Onychomycosis in Foot and Toe Malformations.

Introduction: It has long been accepted that trauma is one of the most important and frequent predisposing factors for onychomycoses. However, the role of direct trauma in the pathogenesis of fungal nail infections has only recently been elucidated in a series of 32 cases of post-traumatic single-digit onychomycosis. The importance of repeated trauma due to foot and toe abnormalities was rarely investigated. Aimof the study: This is a multicenter single-author observational study over a period of 6 years performed at specialized nail clinics in three countries. All patient photographs taken by the author during this period were screened for toenail alterations, and all toe onychomycosis cases were checked for whether they contained enough information to evaluate potential foot and toe abnormalities. Particular attention was paid to the presence of hallux valgus, hallux valgus interphalangeus, hallux erectus, inward rotation of the big toe, and outward rotation of the little toe, as well as splay foot. Only cases with unequivocal proof of fungal nail infection by either histopathology, mycologic culture, or polymerase chain reaction (PCR) were accepted. Results: Of 1653 cases, 185 were onychomycoses, proven by mycologic culture, PCR, or histopathology. Of these, 179 involved at least one big toenail, and 6 affected one or more lesser toenails. Three patients consulted us for another toenail disease, and onychomycosis was diagnosed as a second disease. Eight patients had a pronounced tinea pedum. Relatively few patients had a normal big toe position (n = 9). Most of the cases had a mild to marked hallux valgus (HV) (105) and a hallux valgus interphalangeus (HVI) (143), while hallux erectus was observed in 43 patients, and the combination of HV and HVI was observed 83 times. Discussion: The very high percentage of foot and toe deformations was surprising. It may be hypothesized that this is not only a pathogenetically important factor but may also play an important role in the localization of the fungal infection, as no marked hallux deviation was noted in onychomycoses that affected the lesser toes only. As the management of onychomycoses is a complex procedure involving the exact diagnosis with a determination of the pathogenic fungus, the nail growth rate, the type of onychomycosis, its duration, and predisposing factors, anomalies of the toe position may be important. Among the most commonly mentioned predisposing factors are peripheral circulatory insufficiency, venous stasis, peripheral neuropathy, immune deficiency, and iatrogenic immunosuppression, whereas foot problems are not given enough attention. Unfortunately, many of these predisposing and aggravating factors are difficult to treat or correct. Generally, when explaining the treatment of onychomycoses to patients, the importance of these orthopedic alterations is not or only insufficiently discussed. In view of the problems encountered with the treatment of toenail mycoses, this attitude should be changed in order to make the patient understand why there is such a low cure rate despite excellent minimal inhibitory drug concentrations in the laboratory.

Fibrotic reaction to hyaluronic acid fillers in the face.

BACKGROUND: Hyaluronic acids (HAs) can have very different actions not only depending on injector and host factors but also depending on their molecular weight. Whereas short chain HA has immunological activity long chain HA influences fibroblasts and may stimulate them to produce collagen. Although this is generally thought to be a positive feature it may be disadvantageous in certain localizations. PATIENTS AND METHODS: We have encountered 23 patients who developed fibrous tissue next to the nasolabial folds accentuating them and becoming very obvious while smiling. Hyaluronidase injection did not reduce this mass. RESULTS: Intralesional triamcinolone acetonide injection led to rapid improvement. DISCUSSION: Fibrotic tissue reaction not responding to hyaluronidase may be the result of HA injection and can effectively be treated with intralesional steroid injection.

Clinical, onychoscopic, nail clipping, and histopathological findings of malignant onychopapilloma.

This report describes the clinical, onychoscopic, nail clipping, and histopathologic features of a malignant onychopapilloma. A 71-year-old male presented to our outpatient clinic for a stable, asymptomatic lesion on his left middle finger that had been present for 2 years. Prior nail clipping histopathology showed nail plate thinning with subungual abnormal onychocytes. Clinical examination revealed a 2-mm-wide streak of longitudinal xanthonychia extending to the proximal nail fold, with distal hyperkeratosis and onycholysis. Onychoscopy showed irregular longitudinal nail plate ridging with scattered punctate hemorrhagic foci. An excisional nail unit biopsy demonstrated cellular atypia of the nail bed epithelium, matrix metaplasia, longitudinal abnormal onychocytes, increased Ki-67 staining, and negative HPV immunoperoxidase staining, confirming the diagnosis of malignant onychopapilloma.

What is in a name-Perifollicular fibroma or fibrofolliculoma?

So far, confusion exists regarding the question of whether hereditary perifollicular fibromas and fibrofolliculomas can be distinguished from each other. Here, histopathological arguments are presented to clarify this terminological problem. In 1977, Birt et al. described a large kindred affected with hereditary multiple "fibrofolliculomas," which they thought were "a hitherto unrecognized pilar hamartoma," but they never claimed the fibrofolliculomas were part of a syndrome. A careful microscopic comparison shows, however, that the tumors are clinically and histopathologically identical to perifollicular fibromas, as first described by Burnier and Rejsek in 1925. Their familial occurrence was discovered in 1971 by Civatte and Le Tréguilly. Before 1977, the term "perifollicular fibroma" was used for these skin tumors. By contrast, Hornstein and Knickenberg described in 1975 perifollicular fibromas as a cutaneous marker of a syndrome characterized by a predisposition to colon cancer and pneumothorax. Later, two French groups erroneously proposed the term "Birt-Hogg-Dubé syndrome" to describe the co-occurrence of fibrofolliculomas, trichodiscomas, and acrochordons, which was contrary to what Birt et al. had in mind. Hence, today, we should discriminate between the hereditary nonsyndromic perifollicular fibromas, as documented by Civatte and Le Tréguilly and later by Birt et al., and the syndromic perifollicular fibromas, as delineated by Hornstein and Knickenberg.

Post-Traumatic Single-Digit Onychomycosis.

Onychomycoses are a group of fungal nail infections commonly classified either according to the pathogenic fungus, to the duration of the disease or to the mode of fungal invasion. Most cases are diagnosed clinically, although there is a general consensus that the pathogen should be identified prior to initiating a treatment. However, this is often difficult as the classical mycologic methods of direct microscopy and culture frequently remain negative. We came across a particular subset of onychomycoses, which posed extreme diagnostic and therapeutic challenges. Over a period of 15 years, 44 patients were seen in specialized nail clinics with a single nail dystrophy that was examined and treated in vain by many practitioners and dermatologists prior to their consultation. Of the forty-four cases, thirty-nine patients had a fingernail affected and five had a toenail affected. The nail was almost completely onycholytic, the nail bed visibly keratotic, the proximal nail fold smooth and shiny and slightly swollen. All patients except five brought the results of negative mycologic cultures. Thirty-four patients had received antifungal therapy, mostly topical, as a single nail would not qualify for systemic treatment according to most national and international guidelines. The diagnosis was finally confirmed by histopathology of the nail plate showing an invasive onychomycosis in all cases. After nail avulsion and combined topical and systemic antifungal therapy, thirty-six patients were cured, three were lost from follow-up, and five showed improved nails but not a complete clinical and mycologic cure. A single-digit nail disease raises the suspicion of a tumor or a trauma; although, in rare cases, diseases normally affecting several nails may only affect a single nail. Such a case should prompt the clinician to ask for a previous trauma to this digit and to intensify the search for a specific pathogen. This study also underlines the importance of histopathology for the diagnosis of onychomycoses.

Histopathological analysis of chronic paronychia.

BACKGROUND: Chronic paronychia is an inflammatory process of the nail folds lasting more than 6 weeks. Clinically, there is hypertrophy and retraction of the folds and absence of the cuticle. Treatment involves clinical measures and, when there is no response or the hypertrophy of the folds is very pronounced, surgical treatment is indicated. Post-surgical histopathology is little studied in the literature. In this sense, we believe that the histopathological study is important not only for the individualized understanding of the patient's chronic disease, avoiding relapses, but also for the understanding of its pathophysiology and treatment possibilities. OBJECTIVE: To describe the histopathological changes found in biopsies of the proximal nail fold of patients with chronic paronychia undergoing surgical treatment. MATERIALS AND METHODS: A histopathological study of 16 nail folds from 6 patients after surgery was performed at 2 study centers. RESULTS: The most prevalent epidermal findings were orthokeratosis, hypergranulosis, acanthosis and spongiosis and the dermal findings were fibrosis and mononuclear inflammatory infiltrate. CONCLUSION: The histopathological study allowed us to conclude that chronic paronychia is primarily an inflammatory process, but it is not possible to conclude whether microorganisms such as Candida and bacterial cocci are part of the etiology or just secondary and opportunistic agents.

Chronic Retronychia: Nonsurgical Treatment.

Introduction: Retronychia is a particular form of post-traumatic ingrown nail associated with repeated microtrauma of the underside of the proximal nail fold. It is caused by the nail embedding backward into the underside of the proximal nail fold, forming multiple generations of nail plate. Methods: The study aims to evaluate the results of a novel nonsurgical treatment of retronychia. A review was performed on 20 patients who underwent the treatment, 16 having suffered from a chronic form of the condition, with the remaining 4 being afflicted with retronychia for less than a year prior to treatment. Results: The treatment was a combination of eliminating the proximal sharp edge of the uppermost nail layer and thinning of the nail with fraises and drills of various sizes. This therapy was repeated every 7-14 days. The patients came for checkup every 6 weeks. Treatment duration varied from 2 to 14 months. The rate, at which the appearance of a healthy nail occurred depended on the length of the intact nail layer below the part of the nail affected by retronychia, the age of the patient, and cofactors such as obesity, diabetes, etc. The treatment result in our case study was completely healthy nail growth without relapse of retronychia in all the 20 patients for a follow-up period of 18 months. Conclusion: By combining a healthy nail growth and the simultaneous protection of the nail, we were able to achieve a normal nail in all cases. In order to maintain the achieved results, we recommended our patients to continue wearing protective tubes whenever they would wear closed shoes because recurrence of retronychia may occur even after minimal trauma.

Description of the most severe signs in nail lichen planus: a strategy to contribute to the diagnosis of the severe stage.

BACKGROUND: Severe nail lichen planus (NLP) does not respond well to treatment and is often poorly considered and described in detail. OBJECTIVE: We sought to describe the characteristics of severe NLP. METHODS: A retrospective data analysis was performed, including the photographic records of the most compromised nails of patients with NLP over 18 years old, who consulted between 2009 and 2019 at the Instituto de Dermatologia Professor Rubem David Azulay in Rio de Janeiro, Brazil. Descriptive and statistical analysis using Fisher's exact test was performed to verify the hypothesis of independence between characteristics (P < 0.05). RESULTS: A total of 102 patients were included. Anonychia was associated with severe thinning of the nail plate, retraction of the nail bed or nail plate, residual nail plate, loss of proximal nail fold limits, and onychoatrophy. Dorsal pterygium was associated with loss of proximal nail fold limits, onychoatrophy, and distal splitting greater than 50%. CONCLUSION: We provide descriptions of the most severe signs in order to facilitate the clinical diagnosis when a biopsy is not feasible and suggest an update of current NLP classifications.

The role of dermoscopy in the diagnosis of subungual glomus tumors.

BACKGROUND AND OBJECTIVES: The dermoscopic features of glomus tumors have only been described in a few case reports. The aim of this research was to define the clinical and dermoscopic features of subungual glomus tumors. METHODS: Thirty-two patients with subungual glomus tumors were evaluated retrospectively. RESULTS: On the photographs, longitudinal erythronychia, longitudinal leukonychia, punctate leukonychia, splinter hemorrhage, isolated capillaries, distal notching, distal subungual hyperkeratosis, onycholysis, and onychoschizia were found. There was no statistical difference between the rates of detection of these findings by evaluation from clinical photographs alone and from both clinical and dermoscopic photographs. While ramified vessels with bluish spots could be detected in only five of 26 cases with bluish spots in their clinical photographs, these ramified vessels were seen in 14 cases in bluish spots in dermoscopic photographs (P = 0.004). Compared to clinical examination, dermoscopy was able to detect blue spots in three more cases. Lesion duration was higher in the cases with ramified vessels (P = 0.018). CONCLUSIONS: Dermoscopy seems to contribute to the clinical examination in displaying only ramified vessels located in bluish spots and in determining the localization of the subungual tumors. The presence of ramified vessel in the bluish spots is strongly related to lesion duration.

Melanoma of the Nail Apparatus: An Analysis of Patients' Survival and Associated Factors.

BACKGROUND: There are no proper management guidelines for nail apparatus melanoma (NAM). OBJECTIVE: This study aimed to describe the clinical features, the presence of locoregional and distant metastases and disease-free and overall survival of NAM treated at our institution. METHODS: A retrospective cohort review of patients with single, primary localized histopathologically confirmed NAM was performed. Collected data consisted of patients' characteristics and tumor features. In addition, local recurrence, locoregional metastases, distant metastases, disease-free survival (DFS) and overall survival (OS) were used as the main outcomes in our analysis. RESULTS: Thirty patients with NAM were included. The overall survival (OS) in our patients at 5 and 10 years was 85.6 and 73.4%, respectively. DFS was significantly higher in patients with primary tumor location in the hand and without tumor-infiltrating lymphocytes (p value = 0.01 and 0.04, respectively). The patients with in situ melanoma or Breslow thickness <1 mm had a significantly higher chance of DFS and OS (90.0 and 94.1% at 5 years, respectively) than those with thicker NAM (58.3 and 55.6% at 5 years, respectively). A total of 53.3% of 30 patients underwent primary excision and covering with a full-thickness skin graft, while 13.3% of our 30 patients underwent digit amputation. The patients who underwent excision and covering with a full-thickness skin graft showed a complete overall survival (100% at 5 years). CONCLUSION: Primary tumor location in the hand and lower tumor thickness might be correlated with better patients' survival. The study results suggest that total amputation might not be necessary in all NAM cases.

Subungual Elastofibroma.

Cutaneous elastofibroma is part of the connective tissue nevus complex. Two subungual cases remotely similar to the one presented here have been described before. This patient presented with an unusual form of subungual elastofibroma of the big toe, which was surgically removed. Histopathology revealed a connective tissue tumor extremely rich in very fine elastic fibers. Their relationship to oxytalan and elaunin fibers is discussed as is the potential association of this nail bed lesion with the onychodermis.