Dermoscopic Nail Changes in Psoriasis, Lichen Planus, and Lichen Striatus.

Background: Onychoscopy is a noninvasive method helpful in diagnosing nail disorders. The aim of the study was to review literature on the usability of onychoscopy in nail psoriasis, nail lichen planus, and nail lichen striatus. Summary: Onychoscopic features of nail psoriasis are pitting, onycholysis with erythematous border, salmon patches, splinter hemorrhages, dotted vessels in lateral and proximal folds, and hyponychium. Onychoscopic features of nail lichen planus are onychorrhexis, onycholysis, longitudinal melanonychia, and red lunula. The literature on the usability of onychoscopy in nail lichen striatus is scarce. Keynotes: Onychoscopy facilitates evaluation of nail abnormalities compared to the clinical examination. Lunular alterations, salmon patches, erythematous border of onycholysis as well as splinter hemorrhages in nail psoriasis are better visualized with onychoscopy compared to the naked eye. Onychoscopy enhances detection of melanonychia, dyschromia, and lunular changes in nail lichen planus. Onychoscopic features are different in fingernails and toenails.

Onychoscopy (nail dermoscopy) is a noninvasive method used in diagnosing of nail disorders. In this review, we evaluated if onychoscopy may be helpful in diagnosing inflammatory nail disorders such as psoriasis, lichen planus, and lichen striatus. Nail psoriasis can be characterized with the presence of pitting, salmon patches, splinter hemorrhages, onycholysis with or without erythematous border and dilated vessels in the hyponychium on onychoscopy. Onychoscopy of nail lichen planus shows the presence of longitudinal ridging and splitting (onychorrhexis), splinter hemorrhages, longitudinal melanonychia as well as red lunula (distal part of nail matrix). The data on onychoscopy in nail lichen striatus are scarce. Onychoscopy is a helpful tool in visualization of nail abnormalities, with most of the features better visualized with onychoscopy compared to the naked eye.

Clinical, onychoscopic, nail clipping, and histopathological findings of malignant onychopapilloma.

This report describes the clinical, onychoscopic, nail clipping, and histopathologic features of a malignant onychopapilloma. A 71-year-old male presented to our outpatient clinic for a stable, asymptomatic lesion on his left middle finger that had been present for 2 years. Prior nail clipping histopathology showed nail plate thinning with subungual abnormal onychocytes. Clinical examination revealed a 2-mm-wide streak of longitudinal xanthonychia extending to the proximal nail fold, with distal hyperkeratosis and onycholysis. Onychoscopy showed irregular longitudinal nail plate ridging with scattered punctate hemorrhagic foci. An excisional nail unit biopsy demonstrated cellular atypia of the nail bed epithelium, matrix metaplasia, longitudinal abnormal onychocytes, increased Ki-67 staining, and negative HPV immunoperoxidase staining, confirming the diagnosis of malignant onychopapilloma.

Dermoscopic features of nail psoriasis: a systematic review.

INTRODUCTION: Nail psoriasis is common in psoriasis vulgaris and even more prevalent in psoriatic arthritis. Dermatoscopy of the nail proves helpful in enhancing the visualization of psoriatic nail lesions. OBJECTIVE: This systematic review aimed to summarize the existing studies published in the literature that reported the various dermoscopic features of nail psoriasis. MATERIALS AND METHODS: A systematic search of two medical databases, PubMed and Scopus, was conducted in April 2023. In total, 11 records were included. The number of reported cases in the included studies was 723. RESULTS: The average age was 42.39 years. Sixty percent of patients were males, and 40% were females. Pitting constituted the most common onychoscopic feature indicating nail matrix involvement, followed by various other features such as leukonychia, nail plate thickening, transverse and longitudinal ridges, and different lunula abnormalities. The predominant onychoscopic feature indicating nail bed involvement was onycholysis, followed by splinter hemorrhages, oil drop sign, subungual hyperkeratosis, dilated capillaries, agminated capillary dots, erythematous border, and pustules. Vascular abnormalities observed in all locations were present in 52% of patients. CONCLUSIONS: The clinical signs of nail psoriasis are diverse, and for the majority, they are nonspecific. Nail dermoscopy is a noninvasive tool that enhances the visualization of the nail manifestations of psoriasis. It may facilitate the establishment of diagnostic criteria for this pathology without resorting to more invasive procedures, such as nail biopsy.

Onychoscopic characteristics of Trichophyton rubrum and Trichophyton interdigitalis fungal infections: A multicentric study.

BACKGROUND: Trichophyton rubrum and Trichophyton mentagrophytes variant interdigitalis are the most frequent etiologic agents of onychomycosis. Diagnosis of certainty requires mycological examination, which often results unfeasible. OBJECTIVES: The aim of our study is to describe pathogen specific dermoscopic features, allowing a differential diagnosis without the need for cultural examination, in order to prescribe the most appropriate treatment anyway. PATIENTS AND METHODS: We conducted an observational retrospective study on 54 patients with a culture proven diagnosis of distal subungual onychomycosis of the toenail, caused by Trichophyton rubrum or Trichophyton mentagrophytes variant interdigitalis. Using a videodermatoscope we collected data on nail colour (white, yellow, orange, brown, dark) and on dermoscopic patterns (aurora, spikes, jagged, ruin, linear edge, dots, striae). RESULTS: Fifty-four patients, with a total of 72 nails, were eligible for this study. Analysing the association between discoloration of the nail plate and type of infection (T. rubrum or T. interdigitalis), no correlation turned out to be statistically significant. Instead, significant associations between spikes and T. rubrum infection and striae and infection from T. interdigitalis were identified. Finally, a 100% specificity was identified for white colour and ruin pattern for T. rubrum infection, and brown colour, jagged border and aurora pattern for T. interdigitalis. CONCLUSIONS: Trying to find relationships between specific pathogens and dermoscopic patterns, we found out an association between spikes and striae and T. rubrum and T. interdigitalis respectively. Further larger studies are however necessary to evaluate our preliminary findings.

Dasatinib-Induced Transverse Melanonychia.

Introduction: Transverse melanonychia, characterized by grey to black pigmented bands traversing the nail plate, can occur as a side-effect of certain medications. While no documented reports specifically associate dasatinib, a tyrosine kinase inhibitor used in the treatment of chronic myeloid leukaemia (CML) and acute lymphoblastic leukaemia, with nail changes, we present a case of transverse melanonychia possibly related to dasatinib therapy. Case Report: A 54-year-old male with CML, receiving dasatinib for 1.5 years, presented with transverse pigmented lines involving all fingernails and toenails. Clinical examination revealed discrete bands of transverse melanonychia in the nails. Onychoscopy of all finger- and toenails revealed multiple longitudinal grey lines within transverse grey bands of homogeneous chromonychia. Based on clinical presentation, onychoscopic features, and temporal association with dasatinib therapy, a provisional diagnosis of dasatinib-induced transverse melanonychia was made. Discussion: The exact mechanisms underlying melanonychia are not fully understood but may involve nail matrix or toxicity, stimulation of nail-matrix melanocytes, or drug deposition within the nail plate. This case highlights the possibility of dasatinib-induced transverse melanonychia and underscores the importance of monitoring and evaluating nail changes in patients undergoing dasatinib treatment.

An Uncommon Cause of Pincer Nail.

Pincer nail is a deformity characterized by excessive transverse curvature of nail, progressively increasing along its longitudinal axis. The curvature is greatest at the distal end, leading to an ingrown nail, producing pain, discomfort, and significant cosmetic alteration. It is a severe variant of ingrown nail, often attributed to causes such as anatomical variation of nail plate axis, tight footwear, gait abnormalities, and so on. Correspondingly, its management involves the removal of the lateral ingrowing nail plate or the lateral hypertrophic nail folds. We report a young male who presented with symptomatic pincer nail deformity. However, on exploration there was a midline onychomatricoma, leading to the thickening of the central part of the nail plate, causing incurving of the lateral nail plate and discomfort. The report serves to highlight the need for a comprehensive evaluation of pincer nails, to assess for matrix disease as well, because the surgical approach will differ accordingly.

Dermoscopic Nail Disorders in School-Going Children.

Introduction The majority of nail diseases in children are comparable to those in adults, while there are some physiological changes that start to happen around this age and go away over a few years. These conditions could be symptoms of infections and systemic illnesses. Pediatric nail disorders are typically easy to diagnose clinically, although there are occasionally conditions that masquerade as juvenile nail problems. Dermoscopy has grown in favour as a rapid, easy, non-invasive clinical procedure for examining nail diseases. This study aims to assess dermoscopic findings of child nail diseases. Methods A prospective analysis was conducted for seven months between January and July, 2022, at PNS Shifa Hospital, Karachi, Pakistan. A total of 180 patients who presented in the outpatient department with any dermatological complaint underwent thorough history and examination. Special emphasis was given to clinical and dermoscopic examinations of nails. Data analysis enclosed descriptive and inferential statistics. The quantitative data was presented with help of mean and standard deviation, while the qualitative data was presented with help of frequency and percentage tables. Chi-square test was applied to compare nail findings diagnosed on clinical examination and dermoscopic examination. Results The mean age of study subjects was 9.4±3.2 years and ranged between five years and 18 years. The most common nail changes were hand eczema (n=41, 23%) followed by nail changes due to nutritional disorders (n=38, 21%), anaemia (n=34, 19%) and habit tic deformity (n=31, 17.2%). Conclusions Clinical evaluation is crucial for nail disease diagnosis. Dermoscopy of nails can help with the final diagnosis of nail disease and confirm clinical diagnoses. Also, it aids in the management of nail illnesses by providing a clearer picture of pathology and nail structure.

Incipient Melanonychia: Benign Finding or Occult Malignancy? A Case Report of Subungual Melanoma.

Subungual melanomas are rare neoplasms that tend to debut as longitudinal melanonychia. They are primarily found in patients over 60 years of age and are usually diagnosed late, representing a diagnostic challenge. We present a case report of a 59-year-old female Hispanic patient who initially presented with melanonychia and was eventually diagnosed with subungual melanoma in situ. She was surgically treated and, after three months, remained healthy. Relevant risk factors, clinical and onychoscopic findings, diagnostic criteria, and treatment options are also discussed. Since many benign entities present similarly, high clinical suspicion is critical for diagnosing this entity.

Diagnostic accuracy of dermoscopy for onychomycosis: A systematic review.

Background: Dermoscopy is a non-invasive adjuvant diagnostic tool that allows clinicians to visualize microscopic features of cutaneous disorders. Recent studies have demonstrated that dermoscopy can be used to diagnose onychomycosis. We performed this systematic review to identify the characteristic dermoscopic features of onychomycosis and understand their diagnostic utility. Methods: We searched the Medline, Embase, Scopus, and Cochrane databases from conception until May 2021. Studies on the dermoscopic features of onychomycosis were screened. The exclusion criteria were as follows: fewer than 5 cases of onychomycosis, review articles, and studies including onychomycosis cases that were not mycologically verified. Studies on fungal melanonychia were analyzed separately. We adhered to the MOOSE guidelines. Independent data extraction was performed. Data were pooled using a random effects model to account for study heterogeneity. The primary outcome was the diagnostic accuracy of the dermoscopic features of onychomycosis. This was determined by pooling the sensitivity and specificity values of the dermoscopic features identified during the systematic review using the DerSimonian-Laird method. Meta-DiSc version 1.4 and Review Manager 5.4.1 were used to calculate these values. Results: We analyzed 19 articles on 1693 cases of onychomycosis and 5 articles on 148 cases of fungal melanonychia. Commonly reported dermoscopic features of onychomycosis were spikes or spiked pattern (509, 30.1%), jagged or spiked edges or jagged edge with spikes (188, 11.1%), jagged proximal edge (175, 10.3%), subungual hyperkeratosis (131, 7.7%), ruins appearance, aspect or pattern (573, 33.8%), and longitudinal striae (929, 54.9%). Commonly reported features of fungal melanonychia included multicolor (101, 68.2%), non-longitudinal homogenous pigmentation (75, 50.7%) and longitudinal white or yellow streaks (52, 31.5%). Conclusion: This study highlights the commonly identified dermoscopic features of onychomycosis. Recognizing such characteristic dermoscopic features of onychomycosis can assist clinicians diagnose onychomycosis by the bedside.

A descriptive study of onychoscopic features in various subtypes of onychomycosis.

Background: The diagnosis of onychomycosis is usually clinical and is confirmed by 40% KOH examination. A diagnostic dilemma occurs when KOH examination is negative despite strong clinical suspicion. Dermoscopic evaluation of the nail is referred to as onychoscopy. We attempted to assess the dermoscopic findings in Onychomycosis positive with KOH examination. Methods: A cross sectional study was conducted in a tertiary care center including 122 patients with clinical suspicion of onychomycosis with KOH positivity. After assessment of risk factors and gross nail examination, onychoscopic examination was done to identify the presence of the specific features. Results: Primary findings of onychoscopic examination were 'spiked pattern' in 80.3% subjects, of which 95 were distal lateral subungual onychomycosis (DLSO), 8 of total dystrophic onychomycosis (TDO). True leukonychia was seen in the single patient of proximal subungual onychomycosis (PSO) and pseudoleukonychia in the single patient of white superficial onychomycosis (WSO). Distal irregular termination was observed in 23% of subjects - 8 from DLSO and in all 20 patients of TDO. 'Ruin appearance' was observed in all 20 patients of TDO, 56 patients with DLSO and not seen in other types of onychomycosis (OM). Presence of spiked pattern, Longitudinal striae, Distal irregular termination and Ruin appearance were found to be statistically significant (p < 0.001). Conclusion: In suspected onychomycosis, specific onychoscopic findings such as Spiked pattern, Longitudinal striae, Ruin appearance and Distal irregular termination can be used as supporting evidence for diagnosing onychomycosis clinically and initiating antifungal therapy if mycological testing is unavailable or negative.

Description of the most severe signs in nail lichen planus: a strategy to contribute to the diagnosis of the severe stage.

BACKGROUND: Severe nail lichen planus (NLP) does not respond well to treatment and is often poorly considered and described in detail. OBJECTIVE: We sought to describe the characteristics of severe NLP. METHODS: A retrospective data analysis was performed, including the photographic records of the most compromised nails of patients with NLP over 18 years old, who consulted between 2009 and 2019 at the Instituto de Dermatologia Professor Rubem David Azulay in Rio de Janeiro, Brazil. Descriptive and statistical analysis using Fisher's exact test was performed to verify the hypothesis of independence between characteristics (P < 0.05). RESULTS: A total of 102 patients were included. Anonychia was associated with severe thinning of the nail plate, retraction of the nail bed or nail plate, residual nail plate, loss of proximal nail fold limits, and onychoatrophy. Dorsal pterygium was associated with loss of proximal nail fold limits, onychoatrophy, and distal splitting greater than 50%. CONCLUSION: We provide descriptions of the most severe signs in order to facilitate the clinical diagnosis when a biopsy is not feasible and suggest an update of current NLP classifications.

Study of Nail Psoriasis and Dermoscopic Correlation with Dermoscopic and Modified Dermoscopic Nail Psoriasis Severity Indexes (dNAPSI and dmNAPSI).

BACKGROUND: Nail involvement in psoriasis may be assessed clinically, ultrasonologically, and dermoscopically. The aim of this study was to assess the dermoscopic features of nails in psoriasis, to compare them with the clinical findings, and to correlate them with the Nail Psoriasis Severity Index (NAPSI) score. METHODS: We recruited 120 patients with psoriatic nail changes for the study. The Psoriasis Area Severity Index (PASI) was used to assess the severity of disease. Clinical and dermoscopic (Derm-Lite DL4, ×10, polarized and non-polarized) nail examination determined NAPSI, modified NAPSI (mNAPSI), and NAPSI determined with dermoscopic findings (dermoscopic NAPSI [dNAPSI] and dermoscopic modified NAPSI [dmNAPSI]) were used to assess severity of nail involvement. RESULTS: Subungual hyperkeratosis (50.8%) and nail plate thickening (56.7%) were the commonest clinical nail changes found, and dermoscopically, they were subungual hyperkeratosis and pitting (68.3% each). The average median with interquartile range of PASI and NAPSI scores were 7.5 [5.7-10.8] and 8.0 [6-12], respectively. NAPSI scores increased significantly with the increase in PASI scores (P < 0.001). A comparison of NAPSI and mNAPSI with dNAPSI and dmNAPSI revealed that NAPSI, mNAPSI, and dNAPSI increased significantly with an increase in PASI scores. The dNAPSI scores increased significantly with increased mNAPSI and dmNAPSI, and mNAPSI and dmNAPSI were significantly good predictors of joint involvement in psoriasis. CONCLUSIONS: Dermoscopy allows for better visualization of nail findings. Evaluating NAPSI and mNAPSI scores in conjunction with dNAPSI and dmNAPSI increases their helps detect early psoriasis, detection of worsening moderate-to-severe psoriasis (PASI >10) and predict joint involvement and their severity.

Dermoscopy of the Nail Unit.

Nail dermoscopy (onychoscopy) is being used for a more accurate diagnosis of all nail disorders and has become a routine diagnostic instrument. In daily practice, nail signs can be magnified, and dermoscopy may confirm the clinical diagnosis and guides in management of nail diseases and treatments, permitting a better visualization of symptoms. Onychoscopy is used by the experts in almost all nail diseases. It can be performed dry or with ultrasound gel in order to make the stratum corneum translucent, depending on which part of the nail unit has to be evaluated.

Deferring Nail Mycological Sampling during the COVID-19 Pandemic: Recommendations from a Multidisciplinary Panel of Nail Specialists.

Onychomycosis is the most common nail condition seen in clinical practice, with significant impact on quality of life. Clinical examination alone is insufficient for accurate diagnosis, but mycological confirmation can be challenging during the COVID-19 pandemic. In this letter, a multidisciplinary panel of dermatologists, a podiatrist, dermatopathologists, and a mycologist, discuss considerations for mycological sampling during the pandemic.

Management of nail psoriasis with a single injection of abobotulinum toxin.

Nail psoriasis is challenging; as topical agents generally fail and systemic therapies are doubted especially when the involvement of the skin is rather localized. The response of chronic plaque-type psoriasis to botulinum toxin injections is reported in case series that is essentially explained through the modulation of neurogenic inflammation. Herein, we report the successful treatment results of two cases demonstrating different features of nail psoriasis treated by abobotulinum toxin.

Nail Changes in Leprosy: Onychoscopy Evaluation.

CONTEXT: Repeated trauma involving extremities (in the setting of peripheral neuropathy) and poor vascularity that impairs wound healing are important causes of disability and deformity in leprosy patients. Nail changes can serve as indicators of trophic changes due to leprosy. AIMS: To describe the onychoscopy findings in leprosy cases and to identify any specific findings in leprosy patients in comparison to controls. SETTINGS AND DESIGN: The first 30 leprosy patients and 30 age and sex-matched controls who attended our tertiary care center from 1 August 2018 were included in this cross-sectional study. MATERIALS AND METHODS: Onychoscopy examination of all fingernails was performed at 50× magnification using dinolite dermoscope AM4113ZT under non-polarizing light to document surface changes and under polarizing light to document pigmentation and vascular changes. STATISTICAL ANALYSIS: The observed nail changes in cases and controls were compared using Pearson's Chi-square test. RESULTS: Statistically significant association with leprosy was found for pitting, onycholysis, melanonychia, transverse lines, nail pallor, and onychauxis. Nail pallor was unique to leprosy patients. LIMITATIONS: Small sample size and not evaluating toenails were the major limitations of the study. CONCLUSIONS: Studies with large sample size are needed to assess the significance of nail pallor as a specific onychoscopy finding in leprosy.

Dermoscopy of Onycholysis Due to Nail Psoriasis, Onychomycosis and Trauma: A Cross Sectional Study in Skin of Color.

BACKGROUND: Clinical differentiation of onycholysis due to various etiologies is difficult task that compels to do invasive investigations to arrive at accurate diagnosis. Wrong diagnosis often leads to treatment failure and physicians and patient's anxiety. Dermoscopic patterns in nail psoriasis, onychomycosis are well established. Here, authors attempted to describe dermoscopic patterns in onycholysis due to psoriasis, onychomycosis and trauma in skin of color. METHODOLOGY: Study was conducted in a tertiary hospital in Southern India. Ethical clearance and informed consent from patients was obtained. Sixty consecutive patients who attended dermatology outpatient department with onycholysis were included in the study. Nail potassium hydroxide (KOH) study was done in all the cases. Onychoscopy was done with DermLite 3 with ultrasound gel as interface medium. RESULTS: Totally 60 patients (42 males; 18 females) with onycholysis were included. Mean age was 37 years (range; 6-68 years). KOH was positive in 22 (36.6%) cases. Onychoscopy showed proximal erythematous rim, red dots, splinter hemorrhages in 23(65.71), 26 (74.28) and 21(60) in nail psoriasis respectively. Spiked and jagged-edges, aurora borealis and ruins pattern (65%) suggestive of onychomycosis were seen in 18(90%), 17 (85%) and 13 (65%) patients respectively. Plain edges without erythema or spikes were noted in 5 (8.33%) in traumatic onycholysis group. CONCLUSION: Onychoscopy is a non- invasive modality to diagnose psoriasis, onychomycosis and traumatic involvement of nail apparatus by demonstrating characteristic patterns. Hence, it also plays an important role in effective management of such cases.