Unilateral Onychodystrophy and Puffy Fingers: Think about Carpal Tunnel Syndrome.

An 87-year-old man was referred to our department for evaluation of his dystrophic left fingernails that developed progressively for the past 2 years. His past medical history included hemodialysis for 10 years for chronic renal failure. Examination of his nails revealed xanthonychia, onycholysis, Beau's lines, and marked hyperkeratosis of the nail plate involving all of his left fingernails. However, his right fingernails were not affected (Figure 1). He also had edema of the left hand associated with puffy fingers but without trophic disorders (Figure 2). Mycologic exam-ination with direct microscopy and culture of his affected nails were negative. Antinuclear antibodies (ANAs), Scl-70 (anti-topoisomerase) antibodies, anti-centromere antibodies, and anti-RNA polymerase III antibodies were all negative. Capillaroscopy showed no abnormalities. An X-ray of his left hand showed no bony abnormalities. For the past 5 years, the patient had suffered from paresthesia and numbness on the left hand in the area of the median nerve. Paresthesia, pain, burning, and tingling involved mainly the thumb, plus the index and middle fingers, but not the little finger. Carpal tunnel syndrome (CTS) was suspected. Neurologic examination and electromyography (EMG) confirmed the diagnosis of CTS of the left hand explaining his unilateral onychodystrophy. The patient was then referred to a hand surgeon for his CTS.

[A toddler with loose nails]. / Een peuter met loslatende nageltjes.

A father consulted his general practitioner with his 18-month-old son with several loose fingernails. We saw a toddler with nine fingernails that peeled off on the proximal side. The normal nails were visible under the loose nails. Diagnosis: onychomadesis.

Leukonychia: What Can White Nails Tell Us?

Changes in nail color can provide important clues of underlying systemic and skin disease. In particular, white discoloration (leukonychia) has a high prevalence with a wide array of potential relevant causes, from simple manicure habits to life-threatening liver or kidney failure. Therefore, a reliable assessment of the patient with leukonychia is essential. In the past, two classifications for leukonychia have been presented. The morphological classifies the nail according to the distribution of the white lines: total, partial, transversal, and longitudinal leukonychia. Mees' and Muehrcke's lines are examples of transversal leukonychia, while Terry's and Lindsay's nails are examples of total and partial leukonychia. The anatomical classifies according to the structure responsible for the white color: the nail plate in true leukonychia, the nail bed in apparent leukonychia, and the surface only in pseudoleukonychia. In this review, both morphological and anatomical features have been combined in an algorithm that enables clinicians to approach leukonychia efficiently and effectively.

Onychophagia: detailed clinical characteristics.

BACKGROUND: Onychophagia is a common disorder affecting 20% to 30% of the general population. It is defined as habitual nail biting and can cause various changes in the nail units. However, to date, there has been a paucity of data focusing on nail deformities related to onychophagia. This study was performed to investigate the clinical characteristics of onychophagia in Korea. METHODS: This study included 53 patients with onychophagia who visited the Pusan National University Hospital (Busan and Yangsan) over a 10-year period (2011-2020). We retrospectively reviewed medical records and clinical and dermoscopic photographs. RESULTS: All 10 fingernails were affected in 37.7% of the patients. The left thumbnail was the most predominantly affected site (81.1%). Clinical findings showed that short nails with ragged distal borders were the most common presentation (100.0%), followed by generalized or patchy rough areas (50.9%), linear and pinpoint hemorrhage (32.1%), longitudinal melanonychia (30.2%), transverse groove (28.3%), brittleness (28.3%), macrolunula (24.5%), washboard nail (13.2%), and pterygium (3.8%). Of the patients, 88.7% had periungual complications, such as periungual exfoliation (77.4%), absent or ragged cuticle (52.8%), hyponychial hyperkeratosis (37.7%), and paronychia (15.1%). CONCLUSIONS: Although onychophagia is a common disorder, its clinical characteristics have not been reported in the literature. The results of this study may be helpful in managing patients with onychophagia.

Distal nail embedding treatment using autogenous nails.

A regrowing nail tip after nail avulsion may excessively curve and invaginate into the nail bed. This is treated as a type of ingrown toenail, and is known as distal nail embedding. In most cases, further growth restores the original shape evenly over the nail bed. However, it is often painful and such cases may require treatment. We report a surgical approach that we applied to six cases of distal nail embedding involving pain or deformity of nails caused by a nail tip invaginating into the nail bed and/or cessation of forward nail growth. As our method involves removing a portion of the embedded tip edge nail and inserting the removed nail into the remaining depressed portion, the nail can grow over the bulge. In all six patients in whom we applied this method, the pain and nail deformity resolved and there was no recurrence. We used autogenous nails, which can reduce the pressure imbalance on a nail bed, and this contributed to improving the morphology of nails and nail beds. In addition, the risk of a hypertrophied nail is reduced because half of the nail adheres to the nail bed. Special materials are unnecessary and this method can be conducted with simple outpatient department procedures. There were no cases of a fixed nail section detaching due to a bulge at the nail tip. The inserted nail was maintained in all cases for several months until the nail grew over the bulge.

Posttraumatic onychoheterotopia: A case and review of the pediatric literature.

BACKGROUND: Onychoheterotopia, or ectopic nail, is a rare nail condition in which nail growth occurs in areas other than the distal phalanges. The majority of cases in the literature are noted to be congenital; however, acquired cases have less commonly been described following either acute or chronic trauma. METHODS: We present a case of acquired onychoheterotopia in a child, with a corresponding literature review of acquired pediatric onychoheterotopia cases for comparison. RESULTS: There were a total of 10 cases of acquired onychoheterotopia in pediatric patients in the literature. Including our patient, 81.8% (9/11) developed an ectopic nail on the fingers. Crush injury preceded the ectopic nails in 45.5 % (5/11) of cases. Infection occurred in 27.3% (3/11). CONCLUSIONS: Although the incidence and prevalence of acquired onychoheterotopia are unknown, it seems to be an uncommon phenomenon. From our case and others from the literature, there may be associations with crush injury specifically. Further research will be needed to fully elucidate the pathophysiology and risk factors for ectopic nail growth.

Congenital malalignment of the great toenail: Conservative and definitive treatment.

Congenital malalignment of the great toenail, or ungual malalignment, is a rarely recognized disorder. It is characterized by lateral deviation of the longitudinal axis of the nail plate with respect to the distal phalanx, and if untreated, complications in the late teens and adulthood may arise. In this study, we have reviewed conservative and definitive treatments for this disorder.