Causes of longitudinal nail splitting: a retrospective 56-case series with clinical pathological correlation.

BACKGROUND: Split nail (SN) is a rare type of nail fragility syndrome, characterized by a longitudinal fissure involving the entire thickness of the nail plate. Longitudinal nail splitting may be caused by direct injury to the nail plate or matrix insult. Few articles have been published on the topic, most were related to the traumatic aetiology. Some case reports mention tumours and inflammatory disorders as other causes. OBJECTIVES AND METHODS: The aim of this retrospective study was to analyse the clinical and histopathological features of 56 SN collected at the nail consultation of the dermatology department at Saint Pierre University Hospital in Brussels, between 1997 and 2019. RESULTS: Fifty-six patients were included (34 women and 22 men) with median age of 44.2 years. The fingernails were 3.2 times more frequently affected than toenails, especially the thumb. The most frequent aetiologies were tumours (45.6%), inflammatory diseases (26.3%) and traumas (19.3%). Congenital (5.3%) and systemic disorders (3.5%) were rarer causes. Histopathological slide review confirmed that alteration of the nail matrix integrity causes split nail, resulting either from matrix stretching by an underlying tumour or from impairment of the keratinization process by inflammatory diseases, melanocytic tumours and Bowen's disease. CONCLUSIONS: This study is the largest case series of longitudinal nail splitting to date. It is the first to gather nail disorders causing SN with their clinical pathological correlation. The most common causes are traumatisms, tumours and inflammatory disorders. Congenital and systemic disorders are rarer. Tumours are responsible for half of the cases from which one third are malignant, mainly melanoma. When facing a monodactylic SN, benign as well as malignant tumours should be ruled out before concluding to traumatic aetiology.

European recommendations for management of immune checkpoint inhibitors-derived dermatologic adverse events. The EADV task force 'Dermatology for cancer patients' position statement.

The introduction of immune checkpoint inhibitors (ICIs) opened a new era in oncologic therapy. The favourable profile of ICIs in terms of efficacy and safety can be overshadowed by the development of immune-related adverse events (irAEs). Dermatologic irAEs (dirAEs) appear in about 40% of patients undergoing immunotherapy and mainly include maculopapular, psoriasiform, lichenoid and eczematous rashes, auto-immune bullous disorders, pigmentary disorders, pruritus, oral mucosal lesions, hair and nail changes, as well as a few rare and potentially life-threatening toxicities. The EADV task force Dermatology for Cancer Patients merged the clinical experience of the so-far published data, incorporated the quantitative and qualitative characteristics of each specific dirAEs, and released dermatology-derived, phenotype-specific treatment recommendations for cutaneous toxicities (including levels of evidence and grades of recommendation). The basic principle of management is that the interventions should be tailored to serve the equilibrium between patients' relief from the symptoms and signs of skin toxicity and the preservation of an unimpeded oncologic treatment.

The importance of skin manifestations, serology and nailfold (video)capillaroscopy in morphea and systemic sclerosis: current understanding and new insights.

Since the field around morphea and systemic sclerosis (SSc) is evolving rapidly, this review approaches conventional as well as more recent clinical developments from a dermatological point of view. Skin manifestations are critical in sub-classifying these diseases ensuring a correct prognosis for these patients. They can be discretely present, and therefore, diagnosis can be challenging sometimes, implicating a thorough dermatological examination is mandatory. Furthermore, a growing amount of dermatologists perform nailfold videocapillaroscopy (NVC), a more recent reliable non-invasive imaging technique used for in vivo assessment of the microcirculation at the nailfold. After all, specific NVC-changes are present in a majority of patients with SSc. This way, dermatologists not only take part in the diagnosis process through clinical investigation but also through the use of a modern state of the art imaging technique that is becoming the golden standard in SSc multidisciplinary workup. In this review, current understandings for NVC in morphea and SSc are revised. So far, the role of NVC in the diagnosis/prognosis/classification of morphea patients has not been thoroughly investigated to make proper conclusions. As for SSc, it is well known that NVC contributes to the diagnosis and can make a fundamental difference especially when obvious clinical SSc signs are absent. This review emphasizes the (somewhat underestimated) role of dermatologists in the process of diagnosis and follow-up, and thus, the difference we can make for our patients and fellow colleagues in the multidisciplinary workup of SSc and morphea.

Paediatric nail consultation in an academic centre in Belgium: a 10-year retrospective study.

BACKGROUND: Very few studies have been conducted to establish the nature and prevalence of nail disorders in children. OBJECTIVES: To determine the frequency of various nail conditions in the paediatric setting and to report their management and follow-up. METHODS: This was a retrospective study between 2007 and 2017 of children under 18. All the patients were evaluated in our paediatric nail clinic at the dermatology department of Queen Fabiola Children's University Hospital. The data were synthesized from information obtained through medical records as well as from photographs taken during consultation. Follow-up was completed by phone interview. RESULTS: Three hundred and one patients were included. The majority of nail abnormalities involved the toenails (57.6%). The most common clinical signs were, in descending order, Beau's lines, pachyonychia, subungual hyperkeratosis and onycholysis. The most frequent diagnoses were fever-related Beau's lines or onychomadesis (9.7%), trachyonychia (8.4%), longitudinal melanonychia (8.1%) and congenital malalignment of the great toenail (8.1%). The main diagnoses by age group were as follows: congenital hypertrophy of the lateral nail folds (21.4%) [0-2 years old]; fever-related Beau's lines or onychomadesis (21%) [2-6 years old]; trachyonychia (22%) [6-12 years old]; and juvenile ingrown nail (21.4%) [12-18 years old]. Management included clinical observation for 119 patients and specific advices for 108 patients. A treatment was prescribed for 134 patients, topical in 76.5% of cases. Follow-up demonstrated complete healing in 50.6% of patients and improvement in 19.7%. CONCLUSION: The most frequent nail disorders are benign, and their distribution varies with age. Management mainly involves conservative care, and the prognosis is favourable in the majority.

Onychopapillomas: a 68-case series to determine best surgical procedure and histologic sectioning.

BACKGROUND: Onychopapilloma (OP) is a benign longitudinal nail bed tumour usually presenting as longitudinal erythronychia. Evidence-based recommendations for proper histologic sectioning and definitive surgical management are not available. OBJECTIVES: The aim of this study was threefold. The first was to review the clinical and histopathological features of all OP diagnosed in our department. The second was to identify the most accurate histological technique. The third aim was to determine the most effective surgical procedures by examining recurrence rates and complications over the long term. METHODS: This retrospective analysis collected all patients with OP in the dermatology department of Saint-Pierre - Brugmann University Hospital (Brussels, Belgium) between January 2007 and March 2017. Clinical findings and type of surgery performed were recorded from medical files and iconographic documents. All slides were reviewed by a dermatopathologist with expertise in nail disease. Longitudinal follow-up was performed. RESULTS: A total of 68 patients were included (42 women, 26 men) with a median age of 46 years. Two children were 9 and 11. The histological interpretation was more difficult for the transverse sections than for the longitudinal ones (29.4% vs. 2.2%). The pathological diagnosis of OP was typical in 30.6%, suggestive in 51.6%, slightly suggestive in 12.9% and not contributive in 4.8%. 50 patients had a mean follow-up of 50 months. 38% recovered completely and 20% recurred. 42% had mild to moderate sequelae. CONCLUSIONS: We report herein the first two paediatric cases. Classical longitudinal excision with careful removal of the lesion from the inferior face of the nail plate seems to be the most accurate surgical technique. In the pathology laboratory, longitudinal sections should be recommended. In our series, a recurrence rate of 20% was observed. This was more frequent when a tangential longitudinal excision was performed.

[Management of non melanoma skin cancer by the general practitioner]. / Prise en charge des cancers cutanés non-mélanome par le médecin généraliste.

The incidence of skin cancer cases has increased significantly during the last decades. Non melanoma skin cancer (NMSC) is the most common cancer in Caucasian populations. This term refers to 2 major types of skin cancer : basal cell carcinoma (BCC) and squamous cell carcinoma (SCC). Mortality from BCC and SCC is low but there may be substantial morbidity from disfigurement as these lesions tend to be located on the skin of the head and neck. Actinic keratosis is a premalignant condition that may evolve into SCC. Fortunately, skin cancer is amenable to early detection and potential cure. General practitioners may play a very important role in the timely diagnosis and management of these tumors. They are on the front line to detect NMSC : opportune examination coupled with good observation skills allow a high detection rate of suspicious lesions. It is essential to identify the high-risk patient as well as the clinical signs of suspicious lesions. This article outlines the clinical features of common NMSC and highlights which lesions should be best referred to a dermatologist.

L'incidence des cancers cutanés s'est considérablement accrue ces dernières décennies. Le terme de cancer cutané non-mélanome (CCNM) définit deux types principaux de cancers cutanés : le carcinome basocellulaire (CBC) et le carcinome spinocellulaire (CSC). Ce sont les néoplasies les plus fréquentes chez les sujets caucasiens. Leur mortalité est faible mais leur localisation préférentielle au visage et au cou est responsable d'une morbidité conséquente par séquelles cicatricielles, parfois lourdes. Les kératoses actiniques sont des lésions précancéreuses qui peuvent évoluer en CSC. La détection précoce des cancers cutanés permet d'obteni r un taux élevé de guérison. Les médecins généralistes jouent un rôle majeur dans le diagnostic et la prise en charge adéquate de ces tumeurs. Ils sont en première ligne pour détecter les CCNM : un examen clinique opportun associé à des compétences observationnelles assure un taux élevé de dépistage de lésions suspectes. Il est essentiel de reconnaître les patients à risque et d'identifier les lésions suspectes. Cet article reprend les présentations cliniques des principaux CCNM et souligne celles qui doivent être orientées vers le dermatologue.

[Skin sampling for the general practitioner]. / Prélèvements cutanés en médecine générale.

Skin samplings are easily performed in general practice. They include skin biopsies, nail clippings, skin scrappings, hair pluckings as well as trichograms. The different types of skin biopsies are curetage, shaving, punch and elliptic biopsies. They are most commonly used for the diagnosis of inflammatory skin conditions and cutaneous tumors. The biopsies are performed under local anesthesia and each has specific indications. Their complications are minimal. In order to obtain as much information as possible the lesion to be biopsied should be judiciously selected, harvested without being harmed and sent to a skin-oriented pathologist. Nail clippings, skin scrapings and hair plucking allow diagnosis of superficial skin mycosis (tinea, pityriasis versicolor) and are mandatory before prescribing systemic treatment. Scrapping of an itch mite burrow may sometimes reveal the sarcopte. Trichogram may be useful in the work up of a hair loss.

Management of in situ melanoma of the nail apparatus with functional surgery: report of 11 cases and review of the literature.

BACKGROUND: Nail apparatus melanoma (NAM) is a rare melanocytic neoplasm with pejorative prognosis often related to late diagnosis. Early diagnosis at in situ stage (NAMis) is difficult, but essential to improve prognosis. NAMis management is not well established yet. Removal of the whole nail unit has been advocated in several small series as a potential treatment for NAMis. OBJECTIVE: To report and assess 'functional' or 'conservative' surgery for NAMis and evaluate its long-term oncologic safety. METHODS: Retrospective study of cases diagnosed in the University Hospital Saint-Pierre collected over a 13 year period and compared with the published data. RESULTS: Eleven cases of NAMis were identified: 73% concerned females. Thumb and first toe were the most affected digits (63% of total). Monodactylic longitudinal melanonychia (LM) was the most frequent presentation (92%). Mean diagnosis delay was 5 years. Diagnosis was suspected on the basis of clinical and dermatoscopic signs and was confirmed by pathological examination. All patients underwent complete nail unit removal with 6 mm security margins around the anatomic boundaries of the nail. Two late local recurrences were observed at 7 and 11 years follow-up. CONCLUSIONS: Our series, the largest up to now, demonstrates that 'functional surgery' is a rational approach for NAMis with an excellent oncologic safety at 5 years. However, this study suggests that a very long-term follow-up is mandatory, as recurrences may appear late.

[Superficial acral fibromyxoma in a sub-matricial location: An unusual variant]. / Fibromyxome acral superficiel de localisation sous-matricielle : une forme clinique inhabituelle.

BACKGROUND: Superficial acral fibromyxoma (SAFM) is a benign soft tissue tumor located in the acral areas, particularly the peri- and sub-ungueal areas. Sub-matricial localisations have not been reported to date. PATIENTS AND METHODS: We report herein the clinical and pathological presentation of three cases of SAFM located solely under the matrix. The patients presented with pseudo-clubbing, onychogryphosis or triangular macrolunula. The histopathological appearance was characteristic. DISCUSSION: SAFM is a slow-growing, skin-colored, firm nodule, located chiefly on the digits or the toes, and especially in the nail area. It may or may not be painful. Microscopically, it presents as a relatively well-circumscribed but unencapsulated dermal tumor, composed of spindle shaped cells integrated in a myxocollagenic matrix, sometimes invading the subcutis. Tumor cells diffusely express CD34. A conservative surgical approach is recommended. Both clinicians and pathologists should be aware of this entity in order to avoid misdiagnosis, which can lead to unwarranted mutilating surgery. CONCLUSION: Sub-matricial localisation of SAFM is extremely rare and may present as pseudo-clubbing, isolated onychogryphosis or a triangular macrolunula. A conservative surgical approach should be recommended.

Efficacy, safety and tolerability of an optimized avulsion technique with onyster® (40% urea ointment with plastic dressing) ointment compared to bifonazole-urea ointment for removal of the clinically infected nail in toenail onychomycosis: a randomized evaluator-blinded controlled study.

BACKGROUND: Toenail onychomycosis is highly prevalent, with 14-28% of people aged 60 or over suffering from the disease. Use of a topical antifungal alone in toenail onychomycosis is associated with low cure rates. This may be due to limited penetration of the topical antifungal through the diseased nail. The objective of the present study was to compare two treatment modalities to obtain diseased nail chemical avulsion in toenail onychomycosis. METHODS: In this European, multicenter, randomized, parallel-group, open-label, active-controlled study, male or female adult patients with distal-lateral or lateral subungual dermatophyte onychomycosis on at least 12.5% of the great toenail were randomized either to a 40% urea ointment with plastic dressing group (n = 53) or to a bifonazole-urea ointment group (n = 52). The ointments were applied daily for a maximum of 3 weeks according to the summary of product characteristics. After assessment of infected nail debridement, topical antifungal treatment with bifonazole cream was applied daily in both groups for 8 weeks. 102 patients were evaluated, i.e. 51 in the 40% urea ointment with plastic dressing group and 51 in the bifonazole-urea group. The primary end point was complete removal of the nail plate at day 21 (D21). Secondary end points were: complete cure and mycological cure evaluated at D105. Ease of use and local tolerability were also assessed. RESULTS: Complete removal of the clinically infected target nail plate area, assessed by blinded evaluators, was significantly higher in the 40% urea ointment with plastic dressing group (61.2%) than in the control group (39.2%), showing the superiority of 40% urea ointment with plastic dressing (p = 0.028). The same results were observed in the per-protocol population (63.0 vs. 36.6%; p = 0.014). Complete removal of the infected area assessed by the investigator at D21 showed a significantly higher success rate in patients treated with 40% urea ointment with plastic dressing (86.3%) as compared to patients treated with bifonazole-urea (60.8%), confirming the superiority of 40% urea ointment with plastic dressing (p = 0.004). At D105, the complete cure of onychomycosis, a criterion combining clinical and mycological assessments, showed a success rate of 27.7% for 40% urea ointment with plastic dressing versus 20.8% for the control group. No statistical difference was observed between the two treatment groups. The number of patients with at least one adverse event was twice as high in the bifonazole-urea group in comparison to the 40% urea ointment with plastic dressing group. Overall assessment of local tolerability by the investigator was considered good/very good in 98.0% of the 40% urea ointment with plastic dressing patients versus 90.4% of the bifonazole-urea patients, at D21, with no significant difference between both groups. CONCLUSION: This study shows the superiority of 40% urea ointment with plastic dressing to bifonazole-urea ointment for complete removal of the infected target nail assessed by blinded evaluators and by the investigators. Further studies are needed to assess the impact of preliminary chemical nail avulsion on the efficacy of topical treatment of onychomycosis as assessed by complete cure at 1 year.

Ractopamine does not rescue Halothane and Rendement Napole metabolism postmortem.

The objective of this study was to determine if ractopamine (RAC) impacts postmortem muscle metabolism and subsequent pork quality in Halothane (HAL) and Rendement Napole (RN) mutant pigs. All RAC fed pigs had increased (P < 0.04) L* values. HAL and RN mutants muscle had lower (P < 0.01) pH values but RAC feeding had no effect. RN mutants had higher and lower (P < 0.05) muscle pH and temperatures, respectfully at 15 min and RN mutant pigs had greater (P < 0.0001) glycogen initially but lactate levels similar to wild type (WT) pigs at 24 h. RAC lowered (P < 0.05) glycogen in RN mutants but not in HAL mutated or WT pig muscle. These data show RAC feeding changes postmortem energy metabolism but does not change pH and pork quality hallmark of two major pig gene mutations and supports our contention that ultimate meat quality traits and their biochemical drivers may be more complex than originally reasoned.

[Differential diagnosis of onychomycosis]. / Diagnostic différentiel des onychomycoses.

Almost 50% of nail pathology is caused by onychomycosis. However, the nail has a limited reservoir of clinical expressions and many conditions may mimic onychomycosis. Its differential diagnosis should be known in order to avoid useless or even toxic treatments. When confronted with ungual alterations restricted to one or some nails, it is fair to evoke onychomycosis but one should keep in mind repeated traumata to the toenails, psoriasis and chronic paronychia on the fingernails. Involvement of a large number of nails, especially all twenty nails, should not first suggest a fungal infection but rather an inflammatory or systemic condition. It is mandatory to always sample the nail for mycological examination before prescribing any systemic treatment.

Ractopamine changes in pork quality are not mediated by changes in muscle glycogen or lactate accumulation postmortem.

Pork quality is a product of the rate and extent of muscle pH decline paced by carbohydrate metabolism postmortem. The beta-adrenergic agonist ractopamine (RAC) alters muscle metabolism but has little impact on pork quality. The objective of this study was to determine how feeding RAC alters postmortem carbohydrate metabolism in muscle. Muscle pH was higher early postmortem in pigs fed RAC for 2 wks compared to control, while other time points and temperatures were largely unaffected. Early postmortem, muscle lactate levels were reduced (P < 0.05) after feeding RAC for 1 and 2 wks. Similarly, pigs fed RAC for 4 wks had reduced (P < 0.05) glycogen levels early postmortem compared to control pigs, but unexpectedly, L* values (lightness) increased (P < 0.05) after inclusion of RAC in the diet for 4 wk. These data show RAC feeding reduces glycogen content and changes lactate accumulation postmortem, but raise questions about the role glycolytic flux has in driving pork quality development.