Dermoscopic features of nails in Leprosy patients in a tertiary referral hospital in West Java, Indonesia.

INTRODUCTION: Leprosy is a chronic granulomatous infectious disease, mainly affecting the skin and peripheral nerves, caused by the obligate intracellular bacteria Mycobacterium leprae. The disease has been discussed in several review articles in recent research, but as far as we know, only a few have addressed the effects of leprosy on nails, especially those who examine the dermoscopic features of nails in leprosy patients. PURPOSES: We aimed to document nail changes in leprosy patients and identify any particular findings through dermoscopic examination. METHOD: This was an observational study conducted in the Dermatology and Venereology Clinic of Hasan Sadikin Hospital, West Java, Indonesia, from March 2023 through May 2023. All patients have established cases of leprosy, and the diagnosis is based on clinical and bacteriological examinations. Recruitment was done through total sampling. Dermoscopic examination of all fingernails and toenails was performed at 10x magnification using a handheld dermatoscope (Heine DELTA 20 T Dermatoscope) in polarized mode without the linkage fluid to document the dermoscopic features. RESULT: Of a total of 19 patients, 15 had nail changes due to leprosy. Out of 15 patients, 13 patients were male. Patients below 25 years old had more nail changes. Most of the patients had a duration of disease greater than two years. Both fingers and toes were involved in nine patients. In this study, the most common dermoscopic feature found was the longitudinal ridge. Other dermoscopic features found in this study were transverse lines, onycholysis, longitudinal melanonychia, leukonychia, subungual hemorrhage, subungual hyperkeratosis, anonychia, and onychorrexis. CONCLUSION: Nail changes are found in leprosy patients and have a wide variety of clinical appearances. A dermoscopy should be performed to assess nail changes in leprosy.

Prevention of taxane chemotherapy-induced nail changes and peripheral neuropathy by application of extremity cooling: a prospective single-centre study with intrapatient comparison.

PURPOSE: Common side effects of taxane chemotherapy are nail toxicity and peripheral neuropathy (CIPN) causing severe impact on the quality of life. Different methods of cryotherapy to prevent these side effects have been tested. We investigated the use of machine-controlled cooling of hands and feet to reduce nail toxicity and CIPN in patients receiving taxane chemotherapy. METHODS: Patients receiving Docetaxel (planned dose ≥ 300 mg/m2) or Paclitaxel (planned dose ≥ 720 mg/m2 - ) in the adjuvant or palliative setting of different cancers were included. The dominant hand and foot were cooled to approximately 10 °C using the Hilotherapy machine. The contralateral hand and foot were used as intrapatient comparison. The primary endpoint was the occurrence of any CIPN due to paclitaxel or nail toxicity due to Docetaxel. Both the intention to treat population (ITT) and the per protocol population (PPP) were analyzed. RESULTS: A total of 69 patients, 21 treated with Docetaxel and 48 with Paclitaxel, were included at our centre between 08/2020 and 08/2022. Nail toxicity due to Docetaxel was overall not significantly improved by cooling in the ITT or PPP but a significant benefit across visits was found for the ITT. CIPN due to Paclitaxel was numerically better in the ITT and significantly better in the PPP. A significant benefit of cooling on CIPN occurrence across visits was found for the ITT and the PPP. Cooling was very well tolerated. CONCLUSION: Cooling of hands and feet has a clinically meaningful impact on reducing occurrence of CIPN and nail toxicity on treatment with taxanes. Effects are more significant over time and are dose dependent. TRIAL REGISTRATION NUMBER: 2020-00381. Date of registration. 24th February 2020.

Onychomadesis in a COVID-19 patient.

We report the case of a 67-year-old woman who developed onychomadesis on 9 of her fingers 2 months after recovering from COVID-19, with subsequent full nail regrowth after 4 months. The development of onychomadesis in COVID-19 is probably related to inhibition of nail proliferation due to fever, direct viral damage, or an inflammatory process associated with endothelial damage and obliterative microangiopathy in the nail matrix area. Clinicians should be aware of nail changes and actively seek them out in patients with COVID-19.

Nail changes in upper extremity allotransplantation: onychomadesis as the presenting sign of allograft rejection - a retrospective study.

Upper extremity allotransplantation (UEA) is the more common type of vascularized composite allotransplantation of which more than 80 patients have benefited worldwide. These allografts include - along with the skin - the nail unit, a specialized epithelial appendage which may be the target of graft rejection. We report an UEA recipient who developed, as an initial manifestation of graft rejection, onychomadesis, that is shedding of the nail plate starting from the proximal nail bed. On this occasion, we reviewed the nail changes we have observed in a series of eight patients with UEA who were grafted and followed in our hospital since 1998 (mean follow-up period of 9.75 years). We also reviewed the relevant literature reporting nail changes in UEA recipients. A brief discussion on the significance of these changes in the context of UEA is provided with emphasis on onychomadesis, a finding usually related to graft rejection in this specific setting.

Carpal tunnel syndrome and associated nail changes: Review and examples from the author's practice.

Carpal tunnel syndrome (CTS) is commonly seen by general practitioners and often presents with neurologic symptoms of nocturnal pain and paresthesia along the median nerve distribution. Approximately 20% of patients also present with cutaneous findings (ulcerations, blistering, sclerodactyly, nail dystrophy) characterizing a severe form called necrotic CTS. Necrotic CTS can also be associated with bone changes (acro-osteolysis). In the author's practice, combined nail and skin findings are not an uncommon presentation of CTS, although this form remains overlooked and underreported in the dermatological textbooks and studies. This manuscript aims to review the literature on CTS cases, with a specific focus on using associated nail findings as diagnostic clues. The literature review along with a few additional recent cases from the author's practice demonstrate that CTS is frequently accompanied by a variety of nail changes including koilonychia, longitudinal fissuring, Beau's lines, onychomadesis, melanonychia, nail thickening, hyperkeratosis, and ischemic ulcerations with paronychia. Furthermore, when these changes are limited to the second and third fingernails, they should prompt the diagnosis of CTS. Once suspected, diagnostic evaluation is not difficult and surgical management can resolve cutaneous findings and prevent irreversible changes such as acro-osteolysis.

Nail involvement in psoriatic arthritis.

Nail psoriasis is considered a significant psychological and social problem causing functional impairment in affected patients. Nail changes hamper their daily and occupational activities and contribute to a worse quality of life. Almost 50% of patients with psoriasis vulgaris and up to 80% of patients with psoriatic arthritis are afflicted with nail lesions. The important correlation between psoriatic arthritis and nail changes is well established - the presence of the latter is a strong predictor of the development of arthritis. There is a broad spectrum of nail dystrophies associated with psoriasis, ranging from the common pitting, subungual hyperkeratosis and loosening of the nail plate to less frequent discolouration and splinter haemorrhages. Some of these symptoms are also observed in other nail diseases, and further diagnostics should be performed. The assessment tools NAPSI (Nail Psoriasis Severity Index), mNAPSI (Modified Nail Psoriasis Severity Index), and PNSS (Psoriasis Nail Severity Score) are most commonly used to grade the severity of nail involvement in psoriasis and enable the evaluation of therapy effectiveness. The treatment of nail psoriasis is a major clinical challenge. It should be adjusted to the extent of dermal, articular and ungual lesions. Systemic therapies of psoriasis, especially biological agents, are most likely to be effective in treating nail psoriasis. However, as their use is limited in scope and safety, topical therapy remains a mainstay, and the combination of corticosteroids and vitamin D3 analogues is considered to be most helpful.

Nail changes in casted and braced clubfoot: A preliminary study.

BACKGROUND: The study aimed at finding whether there are any nail changes specific to treatment in clubfoot. METHODS: Sixty new, 26 undergoing serial corrective casting, and 247 clubfoot patients using foot abduction braces were prospectively studied. The casted and braced group formed the basis of the study to observe nail changes, if any. The new patients and opposite normal foot (in unilateral casted cases) were taken as controls. OBSERVATIONS: Acute paronychia, ingrown toe nail, onychoshizia, onychorrhexis, nail plate concavity, latent onychomadesis, and distal onycholysis were observed in feet undergoing corrective casting and bracing. Micronychia, malalignment and thinning of nail plate were the observed congenital nail anomalies. CONCLUSIONS: Nail changes in clubfeet are not infrequent. Certain nail changes might be etiologically linked to casting and bracing. Some of nail changes might require urgent medical care.

Half-and-half nails in a pediatric patient after chemotherapy.

Half-and-half nail, characterized by a reddish brown distal band with a sharply demarcated white proximal band, is a specific manifestation of chronic kidney disease, but it is unusual to occur after chemotherapy. We report a seven-year-old girl who developed half-and-half nails in her fingers one month after treatment with modified Berlin-Frankfurt-Munster protocol followed by maintenance therapy with oral methotrexate and 6-mercaptopurine for pre-B acute lymphoblastic leukemia.

Alopecia and nail changes associated with voriconazole therapy.

BACKGROUND: Voriconazole was 1 of 2 antifungal agents recommended for treatment of fungal infections associated with injection of contaminated methylprednisolone. Alopecia and nail changes are not commonly reported side effects of voriconazole. Having noted increasing hair loss among our patients treated with voriconazole, we sought to determine the prevalence and characteristics of alopecia associated with this agent. METHODS: Patients who received voriconazole for at least 1 month for probable or confirmed fungal infection were eligible to complete a survey regarding alopecia and nail changes. For those patients who reported alopecia, additional questions about reversal of hair loss were asked after voriconazole had been stopped for at least 3 months. RESULTS: A total of 152 of 175 eligible patients (87%) completed the survey. One hundred twenty-five (82%) reported alopecia. Hair loss on the scalp was noted in 120 (96%), arms and legs in 52 (42%), and eyebrows and eyelashes in 47 each (38%). Nineteen patients (15%) reported wearing a wig or hat because of extensive hair loss. Alopecia developed a mean (standard deviation) of 75 (54) days after initiation of voriconazole. Of 114 patients who were off voriconazole for at least 3 months, hair loss had stopped in 94 (82%) and regrowth had begun in 79 (69%), including those who were changed to either itraconazole or posaconazole. Nail changes or loss occurred in 106 (70%) patients. CONCLUSIONS: Alopecia and nail changes were common adverse effects associated with voriconazole therapy during the multistate fungal outbreak.

Impact of Chemotherapy-Induced Nail Changes on Quality of Life: A Cross-Sectional Study from a Tertiary Care Centre.

Background: Chemotherapy has increased survival rate in patients but is associated with systemic as well as cutaneous adverse effects. Among cutaneous adverse effects, nail changes caused by chemotherapy are often overlooked. But these changes are a major cause of cosmetic concern and negatively affect the quality of life (QoL) of patients. Aim: This study was conducted to evaluate the impact of chemotherapy-induced nail changes on QoL of patients with malignancy and to compare the severity of impact on QoL in various nail changes. Materials and Methods: This hospital-based cross-sectional observational study was conducted for a period of 12 months. Only patients on chemotherapy who developed nail changes were included in the study. A nail-specific QoL questionnaire was used. Statistical analysis was conducted to evaluate the impact of nail changes on QoL. Results: The mean QoL score of 188 patients was 32.37 ± 7.9. The mean QoL score of females was more than that of males. QoL was statistically more significant in younger age groups [<20 years: 46.71 ± 1.7] (P < 0.001). Patients with pigmentary nail changes (melanonychia and leukonychia) had more significant impact on QoL (P < 0.001). Conclusion: There is a significant impact of chemotherapy-induced nail changes on QoL of patients leading to psychological distress, reduced self-confidence and social limitation. This highlights the importance of proper counselling of patients beforehand regarding the possibility of associated nail changes during and after the chemotherapy regimens.

Assessing Comparative Efficacy of Biologics for the Treatment of Psoriasis With Nail Involvement: A Systematic Review.

Background: Despite recent advances in biologics, there is a lack of significant evidence regarding the comparative efficacy of biologics in treating more resistant features of psoriasis, namely nail psoriasis. A systematic review synthesizing data from multiple studies is efficacious in assessing the comparative efficacy among biologics for the treatment of nail psoriasis. Objective: To evaluate and compare the efficacy of biologics for the treatment of nail psoriasis. Methods: Utilizing PRISMA guidelines, a systematic literature review was conducted using the Pubmed database on November 16, 2022. Studies selected were phase 3 or 4 randomized clinical trials, clinical studies, or other randomized trials with data on the treatment with biologics for adults with nail psoriasis. Results: Sixteen studies meeting inclusion criteria were included for analysis. At 24 weeks, the highest mean NAPSI percent improvement achieved at week 24 was by brodalumab (76.9%) followed by etanercept (74%) and ixekizumab (70.5%) while the biologics achieving the greatest proportion of NAPSI 0 were adalimumab (44.6%) and ixekizumab (41%). Conclusions: This study helps elucidate the comparative efficacy of biologics for the treatment of nail psoriasis. This review suggests that brodalumab and etanercept are associated with the highest percent improvement in nail psoriasis while adalimumab and ixekizumab are associated with the greatest probability of complete nail resolution.

Nail pitting in an infant with Kawasaki disease-A novel clinical finding.

A variety of nail changes have been described in children with Kawasaki disease during the convalescent phase. These include Beau's lines, leukonychia, and orange-brown chromonychia. However, nail pitting is distinctly unusual in KD. We report one such case.

Lymphedema in Turner syndrome: correlations with phenotype and karyotype.

OBJECTIVES: Lymphedema (LD) in Turner syndrome (TS) is a commonly reported comorbidity, though its associations with karyotype and other comorbidities are poorly understood. Characteristics of patients with TS and LD, including correlation with phenotype and karyotype, are described. METHODS: Medical records of patients with TS seen in two pediatric institutions from 2002 to 2020 were retrospectively reviewed. Demographic data (age, presentation onset, clinical features, genetics, LD presence, investigations, treatments) were collected. RESULTS: 393 girls with TS with mean age of 12.5 years (SD: 5.7) were identified. LD was noted in 37 % of patients (n=146). Among the 112 patients with TS and documentation of onset of LD, LD was noted within the first year of life in 78.6 % (n=88). 67.6 % (n=96) of total patients with TS and LD had non-mosaic 45, X karyotype. Frequency of webbed neck was significantly greater in girls with TS and LD compared with girls without LD (58 vs. 7 %, p<0.001). Congenital heart anomalies, hypertension, and renal anomalies were also more common in girls with LD. Nail abnormalities with presence of hypoplastic or dysplastic nails were significantly associated with LD (OR: 6.784, 95 % CI 4.235-11.046). The number of girls reporting presence of LD decreased with age. CONCLUSIONS: LD in TS often occurs within the first year of life, is less prevalent in older children and adolescents, and is significantly associated with 45, X karyotype, presence of webbed neck, nail changes, congenital heart anomalies, and renal anomalies.

Atypical Presentation of Pemphigus Vulgaris: Nail Involvement in a 20-Year-Old Male.

Pemphigus vulgaris (PV) mainly causes blistering of the skin and mucous membranes, with nail unit involvement being rare. Nail involvement may serve as an indicator of disease severity. We present a case of a 20-year-old male with PV who had both cutaneous and nail findings, with nail changes corresponding with disease severity. The patient with biopsy-confirmed PV, on prednisone and mycophenolate, presented to the emergency department with an acute flare of PV and severe mandibular pain and lymphadenopathy. At follow-up in our outpatient department, the physical examination was significant for onychomadesis and onycholysis of the fingernails. Prednisone and mycophenolate dosages were increased, and rituximab infusions were initiated. Bullae and mucosal lesions resolved on the follow-up, and nail changes improved. This case appends an unusual perspective to the limited literature on PV-associated nail changes, especially in younger patients. It advocates for meticulous history taking and physical examination and supports a correlation between nail symptoms and PV disease severity.

Nail changes in pemphigus: a systematic review and meta-analysis.

Pemphigus is a group of autoimmune mucocutaneous bullous disorders characterized by acantholysis resulting from autoantibodies targeting epithelial cell surface antigens. Studies reflect the presence of nail manifestations in some patients and suggest a potential correlation with clinical severity. This study examines the overall prevalence and characterizes the diverse manifestations of nail changes in pemphigus. We searched Cochrane, MEDLINE, EMBASE, and LILACS from 1990 to June 26, 2023 for studies reporting different nail changes in pemphigus patients. Data were collected and pooled to obtain proportions of the prevalence of nail changes in patients with pemphigus and subgroup analysis for pemphigus foliaceous and pemphigus vulgaris. The risk of bias was assessed with the Joanna Briggs Institute Checklist. Of 321 studies screened, 14 studies with 1,208 patients were included. Paronychia (n = 185) and Beau's lines (n = 104) were the most common nail changes identified. The pooled prevalence of nail disease in pemphigus patients was 0.389 (number of studies; [95% CI]: n = 9; [0.160-0.680], with high heterogeneity between studies (I2 = 95.0%, P < 0.001). Subgroup analysis revealed the highest prevalence in pemphigus foliaceous at 0.342 (n = 3; [0.109-0.688]) and pemphigus vulgaris at 0.396 (n = 5; [0.114-0.769]). Nail changes exhibited varied temporal relationships with disease onset and flares, preceding, concurrent, or following these events. Correlation with disease severity was noted, although discrepancies between studies were reported. Nail changes in pemphigus, particularly pemphigus vulgaris and pemphigus foliaceous, may be underrecognized. Observations regarding temporal associations and potential correlations with disease severity highlight the diagnostic and prognostic implications of nail changes in pemphigus. The limitations of this study include study heterogeneity and possible bias. Further research to establish the correlation of the presence and severity of nail changes on the overall disease course would be helpful.

Clinical and demographic characteristics associated with nail involvement in alopecia areata: A cross-sectional study of 197 patients.

Background and Aims: Alopecia areata (AA) is an immune-mediated nonscarring alopecia. Nail changes are a common disfiguring feature of AA with an average prevalence of 30%. We aimed to evaluate the frequency of different types of nail changes and determine demographic and clinical associations. Methods: This cross-sectional study included 197 AA patients. Demographic and clinical variables including the Severity of Alopecia Tool (SALT) score, type of AA, and nail changes were evaluated. Results: Among 197 AA patients with a mean age of 28.95 ± 14.45 years, 50.3% were female. Nail changes were detected in 165 patients (83.8%). The most frequent nail abnormalities were pitting (53.3%), linear line (46.7%), and distal notching (26.9%). AA patients with nail abnormalities were significantly younger than patients without nail changes (25.31 ± 14.96 vs. 32.22 ± 9.77 years; p < 0.001). Considering age groups, younger children (less than 10 years) were more likely to have nail changes than adults (97.1% vs. 76.5%; p < 0.001). The prevalence of linear line (69.6%) and distal notching (46.4%) were significantly higher in the universalis variant compared to other variants (p < 0.001). Pitting (54.5%), distal notching (43.9%), and koilonychia (12.1%) were the most common nail changes in severe forms compared to mild-to-moderate forms (p < 0.009). Conclusions: Our study revealed that young patients with severe disease are prone to nail abnormalities. Pitting, distal notching, and linear line were the most common nail changes. Of note, koilonychia, leukonychia, and red spots lunula are more expected in more severe AA.

Nail Changes in Immuno-Bullous Disorders: A Cross-Sectional Study.

Context: Autoimmune blistering (AIBD) disorders affect mucosae, skin, and appendages. Appendageal involvement has not been studied extensively to date. However, they are important as nail changes are commonly encountered during a flare-up of the disease. Aims: To determine the prevalence and patterns of nail changes in various Immunobullous disorders and to study the relationship between the nail changes and the disease duration and severity. Settings and Design: A cross-sectional study was conducted at the Department of Dermatology, venerology, and leprosy at a tertiary care center in Mumbai. Materials and Methods: A cross-sectional study including a total of 74 cases of Immunobullous diseases was conducted and the prevalence of nail changes was determined. The association between the mean number of nail changes and the disease duration and severity was analyzed using ANOVA (Analysis of variance) and unpaired t-test. Statistical Analysis: The Statistical Package for Social Studies (SPSS) software was used for statistical evaluation. Results: We found that the prevalence of nail changes was 91%. There was a significant difference in the mean number of nail changes with respect to the severity grades of mucosal involvement in AIBD (P value < 0.05). There was no significant difference in the mean number of nail changes with respect to the severity grades of Pemphigus vulgaris (PV), Pemphigus foliaceous (PF), subepidermal blistering diseases, and the duration of AIBD. Conclusions: Nails are frequently affected in AIBD. The number of nail changes is related to the severity of mucosal disease but not to duration.

[Common nail diseases in children and adolescents : Recognize, advise, treat]. / Häufige Nagelerkrankungen im Kindes- und Jugendalter : Erkennen, Beraten, Behandeln.

There are a number of nail diseases that primarily occur in children and adolescents. Many of these nail changes are physiologic and are only transient. Thus, they do not need any therapy. Infectious nail diseases or nail involvement in chronic inflammatory dermatoses can be found in both children and adults, and may require specific treatment. Nail pigmentation such as longitudinal melanonychia occur significantly less frequently in children than in adult patients, and have different causes and a better prognosis. Knowledge about these child-specific peculiarities of nail diseases is necessary in order to provide the best possible advice to parents and to offer appropriate treatment. This article focuses on the most common and important nail diseases in children and adolescents and their treatment.

Onychogryphosis Is Associated with Dermatologic and Vascular Disease: A Case-Control Study of the All of Us Research Program.

Introduction: Onychogryphosis is a nail condition characterized clinically by a thickened, curved, yellow-brown, and opaque nail plate and may result in pain, paronychia, and onychogryphosis. Methods: We performed a nested case-control study of 1,114 onychogryphosis patients and 3,423 matched controls to quantify the association between onychogryphosis and self-care limitations, chronic foot injury, dermatologic conditions, and vascular disease. Results and Conclusion: Onychogryphosis was positively associated with increased age, activity limitations (difficulty running errands alone, bathing, and concentrating), psoriasis, onychomycosis, hallux malleus, hallux valgus, peripheral vascular disease, lower extremity ulcers, venous varices, and type II diabetes mellitus. Therefore, physicians should screen patients presenting with onychogryphosis for these conditions.