Retronychia in children: A case series.

BACKGROUND: Retronychia is characterized by proximal ingrowing of the nail plate into the proximal nail fold. It is always associated with the presence of two or more overlapping nail plates under the proximal nail fold, clinical signs of chronic proximal paronychia refractory to antimicrobial treatment, and a yellowish nail that does not grow. It mainly affects young female adults, with less than 30 pediatric cases described in the literature so far. METHODS: Retrospective and observational study of patients between 0 and 18 years with a clinical and/or ultrasound diagnosis of retronychia attending a pediatric dermatology service between December 2020 and January 2022. RESULTS: We identified 9 patients with retronychia, 7 girls and 2 boys. In all cases, the hallux nails were affected with 5 unilateral and 4 bilateral cases. On physical examination we observed the following signs: thickened and opaque nail plate (one patient), yellowish nail plate (7 patients), double nail plate (6 patients), and erythema with edema, pain, and suppuration of the proximal nail fold (7 patients). Ultrasound was performed in 7 patients and specific findings of retronychia were found in 5 of them. All patients received topical treatment and were referred for the appropriate surgical treatment. To date, only one patient underwent nail avulsion, which was followed by complete recovery. CONCLUSIONS: Retronychia is underdiagnosed, particularly in the pediatric population. We present a series of 9 cases of retronychia in children, with clinical and ultrasonographic findings consistent with those of adults. We emphasize the importance of recognizing this entity, which will allow early and adequate treatment.

A comparative study on the efficacy between omega toenail correction and winograd procedure for stage II-III paronychia.

The objective of this study is to conduct a prospective trial comparing the therapeutic efficacy of Omega toenail correction and the Winograd procedure in treating stage II-III paronychia. From August 2018 to August 2023, ninety cases from eighty-three patients were randomly divided into two groups, one receiving Omega toenail correction (experimental group) and the other receiving the Winograd procedure (control group). The clinical therapeutic effects of both treatments were evaluated based on time to resume movement, treatment cycle, one-year recurrence rate, and visual analogue scale (VAS) scores before and after treatment. The clinical efficacy was compared between Omega toenail correction and Winograd procedure treating paronychia of stage Ⅱ-Ⅲ. It has been demonstrated that the time to resume movement in the experimental group is obviously shorter than that in the control group (P = 0.024), while the treatment cycle is longer (P = 0.009) with no significant difference (P = 0.734) in the aspect of one-year recurrence rate. However, the VAS after the correction in the experimental group is significantly lower than that in the control group (P = 0.019). It has been suggested that Omega toenail correction characterized by easy operation, sure efficacy and lower recurrence rate can be widely applied in clinic work.

Surgical interventions for ingrown toenail.

BACKGROUND: Paronychia is a prevalent clinical disease affecting the soft tissue surrounding the nails. Most cases of toenail paronychia are commonly associated with ingrown toenails. While conservative treatment is effective for mild cases of ingrown toenails, surgical intervention becomes necessary for moderate to severe cases, particularly when granulomas form. OBJECTIVE: To provide a systematic understanding of these classic and modified procedures for surgeons to select the appropriate surgical interventions for patients suffering from moderate to severe ingrown toenails and discuss this technology's advantages and limitations for dermatologic surgery. METHODS: A literature search was performed using PubMed/MEDLINE and Google Scholar databases. Studies discussing surgical intervention for ingrown toenails were included. Moreover, the surgical steps were meticulously depicted by detailed schematic diagrams. RESULTS: These surgical techniques can be divided into three categories: matrix resection, debulking of periungual soft tissues, and the rotational flap technique. Each approach possesses distinct advantages and limitations. CONCLUSION: For moderate to severe cases, surgical interventions may exhibit superior outcomes, faster recovery times, and lower recurrence rates. The surgeon must possess a comprehensive understanding and proficient skillset in various surgical techniques for ingrown toenails.

Combination of available topical beta-blockers and antibiotic ointment for epidermal growth factor receptor tyrosine kinase inhibitor-induced paronychia and pseudopyogenic granulomas in Taiwan.

BACKGROUND: Painful paronychia and pseudopyogenic granuloma (PG) are common adverse drug reactions (ADRs) associated with the use of epidermal growth factor receptor tyrosine kinase inhibitors (EGFR-TKIs) to treat non-small cell lung cancer (NSCLC). Multiple local management approaches have been tested with unsatisfactory results. We have introduced an occlusion therapy technique through which available topical drugs for longer than 2 years. METHODS: Based on the cancer registry and case management system of our hospital, from July 2019 to July 2020, we retrospectively enrolled patients with NSCLC who were treated with EGFR-TKIs and received applications of 0.5% timolol ophthalmic solution (TIMOPTOL XE 0.5%®) combined with a neomycin/tyrothricin ointment (Biomycin®) using the occlusion method to treat paronychia or PG. RESULTS: A total of 22 patients were enrolled, with a mean age of 66.5 years, most of whom were women (72.7%). Periungual lesion-related pain was reported by all patients, and periungual bleeding and PG were reported in 14% (3/22) and 64% (14/22) of patients, respectively. After the occlusion therapy application of timolol ophthalmic solution combined with neomycin/tyrothricin ointment twice daily, the overall response rate was 83.3%, including complete response in 18% (4/22) of cases and partial response in 68% (15/22) of cases. CONCLUSION: We presented an occlusion method using available topical beta-blockers and antibiotic ointment for EGFR-TKI-induced paronychia and PG in Taiwan. The result is favorable. Further randomized control trial is urgent to validate our findings.

MEK inhibitor-induced paronychia in a paediatric population: A tertiary centre experience.

The cutaneous toxicity of MEK inhibitors may limit treatment adherence. The authors present a retrospective study of 41 paediatric patients with NF-1 undergoing therapy with selumetinib and propose a treatment algorithm.

A Study on the Efficacy of Ω Toenail Correction Treating Paronychia.

To study the clinical effects of Ω toenail correction in the treatment of paronychia. One hundred thirty-six cases of 130 patients during the period from August 2018 to August 2021 were treated with Ω toenail correction according to clinical stages, the clinical therapeutic effects of which were evaluated in terms of the operation time, the time to resume movement, treatment cycle, 1-y recurrence rate, and visual analogue scale (VAS) scores before and after treatment. The clinical efficacy was analyzed and compared of Ω toenail correction in treating paronychia of different clinical stages. It has been demonstrated that there was no significant difference in operation time, time to resume movement, treatment cycle and recurrence rate among different stages of paronychia, while there existed the significant difference (p < .05) in VAS score of resting-state pain before and after correction which stood at 6.43 ± 0.29 points with the after-treatment VAS scores at 1.10 ± 0.22. There is a statistical difference (p < .05) in VAS score of movement-evoked pain between before and after treatment. The VAS scores of movement-evoked pain stood at 7.55 ± 0.42, which is in contrast with the after-treatment VAS at 1.74 ± 0.93. It has been concluded that Ω toenail correction characterized by easy operation can relieve the pain immediately, which can achieve satisfactory clinical efficacy for treating paronychia of different stages.

A multicenter study of skin toxicity management in patients with left-sided, RAS/BRAF wild-type metastatic colorectal cancer treated with first-line anti-EGFR-based doublet regimen: is there room for improvement?

BACKGROUND: Skin toxicity in patients affected by metastatic colorectal cancer (mCRC) treated with epidermal growth factor receptor (EGFR) inhibitors is well known. However, ad hoc ESMO guidelines have only recently been published. AIM AND METHODS: To describe the management (pre-emptive or reactive) of anti-EGFR-related cutaneous adverse events (AEs), in a real-life clinical context, in a selected population of patients with left-sided, metastatic RAS/BRAF wild-type mCRC treated with doublet chemotherapy plus anti-EGFR monoclonal antibody (i.e., panitumumab or cetuximab) as first-line regimen at 22 Institutions. The measured clinical outcomes were treatment-related adverse events, objective response rate (ORR), progression-free survival (PFS), and overall survival (OS). RESULTS: Of 515 patients included in the analysis, 173 (33.6%) received a pre-emptive and 342 (66.4%) a reactive treatment. The median follow-up period for the overall population was 30.0 months. A significantly lower incidence of any grade acneiform rash was found in the pre-emptive compared to the reactive cohort both in the overall population (78.6% vs 94.4%, p < 0.001) and in patients treated with panitumumab (76.1% vs 93.7%, p < 0.001) or cetuximab (83.3% vs 95.4%, p = 0.004), respectively. A lower incidence of any grade (41.6% vs 50.9%, p = 0.047) but a higher incidence of G3-G4 (9.2% vs 4.7%, p = 0.042) paronychia/nail disorders were found in the pre-emptive compared to the reactive cohort. Nevertheless, a lower rate of patients within the reactive compared to the pre-emptive cohort was referred to dermatological counseling (21.4% vs 15.3%, respectively, p = 0.001). A higher rate of anti-EGFR therapy modification was needed in the pre-emptive compared to the reactive cohort (35.9% vs 41.6%, respectively, p < 0.001). The pre-emptive approach did not reduce the efficacy of antineoplastic therapy compared to the reactive in terms of ORR (69.2% vs 72.8%), median PFS (12.3 vs 13.0 months), and median OS (28.8 vs 33.5 months). CONCLUSION: Although recommended by international guidelines, the pre-emptive approach of anti-EGFR-related skin toxicity in mCRC patients still appears less adopted in daily clinical practice, compared to the reactive one. A wider reception and application of this indication is desirable to improve patients' quality of life without compromising the continuity and efficacy of antineoplastic therapy.

Association between dermatologic adverse events and quality of life in lung cancer patients treated with epidermal growth factor receptor-tyrosine kinase inhibitors.

PURPOSE: Epidermal growth factor receptor-tyrosine kinase inhibitors (EGFR-TKIs) are frequently associated with dermatologic adverse events (dAEs), having great impacts on patients' health-related quality of life (HRQoL) and treatment adherence. We aimed to examine the association between various dAEs and HRQoL in patients treated with EGFR-TKI therapy. METHODS: This was a cross-sectional study including 132 non-small-cell lung cancer (NSCLC) patients treated with gefitinib, erlotinib, afatinib, or osimertinib in Taiwan. The severity level of dAEs was graded by NCI-CTCAE v4.03 and PRO-CTCAE ITEMS v1.0. All participants answered the Functional Assessment of Cancer Therapy-Epidermal Growth Factor Receptor Inhibitors (FACT-EGFRI-18) HRQoL questionnaire. RESULTS: The clinician-reported severity of pruritus, photosensitivity, alopecia, and Karnofsky performance status was associated with HRQoL (ß = - 6.773, p = 0.046; ß = - 5.250, p = 0.032; ß = - 8.121, p = 0.001; ß = 0.327, p = 0.002; respectively). The clinician-reported severity of all dAEs except paronychia had negative correlations with HRQoL. The symptom gradings of CTCAE and PRO-CTCAE had positive correlation. CONCLUSIONS: The severity of pruritus, photosensitivity, and alopecia was associated with HRQoL of patients receiving EGFR-TKI therapy. Using patient-reported outcome measurements helps clinicians to capture the actual impact of symptoms on physical, social-emotional, and functional well-being.

Topical beta-blockers in dermatologic therapy.

An increasing use of beta-blockers in dermatology has been described over the last 10 years, despite the fact that their use in diseases other than infantile hemangiomas is off-label. This review discusses the emerging role of topical beta-blockers in the treatment of infantile hemangioma, but also pyogenic granuloma, Kaposi sarcoma, wounds and nail paronychia. Data in literature demonstrate that topical beta-blockers are a safe and valid therapeutic option in numerous cutaneous diseases. Side effects are mainly restricted to the application site. Further studies and randomized trials may contribute to reinforce the role of topical beta-blockers in the dermatological armamentarium.

Is lymphangitic streaking associated with different pathogens?

OBJECTIVES: Little is known regarding the differences in microbiology associated with cellulitis or abscess with or without lymphangitic streaking. The objective of our study is to assess whether there are differences in the pathogens identified from wound cultures of patients with paronychia with and without associated lymphangitis. METHODS: Retrospective cross-sectional study at a tertiary pediatric emergency department over 25 years. We opted to assess patients with paronychia of the finger, assuming that these cases will have a greater variety of causative pathogens compared to other cases of cellulitis and soft tissue abscess that are associated with nail biting. Case identification was conducted using a computerized text-screening search that was refined by manual chart review. We included patients from 1 month to 20 years of age who underwent an incision and drainage (I&D) of a paronychia and had a culture obtained. The presence or absence of lymphangitis was determined from the clinical narrative in the medical record. We excluded patients treated with antibiotics prior to I&D as well as immune-compromised patients. We used descriptive statistics for prevalence and χ2 tests for categorical variables. RESULTS: Two hundred sixty-six patients met inclusion criteria. The median age was 9.7 years [IQR 4.7, 15.4] and 45.1% were female. Twenty-two patients (8.3%) had lymphangitic streaking associated with their paronychia. Patients with lymphangitis streaking were similar to those without lymphangitis in terms of age and sex (p = 0.52 and p = 0.82, respectively). Overall, the predominant bacteria was MSSA (40%) followed by MRSA (26%). No significant differences were found between the pathogens in the 22 patients with associated lymphangitis compared to the 244 patients without. CONCLUSION: Staphylococcus aureus represent the majority of pathogens in paronychia, although streptococcal species and gram-negative bacteria were also common. Among patients with paronychia of the finger, there seems to be no association between pathogen type and presence of lymphangitic streaking.

Retronychia-an uncommon cause of chronic proximal nail fold inflammation.

Retronychia is defined as nail plate ingrowth into the proximal nail fold causing pain and perionyxis. We report on a case series of seven patients seen from 2001 to 2020 (mean age 20 years). Xanthonychia was observed in all nails. Total nail avulsion was performed in eight nails. Complete remission was obtained in 100%. During follow-up for up to 24 months, no relapse occurred.

[Successful treatment with silver nitrate chemical cauterization for paronychia and granulation in a patient with chronic lymphocytic leukemia undergoing ibrutinib therapy].

A 72-year-old man with leukocytosis, anemia, and lymphadenopathy was diagnosed with chronic lymphocytic leukemia (CLL) in August 2017 and was carefully monitored in a "watch-and-wait" manner until it became an "active disease." Ibrutinib (IBR) was initiated orally in July 2018 at a dose of 420 mg/day after disease progression due to chromosome 17p deletion (del 17p). The patient showed partial response after transient lymphocytosis while on IBR treatment. IBR induces paronychia and skin disorder due to the disruption of disulfide bonds between cysteine and inhibition of epidermal growth factor receptor due to the off-target effect. This results in reduced quality of life. In February 2019, paronychia (grade 1) developed in the patient's right foot's first toe; hence, topical gentamicin and taping therapy were performed. However, the symptoms persisted without any improvements. In July 2019, paronychia/granulation (grade 2) was aggravated and successfully treated with silver nitrate chemical cauterization and taping therapy. The patient was continuously treated with 420 mg/day IBR without dose reduction or discontinuation, resulting in successful disease control of CLL with del 17p.

Recalcitrant trametinib-induced paronychia treated successfully with topical timolol in a pediatric patient.

Paronychia has been described as a side effect in patients undergoing treatment with MEK (mitogen activated protein kinase enzyme) inhibitors. It is usually a recurrent condition that can have a significant impact in the quality of life. Topical beta blocker treatment has been described as an effective therapy in antineoplastic-induced pyogenic granulomas and in antineoplastic-induced paronychia. We describe the first case treated with topical timolol for a trametinib-induced paronychia in a pediatric patient that allowed to continue the third line antineoplastic therapy for his glioma.

Treatment of MEK inhibitor-induced paronychia with doxycycline.

A 12-year-old girl with neurofibromatosis type 1 and a large facial plexiform neurofibroma had been participating in a selumetinib clinical trial for the past 5 years. Despite decreased tumor size, she developed recalcitrant selumetinib-induced paronychia. Various antibiotics, topical medications, and surgeries were only minimally effective. Full-dose doxycycline resolved the paronychia, and sub-antimicrobial dosing has prevented recurrences for several months, permitting her to continue her selumetinib course.

Dermatological side effects of targeted antineoplastic therapies: a prospective study.

INTRODUCTION: Epidermal growth factor receptor inhibitors (EGFRs) are chemotherapeutic agents used in multiple solid organ malignity. These medications have common dermatological side effects, particularly papulopustular (PPL) lesions. The management of the diagnosis and treatment processes for such side effects may facilitate the continuation of chemotherapy and enhance the patient's quality of life. OBJECTIVE: The objective of this study is to report the cutaneous side effects of EGFR inhibitors and to share treatment methods for such side effects. MATERIALS AND METHODS: In this prospective study, 59 patients using EGFR due to breast and colorectal carcinoma at the oncology unit of Haseki Training and Research Hospital were assessed. The patients for whom EGFR was initiated were examined at the beginning of the treatment at weeks 1 and 2, their demographic characteristics were recorded, and the patients who developed a skin rash were followed up from the onset of the lesion. The PPL side effects that developed in the patients and other dermatological findings were recorded. The PPL side effects were graded, and the treatment plans were reported. The study was conducted between February 2016 and February 2018 under the approval of the local ethical committee. RESULTS: The mean age of the 59 patients (47 females, 12 males) taking EGFR inhibitors was 52.4 ± 12.0 (range: 29-84). Forty-five patients had early stage and 14 patients had advanced stage carcinoma. Fourteen patients had colorectal carcinoma, three patients had renal cancer, and 42 patients had breast cancer. Forty-two patients were using trastuzumab (single therapy in 29 patients and combined therapy in 13 patients), five patients were using cetuximab, three patients were using sunitinib, eight patients were using panitumumab, and six patients were using pertuzumab. In 22 patients, PPL side effects were observed in the skin; it was G1 in 19 patients and G2 in three patients. In seven patients who developed acneiform side effects, systemic doxycycline was used, and in others, topical tetracycline and clindamycin were used. Except for one patient using trastuzumab, all patients has lesions on the face, upper trunk, and back. One patient exhibited an atypical rash, which was diagnosed as a granulomatous follicular reaction. Xerosis was present in two cases, and paronychia, pyogenic granuloma, trichomegaly, and madarosis were observed in one patient each. The patients who developed an acneiform rash were treated with topical and systemic antibiotics, light keratolytics, and emollients. The skin side effects of all patients were mild to moderate, and all patients completed the chemotherapy process. An acneiform skin rash and other dermatological side effects are common with EGFR inhibitors. To treat these side effects, emollients, topical steroids, and local, systemic antibiotics are recommended. Clindamycin may be preferred as a topical treatment, and doxycycline may be preferred as a systematic treatment.

A randomized phase 2 trial of the efficacy and safety of a novel topical povidone-iodine formulation for Cancer therapy-associated Paronychia.

Purpose Cancer therapy-associated paronychia (CAP) is a frequent adverse event associated with cytotoxic and targeted therapies that may impact dosing of anticancer therapies and patient quality of life (QoL). There are currently no evidence-based management strategies or approved treatments for CAP. Materials and Methods This was a prospective, multicenter, randomized, double-blind, vehicle-controlled phase 2 study that evaluated the efficacy and safety of 6 to 8 weeks of 1% or 2% povidone-iodine (PVP-I) topical solution versus vehicle-control in adult patients with CAP. Patients were randomized to one of three treatment arms administered twice daily: 1% PVP-I (Cohort A), 2% PVP-I (Cohort B), or vehicle-control (Cohort C). The primary endpoint was a two-grade reduction (or reduction to grade 0 if involved nails were grade 1) on the six-point Paronychia Severity Grading (PSG) scale. Secondary endpoints included safety and the effect on QoL and microbiota. Results A total of 102 patients with cancer were randomized to the study. In Cohort A, 83 of 205 (40.5%, P = 0.6059) affected nails met the primary endpoint versus Cohort C. In Cohort B, 88 of 167 (52.7%, P = 0.0063) affected nails met the primary endpoint versus 64 of 169 (37.9%) in Cohort C. Nineteen of 29 patients (65.5%) in Cohort B reported moderately or very painful nails at baseline that decreased to 15 patients (51.7%) at visit 2 and five patients (17.2%) at visit 3. Conclusions Treatment with twice-daily topical 2% PVP-I was safe and resulted in improvement in CAP compared with control. Clinicaltrials.gov identifier: NCT03207906. https://clinicaltrials.gov/ct2/show/NCT03207906.

Are topical beta-blockers really effective "in real life" for targeted therapy-induced paronychia.

Paronychia and periungual pyogenic granuloma represent one of the most common and bothersome dermatologic toxicities observed with ErbB inhibitors. There is no standardized treatment, and management remains challenging. Moreover, conservative management with noninvasive treatment should be promoted for fragile patients in a metastatic setting. Over the last few years, the efficacy of topical blocking agents has been considered for managing cutaneous or mucosal pyogenic granulomas. Very recently, the use of topical propranolol or of timolol has been reported in several patients undergoing treatment with EGFR inhibitors and developing pyogenic granulomas of the nail. We performed a retrospective single-center review of patients with targeted therapy-related paronychia/periungual pyogenic granulomas who had been treated with topical timolol, either alone or in combination with other topical treatments. Nearly two thirds of patients showed at least a partial response after 1 month of therapy, and the use of a topical beta-blocker in our population was associated with a favorable safety profile. Finally, topical timolol may represent a promising treatment option for the management of cancer patients suffering from painful periungual lesions. Comparative clinical trials, however, are still needed.

Hand Infections.

Infections are common in hand surgery and proper management is important to achieve optimal outcomes. Although most cases are not urgent, less common, severe infections such as flexor tenosynovitis and necrotizing fasciitis require urgent identification with both medical and surgical management. It is common for diagnoses to be missed or delayed because clinical and laboratory indicators are often variably present. Delayed identification and management can result in poor outcomes with permanent deficits. This article will provide a review of hand infections with a focus on identifying serious hand infections requiring urgent or emergent treatment, and distinguishing these from less urgent scenarios.