Council on Nail Disorders
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Council on Nail Disorders
Abstracts from the February 17, 2005 meeting
Phil Fleckman MD, Editor
Clinical Abstracts: International Nail Grand Rounds 2005
Cases presented by Monica Lawry, MD and Beth Ruben, MD.
Clinical Abstracts: International Nail Grand Rounds 2005
Case 1: One year follow up on a 39yo woman with changing longitudinal Melanonychia and Hutchinson's sign. Her nail fold was excised and the pigmented lesion in the matrix was excised using a tangential saucerization technique. Histopathology revealed a benign nevus. Her nail fold healed with minimal atrophy and the nail plate shows no residual pigmentation and there is minimal distal onychoschizia.
Case 2: One year follow up on three women with severe onycholysis. Two cases had onset associated with acrylic nails. All were treated with clear vinegar to eliminate pseudomonas and clobetasol solution. Patients were taught how to use an irrigation syringe to gently instill the medication beneath the nails. Nails were kept short but not cut back to attachment. All 3 patients had very good response and are pleased with cosmesis and function. Our working diagnosis is nail bed psoriasis.
Case 3: 38 yo woman with several month history of an enlarging subungual tumor of the great toe. Trauma from hiking in Europe and a pedicure preceded the changes. Oral antifungals were ineffective. Intraoperative photos of the exploration and removal of this subungual tumor were presented. Several 'layers' of thin nail plate covered this tumor-like lesion. Histopathology revealed a multilayered dermatophytoma.
Case 4: 52yo woman with a 6 year history of a painful tumor of the right index finger, with alteration of the nail plate, and transverse overcurvature, with splinter hemorrhage. Intraoperative photos demonstrated the surgical excision of the lesion. Histopathology revealed typical changes of onychomatricoma of Baran and Kint, with an interdigitating pattern of matrical epithelium and fibrocellular stroma. Post-operative follow up demonstrated good cosmesis.
Case 5 (Janet Hickman, MD) : 67 yo woman in good general health, on no medications. In Sept. 2004, she noted changes in the L thumbnail, with elevation at the base of the nail and separation of the distal nail plate from the bed. The thumb was tender but not throbbing or cold-sensitive. There was no history of trauma. The other nails were not affected. She treated it with Reclaim (benzalkonium chloride soln.) without improvement. KOH and fungal culture were negative on 11/08/04. X-ray of the digit on 11/09/04 showed elevation of the nail from the bed but the underlying distal phalanx was normal without erosion. Biopsy was performed on 11/16/04, and revealed psoriasiform hyperplasia and spongiform neutrophilic pustules, consistent with psoriasis, with a negative PAS-D stain, making Candidiasis unlikely.
A Puzzling Monodactylic Distal Onychorrhexis
André Ja, Theunis A, Laporte M, Van Geertruyden J, Frébutte V
CHU St Pierrea, Hôpital Erasmeb, Erbisoeulc and Free University of Brussels, Belgium
We report a unique clinical presentation of amelanotic melanoma diagnosed at an early stage. A 51 year-old woman was referred for a distal onycholysis of the right thumb, evolving for 1.5 year. The distal 2/3 of the median nail plate showed thin longitudinal furrows and sparse splinter haemorrhages. Clinical presentation evoked either lichen planus or psoriasis since the patient suffered from scalp psoriasis. Punch biopsy in the distal nail bed was performed. Histological examination revealed a prominent junctional melanocytic hyperplasia with nuclear atypias. The diagnosis of incipient acral melanoma was made. Total excision of the nail apparatus confirmed the diagnosis of in situ acral lentiginous amelanotic melanoma, extending from the proximal matrix to the hyponychium. This illustrates that biopsy is mandatory in any unusual chronic monodactylic nail disease.
References
Metzger S, Ellwanger U, Stroebel W, Schiebel U, Rassner G,
Fierlbeck G. Extent and consequences of physician delay in the diagnosis of acral melanoma. Melanoma Res 1998; 8: 181-186.
Thai KE, Young R, Sinclair RD. Nail apparatus melanoma. Australasian J Dermatol 2001; 42: 71-83.
A Huge Slowly Evolving Subungual Tumour
Richert B, André J, Theunis A, de Saint Aubain N.
CHU de Liègea, CHU St Pierreb, Institut Bordetc, Belgium.
A 50 year-old nurse presented with a huge painless subungual tumour lifting up the great toenail, slowly enlarging over the last 10 years. X-ray examination was normal. Diagnosis of chondroma was evoked. Excision revealed a circumscribed nodular mass. Histological diagnosis was Superficial Acral Fibromyxoma, a distinct clinicopathologic entity recognised by Fetsch in 2001. 37 cases were described. Most frequent location was the great toe. The nail area was involved in more that 50% of the cases. This tumour probably corresponds to a real clinicopathological entity that should be considered as a benign neoplastic process, involving a specialized fibroblastic cell. Ten-year follow-up showed only one recurrence. No tumour had metastasized. Local excision and follow-up are recommended.
References:
Fetsch JF et al. Superficial acral fibromyxoma: a clinicopathologic and immunohistochemical analysis of 37 cases of a distinctive soft tissue tumor with a predilection for the fingers and toes. Human Pathol 2001;32:704-14.
Kazakov DV et al. Superficial acral fibromyxoma: report of two cases. Dermatology 2002;205:285-8.
Meyerle JH et al. Superficial acral fibromyxoma of the index finger:.JAAD, 2004; 50:134-6.
Painless Periungual Pyogenic Granulomata Associated with Reverse Transcriptase Inhibitor Therapy in a Patient with Hiv
L.H. Williams, P. Fleckman, Division of Dermatology, University of Washington, Seattle, WA 98195, USA.
We report a 53-year-old man with HIV who developed painless periungual pyogenic granulomata after starting antiretroviral therapy with lamivudine, zidovudine and efavirenz. No other underlying causes of pyogenic granuloma were present. The clinical diagnosis was confirmed by histopathology, and the possibility of infection was excluded by culture and immunocytochemistry. There are multiple published cases of painful paronychia, pyogenic-granuloma-like lesions or granulation tissue of the nails associated with protease inhibitors, particularly indinavir, but only one report of such lesions associated with a non-protease-inhibitor antiretroviral, lamivudine. Most of the pyogenic-granuloma-like lesions of the nails associated with antiretroviral therapy have been painful. Painless pyogenic granulomata of the nails may be a distinct entity resulting from non-protease-inhibitor antiretroviral therapy.
ULTRASOUND EXAMINATION OF THE NAILS
Gregor B.E. Jemec, MD, DMedSc
Assoc. Professor, University of Copenhagen, Div of Dermatology, Dept of Medicinem, Roskilde Hospital, Denmark
Objective quantification of biological phenomena aids understanding and the development of new treatments. Nails are complex structures which are mainly studied by clinical examination today. The development of various non-invasive techniques however allows imaging of several aspects of the human nail, and thereby provides additional data by which diagnosis and therapy may be aided.
Ultrasound studies may be conducted by conventional high frequency ultrasound, or by real-time spatial compound imaging (RTSCI) ultrasound. The advantages of each method will be discussed, and images representing both normal nail structure and various abnormalities will be presented. Ultrasound examination is however not the only possibility for in vivo high resolution studies of the nail apparatus. Alternative methods to ultrasound such as optical coherence tomography (OCT) will also be presented, suggesting to the audience the scope for modern imaging of the nails.
Nail imaging currently does not replace invasive diagnostics, but recent developments suggest that newer techniques will become available for detailed imaging which is expected to rival conventional histology in the near future.
Pyogenic Granuloma and the Nail
Bianca Maria Piraccini, Antonella Tosti
Department of Dermatology University of Bologna, Italy
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| Figure 1 |
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Acute paronychia associated with pseudopyogenic granuloma is a possible complication of cast immobilization for hand or wrist fractures. The inflammatory changes usually develop a few days after cast removal. Most patients complain of mild paresthesia during cast wearing suggesting nerve compression by a tight cast. The condition affects 1 fingernail in most cases and regresses spontaneously in a few weeks.
Acute paronychia with pseudopyogenic granuloma can occur in newborns ageing from 6 days to 4 months. This new entity of acute paronychia is caused by the grasp reflex and it is characterised by multiple and bilateral paronychia of the fingernails. The grasp reflex causes the soft tissue to be penetrated by the edge of the nail plate. Secondary infections and ingrowing nails can be associated.
This condition does not occur again when the grasp reflex disappears, usually after 3 months of age.
When several nails are involved the cause is probably a drug. Multiple pyogenic granuloma are a typical side effect of retinoids, as well as antiretroviral treatments. Recently antiepidermal growth-factor antibodies, used as chemotherapic agents, are described as causes of acute paronychia with pseudopyogenic granuloma, both in hands and feet. Nail ingrowing can be associated. The pathogenesis is still unclear, but probably the drug activates angiogenic factors. The responsible drug should be stopped and then topical mupirocin and topical steroids can be utilized as treatment options. Recently a topical retinoid receptor panagonist has been utilized for the treatment of pyogenic granuloma with good results.
Selective Phenolisation of Ingrowing Nails
Cannata G. E.
Division of Dermatology Civil Hospital - Imperia
Indications
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| Figure 2 |
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| Ingrowing toenail |
Equipment (1-2-3-4-6)
- Povidone iodine antiseptic
- 88% phenol solution
- Naropina (Ropivacaina Cloroidrato Monoidrato) 7,5 mg\ml
- Syringe 5 ml with needle 28 gauge
- Tourniquet
- Haemostatic forceps
- Nail clippers
- Cotton-tipped applicators
Procedure (1-2-3-4-6)
- Disinfection
- Local tumescent anaesthesia with Naropina
- Tourniquet below the nail
- The latero-longitudinal nail strip - 1 or 1 - is cut from the distal nail to the matrix
The nail strip is clamped from the lateral groove to the lateral nail horn
- Twist laterally both sides and remove with the nail horn
- All free blood is blotted away by gauze
- The phenol solution is rubbed into for 3 - 4 minutes with 3 - 4 changes of the cotton-tipped applicators.
It is essential to work on a bloodless field since blood inactivates phenol.
Postoperative care (1-2-3-4-6)
- Washing with water and soap, some minutes.
- Drying than dressing the small wound :
- in the morning with application of Povidone iodine solution
- in the evening Antibiotic - Corticosteroid cream.
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| Figure 3 |
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| The healing takes about 4 - 6 weeks . |
Complications (5-6)
- Recurrences
- Pyogenic granuloma
- Malalignment
Phenol cauterisation is easy and efficient and can be used even in the presence of infection.
Bibliography
1. Baran R., Dawber R.P.R.: Diseases of the nails and their management. Ingrowing toenails. Blackwell Scientific Publications - Oxford - Second edition, Chapter 10, 397- 406, 1994.
2. Boll O.F. : Surgical correction of ingrowing nails. Journal of the National Association of Chiropodist 35; 8-9, 1945.
3. Burzotta J.L., Turri R.M., Tsouris J.: Phenol and alcohol chemical matrixectomy. Clinics in Podiatric Medicine and Surgery vol. 6, n. 2; 453 - 467, 1989.
4. Dagnall J.C.: The hystory, development and current status of nail matrix phenolisation. Chiropodist 36; 315- 324, 1981.
5. De Berker D. A. R., Baran R.: Acquired malalignment: a complication of lateral longitudinal nail biopsy. Acta Derm. Venereol. (Stockh.) 1998; 78: 468 - 470.
6. Cannata G. E., Gambetti M.: Fenolizzazione selettiva per l'unghia incarnita. Dermotime vol. III, n. 6; 25, 1991.
The Treatment of Nail Psoriasis with Alefacept
Jenny O. Sobera, MD, Charles A. Parrish, MD, Boni E. Elewski, MD
University of Alabama Birmingham, Birmingham, Alabama.
INTRODUCTION: Psoriatic changes of the nails occur in approximately 50% of patients with psoriasis and can have a negative impact on quality of life. Treatment options for nail psoriasis are limited and efficacy is marginal. Alefacept is a new biologic medication that selectively reduces memory T cells and has been approved for chronic plaque type psoriasis. The purpose of this study was to evaluate the use of alefacept in the treatment of nail psoriasis.
METHODS: Fifteen subjects with psoriatic nail involvement were enrolled in and completed the full 12 week open-labeled course of alefacept 15 mg IM weekly. A modified NAPSI scoring system was developed to assess nail changes. Nail scoring and photographs were recorded at baseline and at week 24. The target NAPSI scoring system used has a possible range of 0 (no disease) to 96 (most severe).
RESULTS: At week 24, the average reduction in NAPSI score was 38%. Five of 15 (33%) subjects achieved a greater than 50% reduction in the NAPSI score.
CONCLUSIONS: Alefacept demonstrated efficacy in treating nail psoriasis. Alefacept may be an appropriate alternative for patients with nail psoriasis.
The Water Content and Other Aspects of Brittle versus Normal Fingernails.
Dana Kazlow Stern MD, Phyllis Spuls, MD/PhD, Elizabeth Smith, Erin Moshier, Wangui Muigai, Roberto Ruggiero, Marsha Gordon MD, Mark Lebwohl MD
Background:
The incidence of brittle nails is 20%. Therapy is often difficult because few treatments have proven efficacy. The diagnostic criteria for brittle nails are not well defined. In our study brittle nails were defined as having: (1) onychorrhexis (longitudinal ridging), and/or (2) onychoschizia (horizontal layering). Upon review of the literature, many authors assert that brittle nails result from dehydration of the nail plate. Many experts specifically claim that normal nails contain 18% water, and brittle nails contain less than 16%.
Objective:
To test the hypothesis that brittle nails contain 2% less water than normal nails. We also investigated the relationship between a number of health and behavioral variables and brittle nails.
Methods:
At random, volunteers, at least 18 years old, visiting our department of dermatology were examined for clinical evidence of either normal (all 10 fingernails) or brittle fingernails. Volunteers filled out a questionnaire concerning their health and behavior. Nail clippings were analyzed in the laboratory by a blinded investigator. The difference in weight between the pre and post-dehydrated nails divided by the pre-dehydration weight was used to express the water content as a percentage (%). Statistical analyses were performed with SAS (SAS Institute Inc., Cary, NC). Chi-Square tests were used to compare proportions of patients with brittle and normal nails among categories of several variables. Logistic regression was used to compute odds ratios and 95% confidence intervals in order to compare characteristics of brittle versus normal nails. Analysis of Variance (ANOVA) was used to compare water content of brittle and normal nails.
Results:
A total of 113 volunteers, (86 women, 27 men) participated. Fifty-six subjects had normal nails and 57 had brittle nails. Of the patients with brittle nails, 47 had onychorhexis, 34 had onychoschizia, and 21 had both. There was no statistical difference between the mean water (%) of normal nails and brittle nails (p=0.9507); the mean water % for normal nails was 11.9976 (SD: ± 0.9368), and for brittle nails 11.9787 (SD: ± 0.4749). There was no significant difference between brittle and normal nails with respect to the following other variables: self described health-status, chronic medical condition, smoking status, vitamin intake, manicure, nail enamel remover use, the use of fingernails to open containers, moisturizer use, hand washing, hand soaking, and climate over last 3 months. The odds of having brittle nails increased significantly with age (OR=1.0364 95% CI [1.0116, 1.0618]). The odds ratios comparing the odds of having brittle nails for women compared to men were approximately equal despite menopausal status.
Conclusion:
There is no significant difference in water content between brittle and normal distal nail plates. The mean water % for normal nails was 11.9976 (SD: ± 0.9368), and for brittle nails 11.9787 (SD: ± 0.4749).
Presence of Dermatophyte in Clinically Normal-Appearing Toenails Correlates with Tinea Pedis Infection
Hobart W. Walling MD, PhD and Thomas Ray, MD
University of Iowa Department of Dermatology
Onychomycosis (OM) and tinea pedis (TP) are common dermatophyte infections and are generally caused by the same fungal organisms, most frequently Trichophyton rubrum. Though these diseases are often found simultaneously, the etiologic interrelationship is not well-defined. OM is suspected in the setting of nail dystrophy but is seldom suspected in clinically normal-appearing nails. We hypothesized that presence of TP is a risk factor for developing OM and that dermatophyte may be present in the nail plate before dystrophic changes develop. As a prelude, we reviewed charts of 260 patients over the prior 34 months who had a clipping of a dystrophic toenail submitted for histology; 124 (47.7%) were positive for dermatophyte; 27/260 (10.4%) had active TP; 18 of these 27 (67%) had OM. We then conducted a prospective study to assess the presence of dermatophyte in normal-appearing toenails in adult patients with and without TP. We excluded anyone with a prior diagnosis of TP and/or use topical antifungals on the feet within the last 6 months. Persons with clinical irregularity of the toenails (including opacity, discoloration, thickening, subungual debris, ridging, or onycholysis) were excluded. Subjects submitted great toenail clippings for periodic acid Schiff staining and histology. To date, we have recruited 94 patients (65% male) with normal appearing nails with TP (N = 33, mean age 47.1 ± 3.0 years) and without TP (N = 61, mean age 43.0 ± 1.9 years). Of these subjects, 5 of 33 (15.2%) with TP and 1 of 61 (1.6%) without TP had dermatophyte in their normal-appearing nail (p = 0.025). These findings indicate that TP is a significant risk factor for development of OM. Further research may show that nail-directed therapy in cases of TP may prevent progression to nail dystrophy and clinically significant OM.
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