The Typical Nail Lichen Planus Severity Index: An Outcome Instrument for Typical Nail Lichen Planus.

INTRODUCTION: Despite numerous treatment options for nail lichen planus (NLP), a validated method for measuring the severity of NLP and therapeutic response in clinical trials is absent. The aim of the study was to develop and validate a measurement instrument, Typical Nail Lichen Planus Severity Index (tNLPSI), for typical NLP that could be used in clinical trials. METHODS: A total of 48 patients pathologically confirmed with typical NLP were enrolled in this study. Five dermatologists were trained to use the tNLPSI activity scale and the Physician's Global Assessment (PGA) scale to score samples independently to estimate inter-rater and intra-rater reliability across two sessions. In addition, tNLPSI activity scores were compared with PGA scores to assess the construct validity. RESULTS: The tNLPSI activity scale had excellent internal consistency and inter-rater reliability (Cronbach's alpha 0.990; ICC = 0.954; 95% CI = 0.930-0.971), and the correlations between the different graders' scores indicate good consistency (rp = 0.934-0.968). In addition, the tNLPSI activity scale demonstrated high intra-rater reliability (ICC = 0.996; 95% CI = 0.993-0.998), showing good reproducibility. And tNLPSI activity scores and PGA scores showed good construct validity (Spearman's rho = 0.941 and Spearman's rho = 0.903-0.935, respectively; p < 0.01). CONCLUSION: The tNLPSI activity scale was demonstrated to be consistent, reliable, reproducible, and feasible, making it a potential valuable tool for evaluating the treatment response in typical NLP clinical trials.

A Misdiagnosed Case of Malignant Melanoma in an Infected Nail: A Case Report.

Subungual melanoma is associated with the highest mortality among all skin cancers and is strongly linked to acquired mutations caused by exposure to ultraviolet radiation in sunlight. The commonest sites of occurrence are the great toe and thumb. Diagnosis of melanoma often becomes a challenge as it is difficult to differentiate it from other pigmented disorders. A histopathological evaluation of the lesion with adequate nail matrix biopsy can address the diagnostic dilemma. Additionally, an early diagnosis of melanoma is critical as once detected early, it is often treatable. We present a case of a 72-year-old diabetic male patient with a pigmented lesion over the right great toe. In view of the patient's age and history of diabetes, the initial presentation was mistaken as onychomycosis which created a diagnostic dilemma. Hence, we present this case to shed light upon the fact that these lesions can mimic several other benign conditions like fungal melanonychia, lentigo, and subungual hemorrhage. To avoid misdiagnosis and subsequent delay in management, early clinical, dermoscopic, and very pertinently, histopathological and radiological co-relations are extremely important.

Outcomes of the Transungual Approach in 56 Consecutive Digital Subungual Glomus Tumours.

Background: Glomus tumour is a painful small tumour of the glomus body commonly located under the nail bed. The aim of this study is to evaluate the correlation of clinical diagnosis with MRI findings, determine the prevalence of the tumour at different subungual locations and determine the differences in outcomes (if any) between a longitudinal and a transverse nail bed incision for excision of the tumour. Methods: This retrospective study of 56 subungual glomus tumour was conducted from May 2010 to December 2021. Data with regard to gender, age at presentation, digit involved, presenting symptoms, duration of symptoms, clinical signs, need for MRI, anatomical location, surgical approach (longitudinal versus transverse), histopathology result, period of follow-up and complications were recorded. Results: All 56 (100%) patients presented with classic triad of symptoms. The average duration of symptoms was 52.9 months (range: 3-204 months). Eleven (20%) tumours were in the sterile matrix, 38 (68%) at the junction of sterile and germinal matrix and 7 (12%) in the germinal matrix. The tumours were excised through the longitudinal incision in 31 (55.3%) patients and transverse incision in 25 (44.7%). One (1.8%) tumour was intraosseous that was diagnosed intraoperatively and excised successfully. Average follow-up was 35.4 months (range: 6-120 months). There was no difference in outcomes (pain or nail deformity) between the two incisions. One patient (1.8%) has persistent pain that was due to a missed satellite lesion in the same digit. This was excised later with resolution of symptoms. There were no recurrences and all patients were cured after excision of tumour. Conclusions: Diagnosis of glomus tumour is usually clinical, and most are located at junction of sterile and germinal matrix. Tumour can be excised either by longitudinal or transverse nail bed incisions without any change of treatment outcome. Level of Evidence: Level IV (Therapeutic).

A case report of onycholemmal carcinoma in a 61-year-old Chinese male.

Onycholemmal carcinoma is characterized as a slowly progressing malignant tumor originating from the epithelium of the nail bed. A limited number of cases have been documented in the English literature. The majority of the patients included in the reports underwent amputation of the affected phalanx, and no instances of recurrence were noted during the follow-up period. A 61-year-old Chinese male presented with a persistent ulceration on the nail bed of the right great toe. Microscopic analysis indicated the presence of an epithelial tumor consisting of small keratocysts with sudden central keratinization and atypical keratinocyte nests that were devoid of a granular layer. The tumor exhibited infiltrative growth within the dermis, displaying a multilobulated pattern, but did not extend into the distal phalangeal bone. Based on these findings, the diagnosis of onycholemmal carcinoma was made for this case. All documented cases indicate that onycholemmal carcinoma is a rare malignant tumor originating from the nail bed epithelium, and its clinical progression is typically slow and non-aggressive. This case is presented to provide an analysis of the clinical and pathological features of onycholemmal carcinoma, aiming to assist in the clinical selection of treatment options.

Malignant melanoma in the hand: current evidence and recommendations.

Malignant melanoma is the leading cause of death from skin cancer. In spite of significant advances in the management of melanoma with the advent of sentinel lymph node biopsy (SLNB) and adjuvant oncological therapies, the death rate continues to increase worldwide. Melanoma in the hand poses additional diagnostic and management challenges. Consequently, these tend to present at a later stage and are associated with a poorer prognosis. It is imperative that hand surgeons treat any pigmented hand lesion with suspicion to ensure rapid diagnosis and treatment. This article outlines the presentation of melanoma, and how to investigate suspicious pigmented lesions of the hand and digits. It guides hand surgeons in their approach to melanoma of the hand, outlining the multidisciplinary team approach as well as current standard surgical and reconstructive options to optimize outcomes.

Influence of optical clearing agents on the scattering properties of human nail bed and blood microrheological properties: In vivo and in vitro study.

Optical clearing agents (OCAs) are substances that temporarily modify tissue's optical properties, enabling better imaging and light penetration. This study aimed to assess the impact of OCAs on the nail bed and blood using in vivo and in vitro optical methods. In the in vivo part, OCAs were applied to the nail bed, and optical coherence tomography and optical digital capillaroscopy were used to evaluate their effects on optical clearing and capillary blood flow, respectively. In the in vitro part, the collected blood samples were incubated with the OCA and blood aggregation properties were estimated using diffuse light scattering techniques. The results indicate that OCAs significantly influence the optical properties of the nail bed and blood microrheology. These findings suggest that OCAs hold promise for improving optical imaging and diagnostics, particularly for nail bed applications, and can modify blood microrheology.

Nail dystrophy for the surgeon.

Injuries to the fingertips are the most frequently occurring damage to the hand. The nail is an exceptional structure within the human body that offers both stability and protection, as well as the ability to perform fine and precise movements. Nail dystrophies are numerous, post-traumatic, post-infection or even degenerative. They raise many difficulties for the treating hand surgeon. Which anatomical structure is dystrophic? Is there any secondary fungal superinfection to be treated before surgery? Among the various techniques proposed, which one will help to improve my patient as a complete cure is rarer than partial failures. In this chapter we have chosen to describe the surgical techniques, their difficulties and drawbacks, that are available for the most frequent dystrophies that the hand surgeons may treat.

Physiology of the nail apparatus: Surgical consequences.

Knowledge of nail physiology is mandatory to understand nail pathologies, and to know what to repair and what to expect from your repair. Unfortunately, nail physiology in humans is not completely understood. However, there are some data that have been validated and must be known before treating patients. The nail plate is mostly made of keratins. It is produced solely by the nail matrix. The nail bed is mostly responsible for nail pate adhesion. At the hyponychium, the plate loses its adherence. The hyponychium is the first barrier of defense preventing bacteria and fungi from invading the subungual area. All these structures, along with the nail folds, are responsible for the orientation of nail-plate growth. However, many questions, such as whether to replace the nail plate at end of procedure, remain open.

Triamcinolone Acetonide Injections in Nail Psoriasis: A Pragmatic Analysis.

Introduction: Treatment of nail psoriasis is challenging. Systemic therapies may be difficult to justify, while topical therapies may be sup-optimal. Triamcinolone acetonide (TA) injections are recommended as first-line therapy in cases with less than 3 nails involved; however, limited studies are available. This study was conducted to evaluate the reduction in NAPSI (Nail Psoriasis Severity Index) with TA injections in patients with isolated nail psoriasis. Methods: A retrospective case record analysis of efficacy and safety of TA (5 mg/mL) nail injections (4-weekly for fingernails, 8-weekly for toenails) was done in 10 patients. NAPSI was evaluated at each visit and treatment endpoint (75% reduction or 10 injections, whichever was earlier). Dropouts and adverse effects were recorded. Results: Among 10 patients (94 involved nails, 61 fingernails, and 33 toenails), 3 patients (30%) dropped out (2, 4, and 5 sessions, respectively), citing procedural pain. Three patients achieved NAPSI-75 (3, 6, and 7 sessions, respectively). Baseline mean NAPSI of 5.03 (4.63 fingernails and 5.78 toenails) dropped to 3.67 (3.13 fingernails and 4.42 toenails) by the 5th injection; and 2.35 (2.13 fingernails and 2.59 toenails) by the 10th injection. Adverse effects included pain (30%), subungual haematoma (1.7%), and proximal nail fold hypopigmentation with mild atrophy (1.1%). Conclusions: TA (5 mg/mL) injections are effective in nail psoriasis and associated with minimal adverse effects.

Open fractures of the limbs in children and adolescents.

Open fracture is rare in children, raising dual issues of sepsis and mechanics. Here, we address certain practical questions regarding childhood open fracture. Should the recognized adult classifications be used in children? Two classifications exist for adults, without pediatric specificities; of these, we recommend Gustilo's, as being more precise in its description of severe grades. Is there any consensus on emergency prophylactic antibiotic therapy in children? The risks seem to be the same, and 24hours' prophylactic antibiotic therapy should be initiated as soon as possible, as in adults. What are the most recent guidelines on time to treatment, type of internal fixation and possible associated procedures in tibial fracture in children? Wound cleansing is indispensable. Treatment under anesthesia can be delayed up to 24hours in the absence of neurovascular complications on condition that antibiotic therapy is implemented immediately. In Gustilo grade I and II, or IIIA, external fixation is not systematic and non-operative treatment or intramedullary nailing is possible. In grades IIIB and IIIC, external fixation is the rule, although conversion is possible if indicated early enough. Do the particular cases of nail bed injury or lawn mower foot injury in children require specific management? Nail bed injury is not to be minimized and should be treated strictly. In case of serious accidents with garden equipment, initial wound care in surgery should be economic, but experienced practitioners should weigh the risk/benefit ratio between conservation and early amputation. LEVEL OF EVIDENCE: IV.

Subungual Hematoma.

The authors present the case of a 64-year-old male who presented to the emergency department due to foot trauma. He sustained a large subungual hematoma, which was drained. Following the procedure, the patient achieved complete resolution of his pain. He also reported no complications at two-week phone follow-up. The management of subungual hematoma, including the trephination procedure, is discussed. Potential complications, although rare, are reviewed.

Surgical Management of Pachyonychia Congenita in a 3-Year-Old.

Pachyonychia congenita is a rare genetic disorder characterized by hypertrophic nail plates, hyperkeratotic nail beds, and thickened hyponychium of the fingers and toes, impairing manual dexterity and resulting in poor aesthetics. The current body of literature describes various treatment modalities, but no singular approach has been defined as the gold standard. In this case, the authors employed different surgical techniques for treating pachyonychia congenita to evaluate the most effective approach. A 3-year-old boy presented with hypertrophic nail growth involving all digits of both hands and feet. Three surgical procedures were performed on the patient's fingers and toes using germinal matrix excision (GME) alone, GME plus partial sterile matrix excision (pSME), or GME plus complete sterile matrix excision (cSME). The digits treated with GME + cSME exhibited no recurrence of nail growth. Those treated with GME alone exhibited recurrence of hypertrophic nail growth, although their growth slowed. Excision of GME + cSME prevented recurrence of hypertrophic nails, while GME alone or with pSME led to slower-growing hypertrophic nails. Complete excision of the germinal and sterile matrices with skin graft closure may be a definitive treatment for pachyonychia congenita, but further studies are needed to validate these findings.

[Effectiveness of finger reconstruction using nail flap anastomosing nerve branch of the first toe nail bed].

Objective: To investigate the effectiveness of finger reconstruction using nail flap anastomosing the nerve branch of the first toe nail bed. Methods: Between January 2016 and December 2022, 18 patients (18 fingers) with thumb or finger nail bed defects were admitted. There were 12 males and 6 females, with an average age of 32 years (range, 19-42 years). Four cases were finger tip tissue damage caused by machine compression, and 4 cases were distal tissue necrosis after finger replantation. There were 9 cases of thumb injury, 3 cases of index finger injury, 5 cases of middle finger injury, and 1 case of ring finger injury. There were 11 cases of distal nail damage and 7 cases of distal nail root (including nail root) damage. The time from injury to admission was 1-5 hours, with an average of 2 hours. After debridement and anti-infection treatment for 5-7 days, the wounds in size of 1 cm×1 cm to 4 cm×3 cm were reconstructed by using nail flaps anastomosing the nerve branches of the first toe nail bed. The size of the nail flaps ranged from 1.5 cm×1.5 cm to 4.5 cm×3.5 cm. The donor sites were repaired with the flaps in 16 cases and skin graft in 2 cases. Results: All nail flaps, flaps, and skin grafts survived after operation and the wounds healed by first intention. All patients were followed up 6-12 months (mean, 10 months). The nails of 18 cases were all grown, in which 16 cases had smooth nails with satisfactory appearances, 1 case had uneven nails, and 1 case had obvious scar hyperplasia around the suture opening. At 6 months after operation, the two-point discrimination of the skin flap was 4-8 mm (mean, 6 mm). Meanwhile, the skin grafts and flaps at the donor sites regained protective sensation, good abrasion resistance, and had no negative effect upon walking and wearing shoes. Conclusion: The application of a nail flap that anastomoses the nerve branch of the first toe nail bed for finger reconstruction has minimal damage and can achieve good nail bed repair results.

Eccrine Angiomatous Hamartoma Occurring on the Nail Bed.

A 71-year-old woman was referred to our clinic with a 2-month history of pain and exudate from her right first toe. Physical examination revealed a subungual nodule that elevated the nail plate and produced distal onycholysis. We performed onychectomy and removed the nodule. A histopathological specimen from the nodule showed hyperkeratosis and acanthosis in the epidermis, papillomatosis and dilated vessels in the superficial dermis, and aggregation of eccrine glands in the mid-dermis. Based on these findings, a diagnosis of eccrine angiomatous hamartoma (EAH) was made. EAH is a rare cutaneous hamartoma that is histologically characterized by proliferation of eccrine glands and vascular components. To our knowledge, EAH occurring in the subungual region has not been reported. The pathogenesis of acquired EAH has not been completely elucidated, but several cases have been reported to be caused by external stimuli. Although the subungual area generally has no sweat glands, our case suggests that a traumatic stimulus can induce EAH anywhere including regions where sweat glands are normally not found.

Nail Unit Squamous Cell Carcinoma with Onycholemmal Features: Case Report and Review of the Literature.

Introduction: Onycholemmal carcinoma (OC) is a rare subtype of squamous cell carcinoma (SCC) that originates from the epithelium of the nail bed. It is characterized by distinct histopathologic features including small clusters of atypical squamous epithelium devoid of a granular layer, with abrupt onycholemmal keratinization. Case Presentation: We present a case of a 75-year-old male with right thumbnail onycholysis, yellow-green nail plate discoloration, as well as bleeding and purulence of the lateral nail fold. Histopathologic evaluation revealed high-grade squamous dysplasia, small clusters of severely atypical epithelial cells, and a pattern of abrupt keratinization consistent with the diagnosis of SCC carcinoma with onycholemmal features. GMS and PAS staining indicated concomitant onychomycosis. Pathologic analysis also disclosed residual SCC and concomitant amyloidosis, possibly light chain related and hence reflective of his underlying multi-organ lymphoplasmacytic lymphoma. The patient subsequently underwent Mohs micrographic surgery. Conclusion: Clinical presentation of nail unit SCC with onycholemmal features is highly variable, making differentiating between similarly presenting benign and malignant nail disorders particularly challenging. This case report demonstrates clinical and histopathological features of nail unit SCC with onycholemmal features to improve diagnosis and management.

Local and Systemic Nail Plate Abnormalities: A Clinical Review.

Nail disorders are often difficult to recognize and diagnose because of the subtlety of their presentation and their shared overlapping features that are common to several conditions. Experientially, this is further complicated by the fact that specific training on diagnosis of nail pathologies varies substantially across most residency programs and for a majority of medical and surgical specialties. To distinguish these presentations from true, potentially deleterious nail disorders, clinicians should have familiarity with the most commonly occurring nail pathologies and their associations, and use a systematic approach when examining or evaluating alterations in the nails. In the present study, we review the most common clinical disorders affecting the nail apparatus.