Self-induced nail disorders (SINDs): What do we know so far?

Self-induced nail disorders are a broad group of different clinical manifestations that share the common trait of being caused more or less voluntarily by the patient. These are distinct conditions within the clinical spectrum of onychotillomania. Most patients diagnosed with these disorders have psychiatric co-morbidities, and a multidisciplinary approach is thus highly recommended. The purpose of this review is to describe the most common clinical features encountered during daily nail consultations and to provide useful diagnostic tools and therapeutic tips for the best approach to these conditions.

Scalp dysaesthesia and lichen simplex chronicus: diagnostic and therapeutic update with literature review.

Scalp dysaesthesia, considered a variant of the cutaneous dysaesthesia syndrome, is characterized by chronic sensory symptoms, including pruritus, pain, burning and stinging in a well-defined location, without objective findings. Its aetiology is not well elucidated and treatment options are limited, thus it can be challenging and frustrating for both patient and physician. It can be associated with lichen simplex chronicus. In this paper, we review the literature on the pathogenetic factors, diagnostic methods and therapeutic options in the management of scalp dysaesthesia. Dissociation, cervical spine disease and muscle tension seem to be the most important pathogenetic factors. Trichoscopy, reflectance confocal microscopy and biopsy are all helpful for the diagnosis of the disease. Therapies include high-potency topical or intralesional corticosteroids, capsaicin and topical anaesthetics, sedative antihistamines, tricyclic antidepressants, transcutaneous electric nerve stimulation, botulinum toxin and vitamin B12.

The value of dermoscopy of the nail plate free edge and hyponychium.

The non-invasive examination of the nail unit using a dermoscope is known as onychoscopy. This technique has become increasingly appreciated to facilitate the clinical diagnosis of nail disorders, opening up a valuable second front with a potential to avoid invasive diagnostic procedures. During a nail consultation, the nail unit should always be examined with the aid of a dermatoscope in all its components. The aim of this paper was to provide practical information about onychoscopy of the nail plate free edge and hyponychium, two components of the nail unit difficult to evaluate at naked eye and often forgotten, but of paramount importance.

Erosive pustular dermatosis of the scalp: a multicentre study.

BACKGROUND: Erosive pustular dermatosis of the scalp (EPDS) is characterized by crusted erosions or superficial ulcerations that lead to scarring alopecia. OBJECTIVES AND METHODS: We performed a multicentre retrospective clinical study including 56 patients (29 females and 27 males, mean age 62.7) with a confirmed EPDS in order to describe epidemiology, clinical findings and therapeutic choices of this disease. RESULTS: Mechanical/chemical trauma was reported in 28.6%, a previous infection in 10.7%, a previous cryotherapy in 5.4% androgenetic alopecia in 48.2% and severe actinic damage in 25%. Trichoscopy showed absence of follicular ostia, tufted and broken hair, crusts, serous exudate, dilated vessels, pustules and hyperkeratosis. Histopathology revealed three different features, depending on the disease duration. The most prescribed therapy was topical steroids (62.5%), followed by the combination of topical steroids and topical tacrolimus (8.9%), systemic steroids (7.1%) and topical tacrolimus (5.4%). A reduction of inflammatory signs was observed in 28 patients (50%) treated with topical steroids and in all three patients treated with topical tacrolimus. CONCLUSION: The relatively high number of patients collected allowed us to identify a better diagnostic approach, using trichoscopy and a more effective therapeutic strategy, with high-potency steroids or tacrolimus, which should be considered as first-line treatment.

Bacterial and viral infections of the nail unit: Tips for diagnosis and management.

The nail unit is the most commonly affected area in hand infections, which can be primary infection or superinfection complicating other nail or skin disorders. Trauma, mechanical or chemical, is usually the trigger enabling infiltration of infectious organisms. Artificial nails and nail polish are also a possible cause of bacterial infection, harboring microorganisms. In severe acute bacterial infection, surgical intervention is often needed to prevent morbidity and disability. Abscess should always be drained, but viral infection such as herpetic whitlow, may mimic an abscess and, in contrast, requires non-operative treatment; to prevent sequelae. A more conservative approach is also generally advisable in less severe bacterial infection, other viral infections and in subacute or chronic nail infection. The present review deals with acute, subacute and chronic bacterial and viral infections of the nail unit, with a focus on diagnostic and treatment options. LEVEL OF EVIDENCE: III, systematic review of level III studies.

Skin rash and splinter hemorrhages from ganciclovir.

Ganciclovir is a nucleotide-analogue similar to acyclovir, which has an in vitro activity against herpes simplex type 1, herpes simplex type 2 and varicella zoster virus. Numerous studies suggest that ganciclovir has clinical efficacy against cytomegalovirus disease, as well as an in vivo antiviral effect, and that this agent reduces morbidity of serious cytomegalovirus infections in immunocompromised patients. Generalised cutaneous rash associated with ganciclovir therapy has rarely been reported in literature.

Scaling-up in industrial winemaking using low electric current as an alternative to sulfur dioxide addition.

AIMS: To better understand the outcome of employing low electric current (LEC) technology as a new preservation and alternative in wine technology, and to contribute to its development. It is used in industrial-scale winemaking with commercial yeast (Saccharomyces cerevisiae) during the grape must fermentation. METHODS AND RESULTS: LEC (200 mA, time 16 days) was applied to fresh grape must as an alternative method to the usual sulfur dioxide addition used in the industrial process; two tanks, each 30,000 l, were employed for parallel fermentations. The results show that LEC decreased the survival time and increased the death rate of apiculate yeasts, whereas it did not affect the growth and survival of S. cerevisiae. A comparison was made of the main chemical and sensory parameters of the wines obtained. CONCLUSIONS: The results have demonstrated that the low-voltage treatment had a positive effect on the grape juice fermentation (yeast microflora) during the early stages of winemaking. SIGINIFICANCE AND IMPACT OF THE STUDY: These results could be of significant importance in developing, for 'biological wine', new winemaking technologies for an innovative control process of yeast fermentation.

Androgenetic alopecia in children: report of 20 cases.

Androgenetic alopecia (AGA) is the most common type of hair loss in adults. Although there are differences in the age at onset, the disease starts after puberty when enough testosterone is available to be transformed into dihydrotestosterone. We report 20 prepubertal children with AGA, 12 girls and eight boys, age range 6-10 years, observed over the last 4 years. All had normal physical development. Clinical examination showed hair loss with thinning and widening of the central parting of the scalp, both in boys and girls. In eight cases frontal accentuation and breach of frontal hairline were also present. The clinical diagnosis was confirmed by pull test, trichogram and dermoscopy in all cases, and by scalp biopsy performed in six cases. There was a strong family history of AGA in all patients. The onset of AGA is not expected to be seen in prepubertal patients without abnormal androgen levels. A common feature observed in our series of children with AGA was a strong genetic predisposition to the disease. Although the pathogenesis remains speculative, endocrine evaluation and a strict follow-up are strongly recommended.

The natural history of androgenetic alopecia.

Androgenetic alopecia (AGA) is the most common cause of hair loss, affecting up to 80% of men and 50% of women in their lifetime. Genetic predisposition to the disease is well known but the responsible genes have not been identified. Polymorphism in the androgen receptor gene has been recently detected in AGA.(1) Although the role of androgens, and particularly dihydrotestosterone (DHT), in causing the disease has been established for a long time, the natural history of AGA is still not completely understood. This paper reviews recent data about natural progression of the disease, as well as factors that may interfere with its course and long-term prognosis.

Pustular psoriasis of the nails: treatment and long-term follow-up of 46 patients.

BACKGROUND: Pustular psoriasis of the nail apparatus is a common disease that greatly influences the quality of life because of its chronic course and poor response to treatment. OBJECTIVES: To review the clinical and histopathological features, the response to treatment and the long-term follow-up of 46 patients with pustular psoriasis of the nail unit. METHODS: Treatments utilized included oral retinoids (n = 12), oral nimesulide (n = 13), topical calcipotriol (n = 15) and topical steroids (n = 18). Retinoids were utilized as first choice in seven patients with involvement of several digits and in five patients with severe relapses, whereas topical calcipotriol, oral nimesulide or topical steroids were utilized in patients with involvement of a single nail. Topical calcipotriol was also prescribed as maintenance therapy in patients who responded to oral treatment. Twenty-five patients were followed for more than 5 years. RESULTS: Improvement or regression of the lesions was obtained in 23 of 46 patients. Retinoids were effective in six of 12 patients, nimesulide in four of 13, topical calcipotriol in nine of 15 and topical steroids in four of 18. The long-term follow-up showed a complete remission of the disease in only two patients, both affected by pustular psoriasis involving multiple nails. All other patients experienced periodic relapses which were in most cases controlled by regular use of topical calcipotriol. CONCLUSIONS: Severe cases of pustular psoriasis of the nail are best treated with systemic retinoids. Topical calcipotriol is effective in about 50% of patients with localized disorder and is also useful as maintenance therapy after retinoid treatment.

Systemic itraconazole in the yellow nail syndrome.

Although a number of treatments have been reported to be effective with yellow nail syndrome (YNS), vitamin E at high doses is the only one that has been successfully utilized in a consistent number of patients affected by YNS. Recent data indicate that itraconazole pulse regimen may be effective in this disease. We report our experience with itraconazole treatment in patients affected by YNS. Systemic itraconazole was administered in eight patients (five males and three females; mean age 55.2 years), at a dosage of 400 mg daily for 1 week a month for 6 months. Nail growth was measured every 3 months. Complete cure was achieved in two of eight patients, with mild improvement in two and no improvement in four. The results of our study show that itraconazole cannot be considered effective for YNS, especially if compared with vitamin E, the efficacy and tolerability of which is already proven.

Brittle nails.

Nail brittleness is a common complaint characterized by weak inelastic nails that split, flake and crumble. It may be a consequence of factors that alter nail plate production and/or factors that damage the already keratinised nail plate. It is often idiopathic. It can also be caused by many dermatological and systemic diseases, nutritional deficiencies, drugs and traumas. Environmental and occupational factors that produce progressive dehydration of the nail plate have an important role in nail brittleness. Treatment of brittle nails is often difficult. Preventative measures, together with oral supplementation of vitamins (especially biotin), oligo-elements and amino acids, can be useful in improving nail strength. Cosmetic treatment affords camouflage and a degree of protection.