).

However, most surgical nail procedures mostly last less than 30 minutes, a short time enough not to require epinephrine to prolong anaesthesia. Most nail surgery, especially phenolization and matricial surgery, requires a bloodless field than is only achieved when using a tourniquet. Therefore, lidocaine with epinephrine may be only interesting in few instances when bleeding may be prominent such as in curettage of pyogenic granuloma or bleopuncture.

Bupivacaine 0.5 % may be added to lidocaine to lengthen the post op analgesia. A study demonstrated that lidocaine has a duration of action of 60 minutes and bupivacaine 480 minutes (12). It may be interesting to inject 0.5 to 1 mL of bupivacaine immediately post operatively as a lateral wing block in order to act as a chemical tourniquet that will avoid further bleeding.

Rovipacaine is used in several surgical fields (breast surgery, eye surgery, dentistry, brachial blocks…) with very nice results: it has the same quick onset as lidocaine, provides better post operative pain relief (up to nine hours)(13, 14, 15, 16) and is less cardiotoxic than buvipacaine (17). We use it on a regular basis (2mg/mL) with very confortable post op for our nail surgery patients.

TECHNIQUES:

It is best to have patients in a reclining position during the administration of anaesthesia in the event of vasovagal episode occurs. It is also best to inform them when the needle stick is about to occur to avoid a dangerous reflex jerk (3).

Regional anaesthesia of a single finger is commonly achieved by the traditional ring block which requires at least two injections of anaesthetics. A 3 mL Luer-Lock syringe with a small gauge needle (27 G for the toes, 30 G for the fingers) is used. One to two percent lidocaine is the reference anaesthetic. With the patient’s hand pronated the needle punctures the skin of the dorsal-lateral aspect of the proximal phalanx, about 5mm from dorsal midline, at a 45 degree angle directed distal to anesthetize the dorsal root. The needle is advanced until it touches bone, where 0.5 mL of the anaesthetic is deposited. Without reinserting the needle, it is slightly withdrawn and then advanced toward the volar surface, where 1 mL of anaesthetic is injected. The procedure is then repeated on the opposite side of the digit to complete the block. A complete block will be achieved in 5 to 15 minutes.

Complications with this technique are rare, but include risk to digital neurovascular bundles, including direct trauma and spasm. The major drawback of this technique is the potential hazard of causing compression and trauma of neurovascular bundles (18). Recently, the use of a needleless injection system (J-Tip device) for digital ring block has been proposed for “needle phobic” and young patients. This is nothing different than a disposable DermoJet. The liquid is delivered in an aerosol form subcutaneously to a depth of 5 to 8 mm, fanning out on maximum penetration to a width of 8 to 10 mm. This technique is not reliable since it requires in all patients an additional anaesthetic administration of 3 mL to achieve adequate anaesthesia of the tip of the toe. The higher cost of the device per unit compared with a conventional needle and syringe may represent a drawback (19).

A variant of this technique is the distal wing block, very useful in nail surgery. The injection site is at a point about 3 to 5 mm proximal and lateral to the junction of the proximal nail fold and the lateral nail fold. By directing the needle at a 45 degree angle directed distal down to the bone, slow injection of about 0.3 to 0.5 mL of anesthetics will distend and blanch both folds and anesthetize the terminal and transverse and descending branches of the dorsal nerve. As the folds distend distally and medially from the local injection point a wing like appearance is noted (3). The anaesthetic solution acts as a tourniquet, rending possible phenolization of the matrix horn without the use of a tourniquet in most instances. Resistance to injection suggests that the needletip has penetrated the periosteum. Careful withdrawal of the needle will result in a free flow. Blanching of the lateral part of the lunula is often noted. It is always necessary to complete the procedure by an injection into the lateral nail fold up to the hyponychium to ensure complete anaesthesia. The needle may be bent at 120° and reinserted at the initial puncture site and pushed distally to the distal extremity of the lateral nail fold. About 0.3 to 0.5 mL of anaesthetics is deposited into the lateral nail fold in a retrograde motion. This will provide anaesthesia of half of the nail apparatus. For complete anaesthesia, the procedure should be repeated on the opposite side and the proximal nail fold infiltrated on its whole width. Anaesthesia takes effect immediately. If more advanced surgery is planned (flaps ie), anesthesia of the ventral root is necessary: the needle is inserted at the initial puncture site and pushed downwards skimming the lateral aspect of the phalanx and 0.5 mL are injected in the pulp to anaesthetize the ventral nerve roots.

Central local distant digital anaesthesia or matricial block (20) allows an immediate anaesthesia of the matricial area and the proximal half of the nail bed. The technique is identical as intramatricial injection of steroids. The needle punctures the skin in the midline of the proximal nail fold, about 5 to 7 mm proximal from the cuticle, bezel upwards, at a 60 degree angle directed distal. The needle is advanced until it touches bone then withdrawn for 1 mm and the anaesthetic very slowly injected. This leads to a progressive blanching of the lunulae and the proximal nail bed. If reflection of the proximal nail fold is expected, infiltration of the junction lateral nail fold- proximal nail fold is mandatory.

The transthecal digital block was first introduced by Chiu in 1990 (21). This technique involved a single palmar percutaneous injection of lidocaine into the space of the flexor tendon sheath, resulting in centrifugal anaesthesia diffusion and complete anaesthesia of the digital nerves of the finger. The procedure requires a small volume of lidocaine (2 mL), has a rapid onset of anaesthesia (3 to 4 minutes) and has a little risk of direct mechanical trauma to the neurovascular bundles because the needle is not placed in the vicinity of vascular structures. His technique was further refined by Wetzel (22) in 1995, who used the proximal digital crease as a visual landmark for the injection site making the technique easier to perform. 3 mL of 2% plain lidocaine in a Luer-Lock syringe with 27 G are used. The technique of injection is as follows: the needle is inserted at the palmar digital crease, sharply through both flexor tendons, straight to the bone, perpendicular to the volar skin. The needle is then withdrawn slowly away from the bone while gentle pressure was applied on the plunger of the syringe. While the needle tip lumen is against the bone or within the substance of the tendon, there is almost complete resistance to anaesthetic flow. Immediately as the needle tip lumen clears the tendon on slow pull-back of the needle, the anaesthetic solution flows easily at low pressure into the tendon sheath. Full block is obtained in about 5 minutes and partial digit amputations have been performed without patient discomfort (22). The theoretical risk of this technique is a possible flexor tendon sheath infection (strict asepsia is mandatory), tendon rupture or late occurrence of trigger finger. No complications have been reported in the more than 1000 transthecal injections in the literature (23). The mechanism of action of this procedure was revealed by study on cadavers: the injected solution escapes from the flexor tendon sheath around the vincular vessels at the base and head of the proximal phalanx, flows smoothly through the perivascular loose areaolar tissue and then spread alongside the digital nerve and vessels and their palmar and dorsal branches. After injection very little fluid remains inside the sheath (24). While injecting, pressure should be applied proximally to the site of puncture in order to promote the distal flow of the anaesthetic (23). Several studies show very nice results using this technique, achieving anaesthesia of the entire digit in 90 to 99% of patients (21, 22). Only one study found that anaesthesia of the dorsal nerve is not consistently achieved (25). A study comparing single injection transthecal block and traditional digital block for anaesthesia of the finger shown that these techniques are clinically equal in terms of time to anaesthesia and visual-analog pain score (26). There is no study comparing the subcutaneous block with the traditional method.

Harbison proposed a subcutaneous single injection digital block that does not violate the flexor tendon sheath, thus avoiding the theoretical risks associated with the transthecal technique (27). The injection of 3 mL of anaesthetic is given into the palmar crease, within the subcutaneous tissue. The mechanism of action relies on the diffusion of the anaesthetic agent through the low resistance soft tissues around the digital nerves. Sometimes, the anaesthetic diffuses sufficiently far around to anesthetize the dorsal nerves but this is not reliable (27). It allows treatment of all condition along the palmar aspect of the fingers and on the dorsal aspect of the distal and middle phalanxes without the need to penetrate the tendon sheath. A study found that single injection transthecal and subcutaneous digital blocks have no differences in effectiveness, distribution, onset and duration (28). Onset of total anaesthesia was around 2 minutes and duration over 6 hours (28). The subcutaneous block would appear to be a better choice as it is easier to perform and has no risk of intraarticular injection or puncture of the tendon. Some authors combined the two techniques. This only slightly improves the chance of anesthetizing the dorsal aspect of the proximal phalanx. Pain at the site of injection 24 hours after injection may be observed in 50% of patients anesthetized with the transthecal technique whereas no pain was noticed in patients anesthetized with the subcutaneous technique (29). It usually resolves in one day.

References

1) Morgan AM, Baran R, Haneke E: Anatomy of the nail unit in relation to the distal digit. In: Nail Surgery: A Text and Atlas. Eds Krull EA, Zook EG, Baran R, Haneke E, Lippincott Williams & Williams, Philadelphia, 2001, pp 1-28.

2) Zook EG, Baran R, Haneke E, Dawber RPR: Nail surgery and traumatic abnormalities. In: Nail Diseases and their Management, Eds Baran R, Dawber RPR, de Berker DAR, Haneke E, Tosti A, Blackwell Scientific Publications, Oxford, 2001, Chap 10, pp 425-514.

3) Salashe S: Surgery. In: Nails: Therapy, diagnosis and surgery. Eds Scher RK, Daniel CD, Saunders, Philadelphia, 1990, Chap19, pp 258-280.

4) Browne J, Fung M, Donnely M, Cooney C: The use of EMLA reduces the pain associated with digital ring block for ingrowing toenail correction. Eur J Anaesthesiol, 2000; 17:182-184.

5) Serour F, Ben-Yehuda Y, Boaz M: EMLA cream prior to digital nerve block for ingrown toenail surgery does not reduce pain at injection of anesthetic solution. Acta Anaesthesiol Scand, 2002; 46:203-206.

6) Cornelius P, Kendall J, Meek S, Rajan R: Alkalinisation of lignocaine to reduce the pain of digital nerve blockade. J Accid Emerg Med 1996; 13:339-340.

7) Sylaidis P, Logan A: Epinephrine in digital blocks: revisited. Ann Plast Surg 1999; 43:572.

8) Sylaidis P, Logan A: Digital blocks with adrenaline. An old dogma refuted. J Hand Surg 1998; 23:17-19.

9) Denkler K: A comprehensive review of epinephrine in the finger: to do or not to do. Plast Reconstr Surg 2001; 108:114-124.

10) Whilelmi BJ, Blackwell SJ, Miller JH, Mancoll JS, Dardano T, tran A, Phillips LG: Do not use epinephrine in digital blocks: myth or thruth? Plast Reconstr Surg 2001; 107:393-397.

11) Andrades PR, Olguin FA, Calderon W: Digital blocks with or without epinephrine. Plast Reconstr Surg 2003; 111:1769-1770.

12) Reichl M, Quinton D: Comparison of 1 % lignocaine with 0.5 % bupivacaine in digital ring blocks. J Hand Surg 1987; 12:375-376.

13) Casati A, Vinciguerra F, Scarioni M, Cappelleri G, et al: Lidocaine versus rovipacine for continuous interscalene brachial plexus block after open shoulder surgery. Acta Anaesthesiol Scand 2003; 47:355-360.

14) Lo Martire N, Savastano S, Rossini L, Pinchera L, Caraccio et al: Topical anaesthesia for cataract surgery with photoemulsification: lidocaine 2% versus rovipacaine 1%: preliminary results. Minerva Anaesthesiol 2002; 68:529-535.

15) Enrberg M, Kopp S: Rovipacaine for dental anaesthesia: a dose finding study. J Oral Maxillofac Surg 2002; 60:1004-1010.

16) Peng PW, Coleman MM, McCartney CJ, Krone S, Chan V et al: Comparison of anaesthetic effect between 0.375 % rovipacaine versus 0.5 % lidocaine in forearm intravenous regional anaesthesia. Reg Anesth Pain Med 2002; 27:595-599.

17) Fayman M, Beeton A, Potgieter E, Becker PJ: Comparative analysis of bupivacaine and rovipacaine for infiltration analgesia for bilateral breast surgery. Aesthetic Plast Surg 2003 (in-press)

18) Flarity-Reed K: Methods of digital block. J Emerg Nurs 2002; 28:351-354.

19) Dialynas M, Hollingsworth S, Cooper D, Barker S: Use of a Needleless Injection System for Digital Ring Block Anesthesia. J Am Pod Med Assoc 2003; 93:23-26.

20) Zaias N: Surgical procedures. In: The nail in health and disease. 2nd Ed, Appleton and Lange, Norwalk, pp 67-80.

21) Chiu DTW: Transthecal digital block: flexor tendon sheath used for anesthetic infusion. J Hand Surg 1990; 15A:471-473.

22) Whetzel TP, Mabourakh S, Barkhordar R: Modified tansthecal digital block. J Hand Surg 1997; 22A:361-363.

23) Torok PJ, Flinn SD, Shin AY: Transthecal digital block at the proximal phalanx. J Hand Surg 2001; 26:69-71.

24) Sarhadi NS, Shaw-Dunn J: Transthecal digital nerve block. An anatomical appraisal. J Hand Surg 1998; 23:490-493.

25) Chevaleraud E, Ragot JM, Brunelle E, Dumontier C, Brunelli F: Local anesthesia of the finger using the flexor tendon sheath. Ann Fr Anesthes Reanim 1993; 12:237-240.

26) Hill RG, Patterson JW, Parker JC, Bauer J, Wright E, Heller MB: Comparison of transthecal digital block and traditional block for anesthesia of the finger. Ann Emerg Med 1995; 25:604-607.

27) Harbison S: Tansthecal digital block. Flexor tendon sheath used for anesthetic infusion (letter) J Hand Surg 1991; 16A:957.

28) Low CK, Wong HP, Low YP: Comparison between single injection transthecal and subcutaneous digital blocks. J Hand Surg 1997; 22:582-584.

29) Low CK, Vartany A, Engstrom JW, Poncelet A, Diao E: Comparison of transthecal and subcutaneous single-injection digital block techniques. J Hand Surg 1997; 22A:901.

Nail Abrasion for Treatment of Onychomycosis: Monotherapy with Amorolfine 5%.
Nilton Di Chiacchio, MD, PhD.
São Paulo - Brazil

BACKGROUND

It is generally accepted that the incidence of onychomycosis is increasing in the world. Today the treatment of onychomycosis is based on the combined therapy. (1 2 3) A new generation of oral antifungal, highly concentrated topical preparations that can penetrate into deeper layers of the nail, and debridment procedures such as urea paste or nail avulsion may be used. A great deal of articles has been published on oral and topical therapy but not many on topical and debridment procedures combined.(4)

METHODS

A total of 20 patients with onychomycosis was submitted to a combined treatment with nail lacquers (5% amorolfine) once weekly, and with nail abrasion only once in the beginning of the treatment which lasted 6 months.

The 20 patients included in this study, had the following inclusion criteria:

- Patients with onychomycosis of hands and/or feet with more than 50% attacked until the lunula, without the damage of nail matrix (onychomycosis confirmed by direct microscopic examination)

- Patients from both sexes, with age between 18 and 65 years old.

- Patient with evolution of the disease less than 5 years.

- Patients that with exception of this disease were healthy and had a follow-up in the ambulatory.

- Patients that have enough understanding to apply regularly the medication - Patients that conceded the consent post-informed.

Could not be included in the study the patients who had:

- Attack of the nail matrix

- The desire to leave the study.

- Topical Antifungal medication used in the two previous weeks to the

inclusion in the study.

- Important clinical problems that could be attributed to the medication in study, preventing the continuity of the study.

- Patients with diseases that would lead to any kind of immune depression.

- Patients with any nail disease associated

- Patients that had received in the last 3 months that preceded the study,

oral treatment or any drug that could interfere in the study.

- Pregnant patients.

The investigator evaluated clinically the evolution, classifying it as showed:

Cured: up to 100% cured, which is, all the signals and symptoms of the disease were eliminated.

Significant improvement: up to 90% of improvement, which is, remained some signals and minimum residual symptoms.

Moderated improvement : up to 50% of improvement.

Unaffected: 0% of improvement.

The follow-up of the patients included photos and mycological examinations. These were done in the beginning of the treatment, after 3 months and in the end of the treatment.

RESULTS

The patients' average age was 51,1 years old with average variation between 40 and 62 years. The higher frequency was to female patients (84,2%) and the white race (78,9%). Twelve patients had concomitant diseases, and the most common disease was high blood pressure. In all patients, the attack only was in the nails of the feet, 14 patients had onychomycosis in both feet and in 6 patients only one foot was attacked

There was not any event's adverse occurrence in the patient included in this study.

The direct mycological examinations demonstrated, in all cases, dermatophytes.

After 24 weeks of treatment, 18 patients (90%) had significant clinical improvement and 2 (10%) had moderated improvement. The laboratory results demonstrated that in 15 patient (75%) there was negativity of the direct mycological examinations.

DISCUSSION AND CONCLUSION

Nowadays the treatment of onychomycosis is based on systemic treatment, topic and surgical treatments. (1 2 3) The combination of these treatments depends on factors related to patient as well as the type of the onychomycosis and the fungal identification. Several reports in the literature try to establish best results with the variation of the systemic and topical medications, however few of them relate the surgical treatments. (4)

The debridment method most used has been the urea paste. The need of occlusion, the unpleasant smell and the frequent possibility of maceration of the periungual tissues, in our experience, makes the patient's adherence to the treatment smaller.

The nail abrasion although is a well-known method, it has not been so much used in the onychomycosis therapeutics. (5 6) During a couple of years we had used this method not only as part of the onychomycosis therapeutics, but also for scales collection for direct microscopic examination, no fungal hyperkeratosis, haematoma drainage and in the place of the nail avulsion.

In onychomycosis, we believe that the nail abrasion decrease the critical fungal mass and can lead to an high concentration of the drug in the deep layers of the nail and the time of treatment can be reduced. It can offer larger comfort to the patient and improve the appearance of the nail plate and consequently patient's adherence to the treatment.

These results suggest that nail abrasion combined with topical treatment is an excellent procedure when it is compared with monotherapy (only topical).

REFERENCES

1 - Hay R J. The future of onychomycosis therapy may improve a combination of approaches. Br J Dermatol 2001: 145, (Suppl 60), 3-8.

2 - Baran R, Hay R J. New evidence for the efficacy of combination therapy in onychomycosis. Br J Dermatol 2001; 145, (Suppl 60), 1.

3 - Baran R, Dawber RPR, Berker DAR, Haneke E, Tosti A. Disease of the Nails and their Manegement. 3 ed. London: Blackwell Science; 2001.

4 - Epstein E. How often does oral treatment of toenail onychomycosis procedure a disease-free nail? An analysis of published data. Arch Dermatol 1998; 134: 1152-4.

5 - Maeda N, Mizuno N, Ichikawa K. Nail abrasion: a new treatment for ingrown toenails. J Dermatol 1990; 17(12): 746-9.

6 - Meek S, White M. Subungueal haematomas: is a simple trephining enough? J Accid Emerg Med 1998; 15(4): 269-71.