An Unusual Pediatric Manifestation of the Herpes Simplex Virus.

Herpetic whitlow is a viral infection of the fingers or toes caused by the herpes simplex virus. Herpes simplex virus is a common pathogen that causes infections in any cutaneous or mucocutaneous surface, most commonly gingivostomatitis or genital herpes. However, infection of the digits is also infrequently reported. Herpetic whitlow occurs when the virus infects the distal phalanx of the fingers or toes by means of direct inoculation, causing pain, swelling, erythema, and vesicle formation. The proper diagnosis is important because the condition can mimic various other podiatric abnormalities such as paronychia, bacterial cellulitis, or even embolic disease. Improper diagnosis often leads to unnecessary work-up, antibiotic therapy, or even surgical intervention. This case will help illuminate the clinical presentation of herpetic whitlow in an atypical location, and the patient's subsequent treatment. We present an atypical case of right hallux herpetic whitlow with delayed diagnosis and associated cellulitis. The patient was admitted after seeing multiple providers for a progressive right hallux infection that presented as a mixture of vesicular lesions and apparent cellulitis. His history was positive for biting his fingernails and toenails, and the lesions were noted to be honeycomb-like, with minimal drainage. The lesions were then deroofed and viral cultures were obtained, which were positive for herpes simplex virus type 1, thus confirming a diagnosis of herpetic whitlow. Although he remained afebrile with negative wound cultures during admission, a secondary bacterial infection could not be excluded because of his nail avulsion and surrounding cellulitis. He was discharged on oral antibiotics, antivirals, and wound care recommendations. Herpetic whitlow should be included in the differential diagnosis of pedal digital lesions that appear as vesicular or cellulitic in the pediatric population.

Red light emitting diode as an adjuvant treatment for epidermal growth factor receptor inhibitors-induced paronychia.

We evaluated the efficacy and safety of red light LED as an adjuvant treatment for epidermal growth factor receptor inhibitor-induced paronychia. Eight patients were recruited in this randomized, single-blinded controlled trial. They were randomized to receive red-light on one hand or foot 2-3 times/week for 6 weeks while the contralateral side served as controls. The standard treatments were continued. Erythema and lesion elevation observed by Anthera® 3D, severity and pain scores were obtained at weeks 0, 2, 4, 6, and 8. The red light group showed significantly lower erythema, severity, and pain scores at weeks 4, 6, and 8. The elevation was significantly lower in the red light group at every follow-up visit. No adverse events occurred. Red light therapy may be an option as adjunctive treatment for EGFRi-induced paronychia.

Is lymphangitic streaking associated with different pathogens?

OBJECTIVES: Little is known regarding the differences in microbiology associated with cellulitis or abscess with or without lymphangitic streaking. The objective of our study is to assess whether there are differences in the pathogens identified from wound cultures of patients with paronychia with and without associated lymphangitis. METHODS: Retrospective cross-sectional study at a tertiary pediatric emergency department over 25 years. We opted to assess patients with paronychia of the finger, assuming that these cases will have a greater variety of causative pathogens compared to other cases of cellulitis and soft tissue abscess that are associated with nail biting. Case identification was conducted using a computerized text-screening search that was refined by manual chart review. We included patients from 1 month to 20 years of age who underwent an incision and drainage (I&D) of a paronychia and had a culture obtained. The presence or absence of lymphangitis was determined from the clinical narrative in the medical record. We excluded patients treated with antibiotics prior to I&D as well as immune-compromised patients. We used descriptive statistics for prevalence and χ2 tests for categorical variables. RESULTS: Two hundred sixty-six patients met inclusion criteria. The median age was 9.7 years [IQR 4.7, 15.4] and 45.1% were female. Twenty-two patients (8.3%) had lymphangitic streaking associated with their paronychia. Patients with lymphangitis streaking were similar to those without lymphangitis in terms of age and sex (p = 0.52 and p = 0.82, respectively). Overall, the predominant bacteria was MSSA (40%) followed by MRSA (26%). No significant differences were found between the pathogens in the 22 patients with associated lymphangitis compared to the 244 patients without. CONCLUSION: Staphylococcus aureus represent the majority of pathogens in paronychia, although streptococcal species and gram-negative bacteria were also common. Among patients with paronychia of the finger, there seems to be no association between pathogen type and presence of lymphangitic streaking.

Purulent Pericarditis Due to Paronychia in a 16-Month-Old Child: A Nail-Biting Story.

Purulent pericarditis is a rare infectious disease with significant mortality, even in the modern antibiotic era. The presenting signs can often be subtle and patients can deteriorate rapidly with cardiac tamponade. We report a previously healthy 16-month-old female who developed purulent pericarditis associated with paronychia and sepsis caused by methicillin-sensitive Staphylococcus aureus. In addition to antibiotic treatment, she required emergent pericardiocentesis for cardiac tamponade, followed by two surgical interventions including full median sternotomy incision and partial pericardiectomy. At 4-month follow-up, she did well with no evidence of constrictive pericarditis on echocardiogram.

Using a novel scoring system for paronychia related to oncologic treatments (SPOT) for assessing paronychia severity and its correlation with pain index and quality of life.

BACKGROUND: Oncologic treatments may lead to the development of paronychia, which may cause severe pain and disability. However, a detailed objective scoring system is lacking. OBJECTIVE: To develop an objective scoring system to quantify the severity of paronychia and also examine the correlation of this score with a pain index and patients' quality of life. METHODS: A novel scoring system for paronychia related to oncologic treatments (SPOT), consisting of four parameters, namely redness, oedema, discharge and granulation tissue, was designed to assess the severity of paronychia. The visual analogue scale (VAS) and Dermatology Quality of Life Index (DLQI) were recorded, and their association with the SPOT scores was analysed. RESULTS: Ninety patients were enrolled from three medical centres in Taiwan. Severity of paronychia was determined by the scores of SPOT. Patients in the severe group had higher DLQI scores (severe vs. mild: P = 0.0018; severe vs. moderate: P = 0.0015). Both the DLQI and pain index scores were significantly higher in patients with higher dominant hand SPOT scores. CONCLUSIONS: The SPOT scores demonstrated the association of the paronychia severity with DLQI and pain. It may thus be useful in clinical practice and future studies.

Paronychia with Sporangium Formation Causing an Ingrown Toenail A Rare Case Report.

Ingrown toenail, or onychocryptosis, is a common inflammatory disease of the hallux. It results from the alteration of fit of the nail plate in the lateral nail fold. Ingrown toenails are usually seen in adolescents and young adults and can affect daily activities and social life. Generally, ingrown toenails are classified into three stages, including the inflammatory stage, the abscess stage, and the granulation stage. In this article, we present the rare case of a man with a diagnosis of paronychia with sporangium formation causing an ingrown toenail.

Factors influencing cure rates of non-dermatophyte mold and Candida onychomycosis: analysis of outcomes in 81 patients who completed treatment.

OBJECTIVES: Onychomycosis shows a poor response to current topical, oral, or device-related antifungal therapies. The aim of this study was to identify factors influencing the cure rates of non-dermatophyte mold and Candida onychomycosis. METHODS: Eighty-one patients who completed treatments were divided into "cured" and "non-cured" groups. The statistical significance of differences between the two groups was studied. RESULTS: Male gender (P < 0.01), long duration of disease before the initiation of treatment (P < 0.02), three or more infected nails (P < 0.0002), continuous exposure to water and detergents (P < 0.05), frequent exposure to mud and soil (P < 0.01), barefoot walking (P < 0.025), concomitant diabetes and hypertension (P < 0.04), eczema (P < 0.03), and associated paronychia (P < 0.01) had negative effects on cure rates of onychomycosis. Patient age, occupation, site of illness (hand, foot or big toe), type of disease (distal and lateral subungual onychomycosis, proximal subungual onychomycosis or total dystrophic onychomycosis), pathogenic fungi, and treatment modality had no statistically significant impact on cure rate. CONCLUSIONS: To minimize the failure rate of antifungal therapies in the treatment of onychomycosis, patients are advised to start treatment as soon as possible, and to avoid predisposing factors such as exposure to water, detergents, mud and soil, and barefoot walking.

Queratoacantoma digital distal en paciente con incontinencia pigmenti / Distal Digital Keratoacanthoma in Patients With Incontinentia Pigmenti

No disponible

Toxicidad asociada a la inhibición de EGFR: Revisión y aspectos clave del manejo de afatinib / Toxicity associated with EGRF inhibition: review and key aspects in the management of afatinib

Afatinib es un inhibidor irreversible de la tirosincinasa de la familia ErbB, aprobado para el tratamiento de pacientes con cáncer de pulmón no microcítico y mutaciones sensibilizadoras del gen EGFR. Como otros inhibidores de EGFR, afatinib puede provocar efectos adversos de clase como la diarrea, el exantema, la paroniquia o la mucositis. El manejo adecuado de estos efectos adversos es clave para mantener la calidad de vida de los pacientes y obtener el máximo beneficio del tratamiento con afatinib. El objetivo de este trabajo es revisar la toxicidad y resumir las recomendaciones de prevención y tratamiento de los efectos adversos más significativos de afatinib (AU)

Afatinib is an irreversible tyrosine kinase inhibitor of the ErbB family, approved for the treatment of patients with non-small cell lung cancer with EGFR-sensitizing mutations. Like other EGFR inhibitors, afatinib can provoke adverse events such as diarrhoea, rash, paronychia or mucositis. The correct management of these adverse events is essential to maintain quality of life in these patients and obtain the maximum benefit from afatinib therapy. This study aimed to review the toxicity of the drug and summarize recommendations for the prevention and treatment of the most significant adverse events associated with afatinib (AU)

Atypical chronic sterile paronychia leading to tissue and joint space destruction in a patient with thromboangiitis obliterans.

We report the case of a patient with severe thromboangiitis obliterans (Buerger's disease) and untreated paronychia which eroded into the digital joint space causing acrolysis of digits and significant soft tissue and joint destruction.

Retronychia : four new cases.

Retronychia (RN) refers to the incarnation of the nail plate in the proximal nail fold. We report four clinical cases of this little-known pathology, where there may be a long delay in diagnosis. RN exhibits a triad of clinical features, which are chronic paronychia, liquid discharge from under the nail fold and disruption of the linear nail growth. Chronic paronychia is often confused with bacterial or fungal infection. Empirical antibiotic treatment is not useful. Nail plate avulsion is the diagnostic and curative procedure of choice. Subsequent nail growth is normal without dystrophia and no recurrences are observed. Knowledge of this pathology avoids misdiagnosis, unnecessary antibiotic or local treatments and allows adequate surgical management.

Cuando las uñas se caen. La onicomadesis / To children, their parents and relatives

El desprendimiento completo de la uña (onicomadesis) es poco frecuente en la infancia y produce alarma entre los familiares y cuidadores de los niños. Puede deberse a una gran variedad de patologías locales y sistémicas o aparecer tras la exposición a determinados fármacos, aunque la mayoría de los casos son idiopáticos. Presentamos dos casos de onicomadesis con distintos factores desencadenantes. En ambos, las alteraciones ungueales se resolvieron espontáneamente en pocas semanas (AU)

Complete nail shedding (onychomadesis) in children is a rare condition and it may be a cause of concern among patient’s family and caregivers. This condition has been associated with a great number of local or systemic diseases and drug exposure, although most cases are idiopathic. We present two patients with different triggering factors of onychomadesis. Nail changes resolved spontaneously in a few weeks in both cases (AU)

Onychomycosis: Diagnosis and management.

Onychomycosis is a common nail ailment associated with significant physical and psychological morbidity. Increased prevalence in the recent years is attributed to enhanced longevity, comorbid conditions such as diabetes, avid sports participation, and emergence of HIV. Dermatophytes are the most commonly implicated etiologic agents, particularly Trichophyton rubrum and Trichophyton mentagrophytes var. interdigitale, followed by Candida species and non dermatophytic molds (NDMs). Several clinical variants have been recognized. Candida onychomycosis affects fingernails more often and is accompanied by paronychia. NDM molds should be suspected in patients with history of trauma and associated periungual inflammation. Diagnosis is primarily based upon KOH examination, culture and histopathological examinations of nail clippings and nail biopsy. Adequate and appropriate sample collection is vital to pinpoint the exact etiological fungus. Various improvisations have been adopted to improve the fungal isolation. Culture is the gold standard, while histopathology is often performed to diagnose and differentiate onychomycosis from other nail disorders such as psoriasis and lichen planus. Though rarely used, DNA-based methods are effective for identifying mixed infections and quantification of fungal load. Various treatment modalities including topical, systemic and surgical have been used.Topically, drugs (ciclopirox and amorolfine nail lacquers) are delivered through specialized transungual drug delivery systems ensuring high concentration and prolonged contact. Commonly used oral therapeutic agents include terbinafine, fluconazole, and itraconazole. Terbinafine and itraconazole are given as continuous as well as intermittent regimes. Continuous terbinafine appears to be the most effective regime for dermatophyte onychomycosis. Despite good therapeutic response to newer modalities, long-term outcome is unsatisfactory due to therapeutic failure, relapse, and reinfection. To combat the poor response, newer strategies such as combination, sequential, and supplementary therapies have been suggested. In the end, treatment of special populations such as diabetic, elderly, and children is outlined.

Can paronychia cause a remote necrotizing soft tissue infection?

Remote necrotizing soft tissue infection (NSTI) resulting from paronychia is very unusual but potentially lethal. We report a case of a 39-year-old woman affected by this unusual infection. The paronychia completely resolved in less than 2 weeks, however, a NSTI involved the right chest and flank and the left thigh. The patient required intensive care and multiple surgical debridements. This recent experience and literature data suggest that paronychia can cause a remote NSTI that can rapidly spread and become life-threatening. Broad spectrum antibiotics and aggressive surgical debridement are essential to a successful outcome.

[A woman with a swollen finger]. / Een vrouw met een gezwollen vinger.

A 70-year-old woman presented with osteomyelitis of the distal phalanx of her left middle finger, after a paronychia which was treated conservatively.

Disseminated Fusarium infection originating from paronychia in a neutropenic patient: a case report and review of the literature.

Fusarium is a saprophytic organism that is widely found distributed in soil, subterranean and aerial plants, plant debris, and other organic substrates. It can cause local tissue infections in immunocompetent patients, such as onychomycosis, bone and joint infections, or sinusitis. The incidence of disseminated disease has notably increased since the initial cases of disseminated Fusarium were described, particularly affecting immunocompromised patients with hematologic malignancies. We report a 39-year-old man hospitalized with newly diagnosed acute myelocytic leukemia who developed disseminated Fusarium infection originating from toenail paronychia in the setting of neutropenia. Pathologic diagnosis of Fusarium is difficult because the septate hyphae of Fusarium are difficult to distinguish from Aspergillus, which has a more favorable outcome. Cultures of potential sources of infection as well as tissue cultures are essential in identifying the organism and initiating early aggressive therapy.

Diseases mimicking onychomycosis.

The diagnosis of onychodystrophy has increased in dermatology consultation. This could be due to its esthetic effect, pain or disability, physician awareness for detecting the disease in the context of dermatologic or systemic diseases, or a greater incidence. One of the first differential diagnoses that should be considered when an onychodystrophic nail is observed is onychomycosis, which is the cause in 50% of cases.