Evaluation of the Recurrence Rate of Ingrown Toenail After a 45-Second Matrix Cauterization With Phenol.

INTRODUCTION: Ingrown toenail is a very common nail disorder, and partial matricectomy by phenolization is considered the most effective treatment technique. However, the contact time of the phenol with the nail matrix remains debatable. OBJECTIVE: To evaluate the recurrence rate of ingrown toenail after partial matricectomy by phenol for 45 seconds. METHODS: A total of 1,460 surgeries were performed, with a photographic record of 802 pictures for a period of 6 months. The presence of any nail spicule or sign of ingrowth during follow-up was considered a recurrence. RESULTS: A total of 802 surgeries were evaluated, with the most affected nails being the right (49.3%) and left (48%) big toes and most frequently the lateral fold (54.5%). The recurrence rate was 0.75% at 3 months and 1.87% at 6 months, and the medial nail fold had a higher recurrence rate than the lateral nail fold. CONCLUSION: Forty-five seconds of contact time of 88% phenol with the nail matrix was enough and effective, resulting in low recurrence rates. Prospective studies are needed to better assess postoperative morbidity.

Role of tangential biopsy in the diagnosis of nail psoriasis.

BACKGROUND: Histopathology can be crucial for diagnosis of inflammatory nail diseases. Longitudinal excision and punch biopsies are the most used techniques to obtain the tissue sample. However, there is a low clinical-histopathological correlation, besides the risk of nail dystrophy. Tangential excision biopsy (TB) is a well-established technique for the investigation of longitudinal melanonychia. TB could also be used to evaluate diseases in which histopathological changes are superficial, as in psoriasis. OBJECTIVE: To study the value of TB in the histopathological diagnosis of nail psoriasis. METHODS: This is a prospective and descriptive study of the clinical-histopathological findings of samples from the nail bed or matrix and nail plate of 13 patients with clinical suspicion of nail psoriasis. Biopsies were obtained through partial nail avulsion and TB. RESULTS: In nine patients, the hypothesis of psoriasis was confirmed by histopathology; in one, the criteria for diagnosing nail lichen planus were fulfilled. The tissue sample of only one patient did not reach the dermal papillae, and, in four of 13 patients, the adventitial dermis was not sampled. No patient developed onychodystrophy after the procedure. STUDY LIMITATIONS: In three patients, the clinical and, consequently, histopathological nail changes were subtle. Also, in one patient's TB didn't sample the dermal papillae. CONCLUSIONS: TB is a good option to assist in the histopathological diagnosis of nail psoriasis, especially when appropriate clinical elements are combined. Using this technique, larger and thinner samples, short postoperative recovery time, and low risk of onychodystrophy are obtained.

Nail Squamous Cell Papilloma: A Rare Case Report.

Introduction: Squamous cell papilloma is a benign tumor whose pathogenesis is generally related to the human papillomavirus. Despite affecting several organs, we did not find cases reported in the nails. Case Presentation: A 67-year-old female presented with a painful lesion in the nail of the right hallux that started in 2021, with an erythematous appearance evolving to black and expansive growth. Due to the evolution and symptoms, she opted for excision, with a histopathological report of squamous cell papilloma. Complementary treatment with imiquimod was performed, with good healing and pain control. Discussion: Due to the lack of previous reports, treatment was based on therapeutic options for papillomas located in other regions. Excision was performed, followed by application of imiquimod with good response. The prognosis is favorable; however, further studies are needed to elucidate the diagnosis and management of nail squamous cell papilloma.

Multiple-Digit Pigmented Bowen's Disease Induced by Human Papillomavirus in an Immunocompetent Child.

Introduction: Bowen's disease is a squamous cell carcinoma in situ, the most common malignancy of the nail unit. Presenting more frequently in the fingernails, common risk factors include ionizing radiation, oral exposure to arsenic or pesticides, dyskeratosis congenita, and quite commonly diverse subtypes of HPV. We report the first case of multiple periungual pigmented Bowen's disease in a pediatric patient. Case Presentation: A healthy 13-year-old boy presented with a 9-month history of a pigmented erythematous patch on the proximal nail fold of his 3rd right finger without associated symptoms. A punch biopsy was taken, and the diagnosis of Bowen's disease was made. The patient received photodynamic therapy and three cycles of imiquimod without response, and two new lesions appeared on the first and second right fingers. Surgical removal was performed on all lesions. A polymerase chain reaction detected an HPV type 16. Discussion/Conclusion: Multiple periungual Bowen's disease is rare, with the most frequent risk factors being HPV infection and chronic immunosuppression. Less than 10% of the cases present as longitudinal melanonychia. To date, there are no previous reports of multiple pigmented periungual Bowen's disease. HPV-induced Bowen's disease is usually present in adults aged between 22 and 89 years as persistent verrucae. In this case, koilocytosis and the fact that all lesions appeared on the right hand are suggestive of HPV infection.

Total Chemical Matricectomy With 88% Phenol: A Prospective Case Series of 37 Patients.

BACKGROUND: Definitive nail dystrophies, congenital, traumatic, or acquired, affecting mainly elderly patients, may not be sufficiently managed with a periodic conservative treatment. A definitive surgical treatment may be considered an alternative method, especially in symptomatic patients. OBJECTIVE: To evaluate the effectiveness of total matricectomy with 88% phenol solution to treat some nail dystrophies, not otherwise satisfactorily managed. METHODS: A series of 48 surgeries were performed on 37 patients. Pain evaluation, interference with shoes and gait, recurrences, and patients' satisfaction with procedure were evaluated. RESULTS: All patients mentioned some pain or impairment in wearing shoes before surgery. Cosmetic results were remarkable, and most of the patients (95.11%) had a dramatic improvement of their discomfort after the procedure. No severe complications occurred during the 12-month follow-up. LIMITATIONS: Single-center study and the limited number of patients. CONCLUSION: Total matricectomy with 88% phenol solution is an effective surgical method with low rates of postoperative morbidity and high success rates for treating symptomatic nail dystrophies. The satisfaction with the cosmetic results is high, and this is a safe procedure for patients with associated comorbidities.

Onychoscopic characteristics of Trichophyton rubrum and Trichophyton interdigitalis fungal infections: A multicentric study.

BACKGROUND: Trichophyton rubrum and Trichophyton mentagrophytes variant interdigitalis are the most frequent etiologic agents of onychomycosis. Diagnosis of certainty requires mycological examination, which often results unfeasible. OBJECTIVES: The aim of our study is to describe pathogen specific dermoscopic features, allowing a differential diagnosis without the need for cultural examination, in order to prescribe the most appropriate treatment anyway. PATIENTS AND METHODS: We conducted an observational retrospective study on 54 patients with a culture proven diagnosis of distal subungual onychomycosis of the toenail, caused by Trichophyton rubrum or Trichophyton mentagrophytes variant interdigitalis. Using a videodermatoscope we collected data on nail colour (white, yellow, orange, brown, dark) and on dermoscopic patterns (aurora, spikes, jagged, ruin, linear edge, dots, striae). RESULTS: Fifty-four patients, with a total of 72 nails, were eligible for this study. Analysing the association between discoloration of the nail plate and type of infection (T. rubrum or T. interdigitalis), no correlation turned out to be statistically significant. Instead, significant associations between spikes and T. rubrum infection and striae and infection from T. interdigitalis were identified. Finally, a 100% specificity was identified for white colour and ruin pattern for T. rubrum infection, and brown colour, jagged border and aurora pattern for T. interdigitalis. CONCLUSIONS: Trying to find relationships between specific pathogens and dermoscopic patterns, we found out an association between spikes and striae and T. rubrum and T. interdigitalis respectively. Further larger studies are however necessary to evaluate our preliminary findings.

Intralesional steroid injections for inflammatory nail dystrophies in the pediatric population.

Intralesional injections of triamcinolone acetonide are widely used to successfully treat several inflammatory nail conditions. This procedure is well described in adults, but less frequently reported in children and teenagers, being largely considered too invasive and fear-provoking for pediatric patients. Our report shows how this procedure is feasible and successful in children, even without a digital block. The step-by-step technique and tips to reduce pain should encourage clinicians to offer it as an alternative option to children with inflammatory nail disorders.

Diagnosis and surgical treatment of benign nail unit tumors.

Little is known about benign non-melanocytic nail tumors, probably due to their low pathogenicity. They are commonly misdiagnosed as inflammatory or infective diseases. They have various features, depending on the type of tumor and its location in the nail apparatus. The typical sign of a tumor is the presence of a mass and/or secondary nail changes from damaged nail structures. In particular, if a single digit is affected by a dystrophic sign or a symptom is reported without any explanation, the presence of a tumor should always be ruled out. Dermatoscopy helps to enhance visualization of the condition and in many cases supports the diagnosis. It may also assist in identifying the right place to biopsy, but it never replaces surgery. Most common non-melanocytic nail tumors are analyzed in this paper, including glomus tumor, exostosis, myxoid pseudocyst, acquired fibrokeratoma, onychopapilloma, onychomatricoma, superficial acral fibromyxoma and subungual keratoacanthoma. The aim of our study is to review the main clinical and dermatoscopic characteristics of the most common benign non-melanocytic nail tumors, to correlate them with the histopathology and to advise practitioners of the best surgical management.

Onychomycosis: Recommendations for Diagnosis, Assessment of Treatment Efficacy, and Specialist Referral. The CONSONANCE Consensus Project.

INTRODUCTION: Onychomycosis is the most common nail disorder in adults, with high recurrence and relapse rates. Its diagnosis may be difficult by non-experts because the clinical signs may overlap with other dermatoses. The treatment may be challenging, as it should be patient-tailored. METHODS: An online survey was conducted among European Nail Society (ENS) members to provide recommendations on the diagnosis and assessment of distal lateral subungual onychomycosis (DLSO) in non-specialized clinical environments, as well as recommendations for patient referral. RESULTS: DLSO diagnosis is predominantly based on clinical aspects, and microscopy and fungal culture are commonly employed to establish the diagnosis. Assessment of clinical features is the main method for DLSO follow-up, and the main criterion to define cure is a combination of mycologic cure and clinical cure. The most commonly selected treatments for onychomycosis include oral antifungals, topical antifungals, and nail debridement. According to the nail experts, predisposing factors of DLSO to be evaluated include concurrent tinea pedis diagnosis, immunocompromised status, and diabetes. The minimum clinical aspects to be evaluated for DLSO diagnosis should include subungual hyperkeratosis, white-yellow-orange subungual scales, and absence of salmon-pink coloration. Recommendations for clinical signs that should be evaluated to confirm treatment effectiveness include normal appearance and color of the nail, reduction or absence of scales under the nail, and absence of onycholysis. Recommendations for specialist referral include lack of treatment effectiveness, need of additional therapies, concurrent presence of other diseases or comorbidities, severe DLSO, and presence of a dermatophytoma or involvement of the nail matrix. CONCLUSIONS: According to the surveyed nail experts, after evaluating clinical signs and predisposing factors for DLSO, the diagnosis should include subungual hyperkeratosis, nail color (yellow-orange), and onycholysis and thickening. In cases of severe DLSO, when there is treatment failure, concomitant diseases/comorbidities, presence of a dermatophytoma or involvement of the nail matrix, or involvement of several/all nails, referral should be considered.

Fungal Viability of Nail Dust from Onychomycosis Abrasion: A Pilot Study.

INTRODUCTION: Onychomycosis is a frequent complaint in dermatological practice and corresponds to the most common nail disease. The treatment of onychomycosis remains a challenge, as several factors end up compromising and making treatment difficult. Nail abrasion is considered a useful method in many cases. However, there is controversy about this approach, as there is an aerosol formation that could contaminate the environment and cause fungal changes or hypersensitivity reactions by the disseminated dust. We conducted a pilot study to investigate the fungal viability of nail particles from nails with onychomycosis after abrasion procedure. METHODS: In this study, nail dust from the gloves and mask, used in the procedure, was collected from 9 patients with clinical and dermoscopic diagnoses of onychomycosis. RESULTS: Hyaline septate hyphae were found in 12 materials (gloves and/or masks) from 7 patients. However, these hyphae were morphologically deformed or mutilated in all exams. In Mycosel® agar, there was no growth of any fungus. DISCUSSION/CONCLUSION: The absence of dermatophyte isolation in all fungal cultures may demonstrate that the deformed fungal structures shown are not viable and would not present risks of contamination after nail abrasion.

Prevalence of Onychomycosis among Patients with Transverse Overcurvature of the Nail: Results of a Cross-Sectional Study.

INTRODUCTION: Transverse overcurvature of the nail (TON) represents one of the main reasons for dermatological consultations due to nail conditions. Association between TON and subungual hyperkeratosis is common and simulates onychomycosis, constituting a difficult differential diagnosis by clinical features. Many cases are treated in daily practice with antifungal therapy even without mycological confirmation. The aim of this study was to determine the prevalence of onychomycosis among patients with TON associated with subungual hyperkeratosis. METHODS: All subjects with clinical diagnosis of TON and subungual hyperkeratosis were subjected to a thorough clinical history, detailed clinical examination, digital photography, and collection of nail clipping and subungual debris for histopathological and microbiological examination (direct microscopy). RESULTS: Sixty-five samples were collected from 62 female (95.4%) and 3 male (4.6%) participants. Age range was between 34 and 83 years (mean age, 61.2 years). Twenty-eight samples were positive for onychomycosis, giving a 43.07% prevalence rate of onychomycosis among TON associated with hyperkeratosis. DISCUSSION/CONCLUSION: According to our data, the prevalence of onychomycosis in patients with TON associated with subungual hyperkeratosis was 43.07%, confirming the need to rule out fungal infection in TON associated with subungual hyperkeratosis prior to considering any unnecessary antifungal treatment.