Enthesopathy in patients with nail psoriasis - a cross-sectional evaluation of clinical, onychoscopic and ultrasonographic features.

Background Nail involvement in psoriasis is common and may be an indicator not only of disease severity, but also of the presence of psoriatic arthritis. However, the relationship of nail psoriasis with enthesitis remains under-explored. Aims This study was conducted to evaluate the clinical, onychoscopic (nail dermatoscopic) and ultrasonographic features in patients with nail psoriasis. Materials and Methods All nails of twenty adult patients with nail psoriasis were examined clinically and onychoscopically. Patients were evaluated for psoriatic arthritis (Classification Criteria for Psoriatic Arthritis), the severity of cutaneous disease (Psoriasis Area Severity Index) and nail disease (Nail Psoriasis Severity Index). Ultrasonography of the clinically involved digits was performed for evidence of distal interphalangeal joint enthesitis. Results Out of 20 patients, 18 patients had cutaneous psoriasis and 2 had isolated nail involvement. Among the 18 patients with skin psoriasis, 4 had associated psoriatic arthritis. The most commonly observed clinical and onychoscopic features were pitting (31.2% and 42.2%), onycholysis (36% and 36.5%) and subungual hyperkeratosis (30.2% and 30.5%), respectively. Ultrasonographic evidence of distal interphalangeal joint enthesitis was seen in 57% (175/307) of the digits with clinical nail involvement. Enthesitis was more common in patients with psoriatic arthritis (77% vs 50.6%). Nail thickening, crumbling and onychorrhexis (all features of nail matrix involvement) were significantly associated with enthesitis (P < 0.005). Limitation The major limitation was the small sample size and lack of controls. Only the clinically involved digits were evaluated for enthesitis. Conclusion Enthesitis was frequently detected on ultrasonography in patients with nail psoriasis, even in clinically asymptomatic individuals. Nail features of thickening, crumbling and onychorrhexis may predict underlying enthesitis and the potential development of arthritis. A comprehensive evaluation could help identify patients with psoriasis at risk for arthritis, helping improve long-term outcomes.

Prevalence of onychomycosis in patients with diabetes mellitus: A cross-sectional study from a tertiary care hospital in North India.

Background Though diabetes mellitus (DM) is a well-recognised risk factor for onychomycosis (OM), the epidemiology of OM in diabetic patients remains largely unexplored, especially from the Indian subcontinent. Aims and objectives To estimate the prevalence of OM in diabetic patients, to identify and analyse risk factors, and correlate the severity of nail changes with glycemic control (HBA1c). Methods This cross-sectional, analytical study involved 300 diabetic patients. Patients with the clinical diagnosis of OM, supplanted by at least two of the four tests (KOH, culture, onychoscopy and nail histopathology) were considered cases of OM. Demographic and haematological profile was analysed using chi-square test/ Fischer's exact test. Logistic regression was applied to assess the independent risk factors. Results The prevalence of OM in DM patients was 34% (102/300) and significant risk factors included; age >60 years, male gender, closed shoes, disease duration >5 years, high BMI (>25) and lack of awareness about nail changes. Distal and lateral subungual OM (78%) was the commonest presentation followed by proximal subungual OM, superficial OM and total dystrophic OM. Correlation between HbA1c and the number of nails involved was found to be significant. Limitation As cases were recruited from a hospital setting, there could be chances of Berksonian bias. Conclusion The prevalence of OM in diabetic patients is high and the severity of nail changes correlates with HbA1C levels. It is important to diagnose OM early in order to treat and prevent complications.

Nail-fold capillaroscopy for the dermatologists.

Nail fold is one of the most accessible sites for studying changes in the microcirculation in various microangiopathies. The characterization of changes in microvasculature can provide useful clues towards the diagnosis and prognosis of a disease. The diagnostic utility of nail fold capillaroscopy has improved and expanded over the past couple of decades. Beyond connective tissue diseases, it is now explored for its role in various systemic and dermatological diseases. Incorporation of nail-fold capillaroscopy in the diagnostic criteria of systemic sclerosis has generated interest among dermatologists. The current review is aimed at providing knowledge about nail-fold capillaroscopy to dermatologists. For the purpose of review, a PubMed search was done using the keywords "nail fold capillaries" and "nail fold capillaroscopy". All the articles were retrieved and classified into reviews and clinical studies of various types. The final data were then analyzed and presented in a narrative fashion.

"Molluscum" Conditions in Dermatology.

In dermatology, the word "molluscum" is used as a prefix for infective and non-infective conditions. The term is used to describe soft papules or nodules with or without central umbilication, which is not a necessary qualification. This article attempts to summarise the conditions in dermatology with the epithet "molluscum" and discuss them in brief.

Simple moulage for improving simulation for objective structured clinical examinations in undergraduate dermatology courses.

BACKGROUND: Objective structured clinical examination (OSCE) is being increasingly used as an assessment tool for undergraduate dermatology courses. One of the practical difficulties in conducting OSCEs in dermatology is getting patients with typical skin lesions which can be used for the whole group to ensure uniformity of assessment. We present a study on the use of simple moulage techniques to create uniform and standardized skin lesions for OSCEs in dermatology. METHODS: As a first step, the dermatology faculty in our department chose the clinical conditions which could be covered by using moulages. The main criteria considered were the importance of the condition to the exam blueprint, ease of making and resistance to handling (should not require frequent retouching). Moulages were created on volunteers after taking consent and the same were used in OSCEs s for a group of 5th-year students (N = 102). Difficulty and discrimination indices were compared between the stations using the moulage and the other stations. Qualitative feedback was obtained regarding the same from both the faculty and the students. RESULTS: There was consensus among the faculty and the majority of the students that the lesions were clearly recognizable. As far as other psychometrics were concerned, average difficulty and discrimination of the stations using the moulage were good (average difficulty index-0.78 and average discrimination index-0.68) and compared favorably with the other stations (average difficulty index-0.77 and average discrimination index-0.57). LIMITATIONS: Limited number of stations included, lack of detailed item analysis and lack of feedback from the simulated patients were the main limitations in this study. CONCLUSION: For most common skin conditions creating moulages to simulate the corresponding lesions is an easy procedure and can be an effective tool to standardize dermatology OSCEs for undergraduates, especially in resource-poor settings.

Characteristic patterns of segmental infantile hemangiomas in Indian children: A descriptive study.

BACKGROUND: Approximately 18% of infantile hemangiomas are segmental. These are larger than other infantile hemangiomas, associated with higher rate of complications and developmental anomalies, and often require treatment. They follow nonrandom patterns on the head and neck as well as extremities which are probably related to embryologic development. AIMS: Our study aimed to describe segmental patterns of infantile hemangiomas in Indian children, with associated anatomical abnormalities if any. METHODS: Over a 9-year period, 59 infants presenting with lesions classified as segmental infantile hemangiomas were evaluated and analyzed. Associated developmental anomalies were assessed and recorded. In addition, patterns of "indeterminate" infantile hemangiomas in another 43 patients were analyzed. RESULTS: There were 14 male and 45 female infants with an average birth weight of 2.7 ± 0.726 kg in our study; the average age at onset was 1 ± 1.25 months with most (50.8%) lesions localized to the head and neck area. Mapping of lesions showed that the most common facial segments involved were mandibular (33%) and maxillary (30%). However, additional repetitive patterns not previously described (such as an "inverted comma" pattern on the chest, bilateral neck involvement and unilateral labium involvement) were seen in our patients. Common local complications were ulceration (27%), amblyopia and nasal obstruction (3% each). Mapping of the additional 43 patients with indeterminate infantile hemangiomas also showed repetitive though incomplete patterns. LIMITATIONS: Relatively small number of patients. CONCLUSION: Segmental infantile hemangiomas present as large, distinctively patterned lesions, even on the trunk and genitalia. These patterns are probably based on embryologic developmental patterns. In addition, indeterminate lesions also showed distinctive repetitive patterns. Our study suggests that additional segments may need to be defined, particularly on the trunk and genital area.

Nailfold capillaroscopy with USB dermatoscope: A cross-sectional study in healthy adults.

BACKGROUND: Nailfold capillaroscopy (NFC) is a convenient method for studying capillary morphology in the proximal nailfold (PNF) and is used for the evaluation of connective tissue and other diseases affecting the microvasculature. However, capillary density and morphological patterns in healthy individuals are largely unknown and this compromises the evaluation of the microvasculature in disease states. OBJECTIVE: To describe and quantify the morphological characteristics of nailfold capillaries in healthy adult Indians. METHODS: A USB 2.0 dermatoscope (Dinolite AM413ZT) with polarizing light was used to study nailfold capillary characteristics in 50 consecutive healthy adult individuals. NFC was performed on all 10 fingers. Images were assessed for both quantitative and qualitative features. RESULTS: The mean capillary density in healthy Indian adults was 7.63 ± 1.12 capillary/mm. Tortuosity (22%), meandering capillaries (14%) and microhemorrhages (14%) were frequently seen in these individuals. LIMITATION: The small sample size limited a conclusive determination of statistically significant differences in NFC findings with respect to gender and age. CONCLUSION: NFC with a USB dermatoscope is a useful technique for studying the PNF capillaries. The normal PNF capillary density in healthy Indian adults was 7.63 ± 1.12 capillary/mm. Capillary alterations such as tortuosity, meandering capillaries and microhemorrhages are seen in a significant number of healthy individuals.

The nail as an investigative tool in medicine: What a dermatologist ought to know.

The nail is an important skin appendage, but not many dermatologists are aware of the importance it receives outside our specialty. This article focuses on the nail in non-dermatological contexts. The nail is a keratinized matrix capable of continuous growth with the ability to incorporate various compounds within its structure. Therefore it can be used to monitor long-term consumption of drugs. It is also an excellent source of germ-line DNA for genetic analyses. With an increased undrstanding of nail physiology, there is now a better understanding of its connection to various pathologies as well. Nails, being peripherally placed, are easy to sample without significant discomfort to the patient, making them a valuable diagnostic tool. For this narrative review, we carried out a PubMed search using the key words "nail clipping," "nail DNA," "nail diabetes mellitus;" "nail clipping oncology," and "nail forensics". Retrieved articles were searched for information pertaining to non-dermatologic uses of nail for evaluation, which is presented in a narrative fashion. It is clear from recent literature that the nail is not just an inert skin appendage, but a dynamic window into the ever-changing metabolic and genetic milieu. We highlight the numerous roles of nail specimens, as well as point towards future research needed therein.

Clinical and serological characteristics of nail psoriasis in Indian patients: A cross-sectional study.

BACKGROUND: Nail involvement in psoriasis is common with a lifetime incidence of 80-90%. It may reflect severity of cutaneous involvement and predict joint disease. Yet it remains, poorly studied and evaluated especially in Indian psoriatic patients. AIM: The present study was undertaken to evaluate clinical and serological profile of nail involvement in psoriasis and to assess quality of life impairment associated with nail involvement in Indian patients. METHODS: Consecutive patients with nail psoriasis were assessed for severity of cutaneous disease (psoriasis area severity index score) and nail disease (nail psoriasis severity index score). The impairment in quality of life attributable to nail disease was scored with nail psoriasis quality of life 10 score. All patients were also assessed for joint disease and tested for inflammatory and serological markers as erythrocyte sedimentation rate, C-reactive protein, rheumatoid factor and anti-cyclic citrullinated peptide antibodies. RESULTS: In our cohort of 38 patients with nail psoriasis, 9 had concomitant psoriatic arthritis. The mean psoriasis area severity index was 14.4 ± 9.6 (range = 0.4-34). The most commonly recorded psoriatic nail changes were pitting (97.4%), onycholysis (94.7%) and subungual hyperkeratosis (89.5%). The mean nail psoriasis severity index score was 83.2 ± 40.1 (range = 5-156) and mean nail psoriasis quality of life 10 was 1.1 ± 0.4. Erythrocyte sedimentation rate and C-reactive protein were raised in 22/38 (57.9%) and 15/38 (39.5%) patients, respectively; rheumatoid factor was positive in 5/38 (13.2%) and anti-cyclic citrullinated peptide antibody was raised in 4/38 (10.5%) patients. LIMITATIONS: Small sample size and lack of a control group. CONCLUSIONS: In Indian patients with nail psoriasis, severity of nail involvement was found to be poorly correlated with the extent of cutaneous disease. In addition the impact of nail disease on patient's quality of life was found to be minimal. This suggests the need for a quality of life questionnaire suited to the Indian population. Serological markers were raised overall in the study patients and more so in the patients with concomitant arthritis.

Onychoscopy: A practical guide.

Onychoscopy refers to the examination of the nail unit using a dermoscope. Since the advent of dermoscopy, attempts have been made to use it for the diagnosis of nail disorders, most commonly pigmented lesions. As of now, onychoscopy has carved out a distinct niche for itself in the diagnostic work up of nail disorders. The nail is capable of mounting only a limited number of reaction patterns to the large number of disorders affecting it. Therefore, simple visual inspection may not be helpful in diagnosing many conditions reliably. Even a nail biopsy may not give a definitive answer every time. Onychoscopy is thus a valuable aid not only in enhancing visible nail features but also in revealing cryptic features of diagnostic value. This review aims to summarize the current level of knowledge about onychoscopic features of various diseases of the nail unit. It also aims to offer practical tips on how to conduct onychoscopy. For the purpose of review, a PubMed search about the indications and results of onychoscopy was done using the keywords "onychoscopy," "nail fold capillaroscopy," "dermoscopy nail" and "dermatoscopy nail." All the articles were retrieved and classified into case reports, reviews and clinical studies. The final data was then analyzed and presented in a narrative fashion.