Surgical Intervention for Paronychia Induced by Targeted Anticancer Therapies.

BACKGROUND: Paronychia is a common toxicity associated with targeted anticancer therapies. Antibiotics and steroids are the standard treatments for severe paronychia, yet they are often inadequate, prolonging the patient's suffering and resulting in changes to effective cancer therapy. OBJECTIVE: This article describes the clinical course of drug-induced paronychia and attempts to identify circumstances under which nail surgery may be beneficial. MATERIALS AND METHODS: This is a retrospective case series from a single institution's electronic medical record for patients on paronychia-inducing anticancer therapies with nail disease visit diagnosis codes. RESULTS: The authors identified 36 nail procedures performed on 12 patients, all of whom were managed with conservative steroid and antibiotic therapy with varying degrees of improvement; however, no further improvement was seen after 90 days. Partial matricectomy, nail avulsion, debridement/clipping, and incision and drainage were performed with resolution rates of 100% (11/11), 38.5% (5/13), 12.5% (1/8), and 0% (0/4), respectively. The average time to surgical intervention was 196 days, and the average time to resolution was 268 days. CONCLUSION: This series highlights the prolonged course of severe drug-induced paronychia and the importance of surgical intervention to reduce pain and impact on cancer treatment. Partial matricectomy should be considered for paronychia unresponsive to conservative therapy by 3 months.

Nail Psoriasis Treatment: Insights into Current Progress and Future Trends.

Nail psoriasis is a chronic condition which causes pain and functional impairment; thus, it restricts the activities of daily living and worsens the quality of life. Different chemotherapeutic options are available for treating nail psoriasis such as systemic, intralesional, and topical therapies. However, current chemotherapy suffers from several limitations and to overcome them, new advancements are being made worldwide. Various reports have been published on current progress in the treatment of nail psoriasis such as clinical efficacy studies of novel antipsoriatic agents and novel formulation strategies for current chemotherapy. There are several novel nail formulations for the treatment of nail disorders, particularly onychomycosis, such as vesicular colloidal structure (liposomes, niosomes, transfersomes, ethosomes, etc.) and nonvesicular colloidal structures (nano-emulgel, nanocapsules, thermosensitive gel, etc.) These formulations can also prove beneficial for the treatment of nail psoriasis, and will be heavily explored in the near future. This review provides a brief introduction to the disease, its pathogenesis, and its treatment modalities. The review also throws light onto progress and future perspectives in nail psoriasis treatment.

Isolated nail lichen planus: An expert consensus on treatment of the classical form.

Lichen planus is a benign inflammatory disorder of unknown etiology that may affect the skin, mucosae, scalp, and nails. When the nails are affected, it may lead to permanent destruction with severe functional and psychosocial consequences. Therefore, prompt diagnosis and early treatment are essential, even in mild cases. There are currently no guidelines for the management of nail lichen planus and the published literature on treatment is limited. The aim of this review is to provide practical management recommendations for the classical form of nail lichen planus, especially when restricted to the nails. Topical treatment has poor short-term efficacy and may cause long-term side effects. Instead, intralesional and intramuscular triamcinolone acetonide should be considered first-line therapies. Oral retinoids are second-line choices, and immunosuppressive agents may also be considered.

Efficacy of Nail Braces for Acute and Chronic Ingrown Toenails: A Prospective Study.

BACKGROUND: Nail braces are an alternative treatment for ingrown toenails. OBJECTIVE: This study aimed to prospectively examine the efficacy of nail braces for treatment of acute inflamed (AI)-type and chronic dystrophic-type ingrown toenails. MATERIALS AND METHODS: The authors conducted a prospective study of patients with ingrown toenails treated at Wan Fang Hospital between January 1, 2017, and July 31, 2018. Evaluation using physician global assessment scores and patient satisfaction questionnaires was performed at 1, 3, and 6 months after the start of treatment and during the final visit. Patient demographics, treatment courses, and outcomes were compared between the 2 types of ingrown toenails. RESULTS: Chronic dystrophic-type and AI-type ingrown toenails were observed in 25 (61 sides) and 28 patients (35 sides), respectively. Of the affected sides, 80.9%, 94.9%, and 100% achieved an excellent or fair result at 1, 3, and 6 months, respectively. Treatment duration and follow-up period were 179.2 ± 96.8 days and 281.6 ± 120.9, respectively. The recurrence rate was 7.4%. The treatment course and response were different between the 2 types of ingrown toenails. CONCLUSION: Ingrown toenails could be effectively treated with nail braces with excellent outcomes, favorable patient satisfaction, and low recurrence rates.

Nail manifestations in atopic dermatitis: a systematic review.

BACKGROUND: Nail involvement is not well-studied in atopic dermatitis but is believed to be more common than what is known. The spectrum of nail disorders that result from underlying atopic dermatitis (AD) is wide and has been reported in several studies, but there has been no systematic review so far to understand and quantify its prevalence. OBJECTIVE: To determine the prevalence and type of nail disorders seen in AD, either as a complication of the underlying condition or as a clue to its early diagnosis. METHODS: The authors performed a systematic review of English and non-English articles using MEDLINE, EMBASE, and Cochrane which reported the proportion of nail changes among AD patients. Only studies specifically looking at AD and its associated nail manifestations were included. Data were extracted and summarized descriptively. RESULTS: Twelve studies reported proportion of nail changes among AD patients. One study reported numbers in both adults and children cohorts, allowing 13 cohorts for final systematic review. CONCLUSIONS: Knowledge of the types and prevalence of nail changes in AD raises awareness among physicians managing AD.

A Stealthy Fungal Attack Requires an Equally Clandestine Approach to Onychomycosis Treatment.

Onychomycosis is a chronic fungal infection of the nail that is recalcitrant to treatment. It is unclear why normally effective antifungal therapy results in low cure rates. Evidence suggests that there may be a plethora of reasons that include the limited immune presence in the nail, reduced circulation, presence of commensal microbes, and fungal influence on immune signaling. Therefore, treatment should be designed to address these possibilities and work synergistically with both the innate and adaptive immune responses.

Toenail concentrations of zinc, selenium and nickel in patients with chronic recurrent warts: A pilot two-group comparative study.

BACKGROUND: Normal immune functioning requires sufficient levels of trace elements including zinc and selenium, while elements such as nickel can be immunotoxic. AIM: To assess long-term abnormalities in zinc, selenium and nickel levels in patients with chronic recurrent warts. METHODS: Toenail samples were taken from 28 patients with chronic recurrent warts and 30 apparently healthy matching controls were analysed. Toenail concentrations of zinc, selenium and nickel were measured using inductively-coupled plasma-optical emission spectroscopy. RESULTS: Selenium levels were significantly higher in patients than in controls (P = 0.03). Levels of trace elements did not correlate with the number or duration of warts. Toenail nickel levels in all subjects were higher than globally reported values. LIMITATIONS: A small sample size and the absence of regional reference ranges for concentrations of trace elements in toenails. CONCLUSION: Zinc does not seem to be involved in the chronicity of warts, and it is unclear if selenium has a protective role against warts. Our finding of high concentrations of nickel in both patients and controls raises concerns about environmental exposure.

Epidermolysis Bullosa (EB) Acquisita in an Adult Patient with Previously Unrecognized Mild Dystrophic EB and Biallelic COL7A1 Mutations.

Circulating anti-type VII collagen autoantibodies are frequently detected in patients with recessive dystrophic epidermolysis bullosa (RDEB). However, evidence supporting their pathogenic role in inducing epidermolysis bullosa acquisita (EBA) has been provided for only one individual with dominant dystrophic epidermolysis bullosa (DDEB). We describe here a patient who presented with dystrophic toenails since early childhood and developed trauma-induced skin blisters and oral erosions at age 26 years. Direct immunofluorescence showed IgG deposits with a u-serrated pattern along the cutaneous basement membrane zone, while no change in the expression of collagen VII could be detected by antigen mapping. High-titre anti-collagen VII antibodies were detected by enzyme-linked immunoassay (ELISA). In parallel, sequencing of epidermolysis bullosa (EB) genes identified compound heterozygous COL7A1 missense c.410G>A (p.Arg137Gln) and splicing c.3674C>T (p.Ala1225_Gln1241del) mutations, previously unrecognized in dystrophic epidermolysis bullosa (DEB). Thus, our patient had RDEB "nails-only" and developed mechanobullous EBA in adulthood. These data support a pathogenic role of circulating autoantibodies to collagen VII in inducing EBA in selected patients with DEB. Unforeseen worsening of skin symptoms in DEB should prompt laboratory investigations for EBA.

Asociación de hipomelanosis de Ito y paquioniquia congénita / Association of hypomelanosis of Ito and pachyonychia congenita

La hipomelanosis de Ito constituye un síndrome genético neurocutáneo caracterizado por lesiones hipopigmentadas en piel y manifestaciones extracutáneas que involucran especialmente el sistema nervioso central, de presentación esporádica. La paquioniquia congénita, es un trastorno de origen genético con onicodistrofia como signo característico y herencia autosómica dominante.Objetivo: Contribuir al asesoramiento genético integral de un paciente con asociación de hipomelanosis de Ito y paquioniquia congénita.Presentación del caso: Se presenta un paciente adulto con hipopigmentación de pelo y piel, además de onicodistrofia, presente también, en varios miembros de su familia, por lo cual presenta dos condiciones genéticas asociadas.Conclusión: Resulta de interés médico demostrar la presencia de estas alteraciones genéticas asociadas en un mismo paciente, para su adecuado asesoramiento genético en la comunidad, por no encontrarse en los reportes publicados…(AU)

[Impacts of mild moxibustion on immune indices and nailfold microcirculation in the subhealthy group].

OBJECTIVE: To compare the difference in the clinical therapeutic effects of the regulation of subhealthy condition between the mild moxibustion on alternate days and Chinese herbal medicine. METHODS: Seventy-two participants of subhealthy condition were assigned into a mild moxibustion group (36 cases) and a medication group (36 cases) according to random number table. In the mild moxibustion group, the intervention of mild moxibustion with moxa stick was applied to Guanyuan (CV 4), Zusanli (ST 36) and Sanyinjiao (SP 6), once every other day. In the medication group, yupingfeng granules were prescribed for oral administration, three times a day. The treatment was continued for 2 months. Before and after treatment, the levels of IgA, IgM and IgG, SOD (superoxide dismutase), the total score of fatigue scale 14 (FS-14) and the score of nailfold microcirculation were observed separately. RESULTS: Compared with the results before treatment, the immune indices, the total score of FS-14 and the scores of nailfold microcirculation were all improved after treatment in the two groups, indicating the significant differences (P<0.05, P<0.01). In comparison between the two groups after treatment, the levels of immune globulin, e.g. IgM, IgG and SOD in the mild moxibustion group were higher in tendency than those in the medication group, but without significant differences (all P>0.05). The total score of FS-14 after treatment in the mild moxibustion group was lower than that in the medication group (P<0.05). After treatment, in the mild moxibustion group, for the nailfold microcirculation, the flow state score, the periloop score and the total score were all reduced more apparently as compared with those in the medication group (P<0.01, P<0.05). CONCLUSIONS: Mild moxibustion with moxa stick on alternate days apparently relieves fatigue state, immune dysfunction and microcirculatory impairment in the subhealthy group. The results are apparently superior to the treatment with yupingfeng granules.

Evaluation of role of Candida in patients with chronic paronychia.

BACKGROUND: Chronic paronychia, earlier considered to be an infection due to Candida, is currently being considered as a dermatitis of the nail fold. Irritant, allergic and protein contact dermatitis are the suggested major pathogenic mechanisms. Hypersensitivity to Candida is more likely to be the etiology, rather than the infection itself. AIMS: To assess the clinico-etiological profiles of patients with chronic paronychia and to determine the role of contact sensitization and hypersensitivity to Candida. METHODS: All consecutive patients of chronic paronychia attending the dermatology outpatient department (OPD) were assessed for risk factors, number of nails affected, clinical presentation and presence of fungus, patch tested for contact allergy and prick tested for hypersensitivity to Candida allergen. RESULTS: A total of 80 patients of chronic paronychia were recruited into our study. There was female preponderance (66 patients, 82.5%), with the most common group affected being housewives (47 patients, 58.8%). Frequent washing of hands (64 patients, 80%) was the most common risk factor. Fungal culture was positive in 56.1% (41 patients), the predominant species cultured was Candida albicans (15 patients, 36.5%). Patch testing with Indian standard series was positive in 27.1% patients (19 out of 70 patients tested), with nickel being the most common allergen. Prick test with Candida allergen was positive in 47.6% patients (31 out of 65 patients tested). LIMITATIONS: Prick test and patch test provide indirect evidence of hypersensitivity, with inherent limitations. CONCLUSION: Our study shows that chronic paronychia is probably a form of hand dermatitis associated with prolonged wet work, and that there is a higher incidence of contact sensitization and Candida hypersensitivity in these patients.

Exploring the biology of the nail: An intriguing but less-investigated skin appendage.

The nail is a highly keratinized structure covering the tip of the digit, and considered to have several important functions in our daily life. In recent years, as biological aspects of the nail organ have been characterized, we realize that the nail unit and the hair follicle share various biological and immunological features. In particular, development and homeostasis of the nail unit also requires intimate epithelial-mesenchymal interactions that involve signaling pathways such as Wnt. There is also a striking immunological resemblance between both appendages, since the nail matrix, like the anagen hair bulb and the bulge, was shown to present unique characteristics of an immune privileged site. On the other hand, considerable progress in identifying nail stem cells has succeeded in locating putative stem cell niches in the nail unit. In this context, it is intriguing that nail stem cells residing in the nail matrix were recently shown to possess the ability to organize the process leading to digit regeneration. Further elucidation of signaling pathways governing epithelial-mesenchymal interactions in the nail unit seems to be a key to develop a novel therapeutic tool to treat amputees using nail epithelium. However, it is at least certain that the nail unit has a promising potential for the future of regenerative medicine. This review explores the biology of the nail organ by focusing on intriguing knowledge gained from recent studies.

Nail disease in psoriatic arthritis: distal phalangeal bone edema detected by magnetic resonance imaging predicts development of onycholysis and hyperkeratosis.

OBJECTIVE: To examine the association between magnetic resonance imaging (MRI) features of distal phalanx (DP) disease and the progression of nail pathology in psoriatic arthritis (PsA). METHODS: Clinical nail assessment and hand MRI scans were done on 34 patients with PsA. Twenty patients had repeat nail assessments after 1 year. RESULTS: Nails with onycholysis and hyperkeratosis at baseline were more likely to have corresponding DP bone erosion and proliferation on MRI. DP bone edema on baseline MRI was associated with development of onycholysis and hyperkeratosis in corresponding nails. CONCLUSION: Our data suggest that DP inflammation is central in the development of psoriatic nail disease.

A portable dermatoscope for easy, rapid examination of periungual nailfold capillary changes in patients with systemic sclerosis.

Microvascular lesions are a predominant feature in systemic sclerosis (SSc) and seem to play a central pathogenic role. The presence of nailfold capillary abnormalities is useful in diagnosing SSc. Capillaroscopy, however, usually requires special equipment and may be time consuming. Dermatoscope has been presented as a new diagnostic tool for quick and efficient examination of nailfold capillaries for circumstances when standard microscope equipment is not available. To assess the practical utility of dermatoscope for assessment of capillary morphology in patients with SSc, 83 Japanese patients with SSc (68 women, 15 men) and 68 healthy controls were examined in the study. Twenty-one patients (16 women, 5 men) had diffuse cutaneous SSc and 62 (52 women, 10 men) had limited cutaneous SSc. Enlarged capillaries and hemorrhages were evaluated in all 10 fingers with either naked eyes or DermLite(®) DL100 dermatoscope. Enlarged capillaries and hemorrhages were significantly more frequently detected with dermatoscope than without it. These findings were observed most frequently in the fourth finger. The presence of two or more enlarged capillaries in one or more fingers showed 83.1% sensitivity and 100% specificity for SSc. Among patients with SSc with anti-topoisomerase I antibody, the disease duration correlated negatively with the dermatoscopic number of enlarged capillaries and hemorrhages. Dermatoscope allows the easy and rapid identification of capillary nailfold morphological changes in SSc and should be routinely used for diagnosing SSc.

Antitopoisomerase antibody positivity predates nailfold capillaroscopy abnormalities in scleroderma. Postulated classification of 'prescleroderma'.

In a patient with early topoisomerase antibody-positive scleroderma, antinuclear antibody positivity was fortuitously observed to predate nailfold capillaroscopy changes. Using this case as a template, the prediagnostic phase of the presumed multifactorial disease may be divided into 5 temporal phases--phase 1 representing conception and intrauterine environment, phase 2 representing the extrauterine environment predating environmental exposure; phase 3 representing the early post-environmental exposure interval with no detectable perturbed body status; phase 4 representing the post-environmental exposure interval characterized by autoantibody production and microvascular changes, and phase 5, the symptomatic clinical prediagnostic interval (Raynaud's, skin, musculoskeletal, gastrointestinal, cardiorespiratory) prompting scleroderma diagnosis. Temporal classification of prescleroderma aids in both the understanding and definition of scleroderma 'onset'. If altered nailfold capillaries and autoantibodies develop at comparable rates, and if the findings from this case--that autoantibody changes precede microvascular changes--are truly representative of the preclinical disease phase, then these findings argue that the evolution of the disease is from within the vessel outwards, rather than vice versa.

The pathogenesis of psoriatic arthritis and associated nail disease: not autoimmune after all?

PURPOSE OF REVIEW: Both psoriasis and psoriatic arthritis (PsA), and by implication psoriatic nail disease, have been considered as autoimmune disorders. This was based on the assumption that T-cell-directed responses against common skin and synovial antigens led to shared immunopathological mechanisms at these different sites, which was indirectly supported by the human leucocyte antigen-Cw6 disease association. This study draws on recent microanatomical and genetic studies of PsA, psoriasis and psoriatic-associated nail disease to show how the prevailing autoimmunity concepts for psoriatic disease need to be redrawn, especially in the case of joint and nail disease. RECENT FINDINGS: Recent microanatomical studies confirm that normal tendon and ligament insertion points to bone (entheses), the key territory for the inflammatory reaction associated with PsA, being subject to microdamage that strongly points to a role for microtrauma in the joints, which is reminiscent of Koebner responses in the skin. Furthermore, the nail is functionally integrated with entheses associated with the distal phalanx that provides anchorage to the skin and joint. Although type 1 psoriasis is strongly linked to the human leucocyte antigen-Cw6, recent genetic studies have suggested that both joint and nail disease do not share this association. SUMMARY: These microanatomical and genetic insights have important implications for a better understanding of PsA and nail disease and for an improved understanding of the psoriatic disease spectrum.