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Indian Journal of Dermatology, Venereology and Leprology
Medknow Publications on behalf of The Indian Association of Dermatologists, Venereologists and Leprologists (IADVL)
ISSN: 0378-6323 EISSN: 0973-3922
Vol. 77, Num. 6, 2012, pp. 631-639
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Indian Journal of Dermatology, Venereology, and Leprology, Vol. 77, No. 6, September-October, 2011, pp. 631-539
Editorial
What's new in nail disorders?
Sunil Dogra, Savita Yadav
Department of Dermatology, Venereology and Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
Correspondence Address:
Dr. Sunil Dogra,
Department of Dermatology, Venereology and Leprology
Postgraduate Institute of Medical Education and Research
Chandigarh-160 012, India.
E-mail: sundogra@hotmail.com
Code Number: dv11199
DOI:
10.4103/0378-6323.86469
Nails have a functional as well as aesthetic importance. Though it is a small structural and anatomical unit, it is
affected by a variety of disorders. Major advances have
occurred in skin and hair disorders at a fast pace over
the last two decades. Nail has received little attention
compared with other dermatological disorders. Nail
disorders are rarely medically serious, but provide
insight into various systemic disorders. Nail diseases
can lead to impairment of hand function, difficulty
in walking, and cosmetic disfigurement. This article
provides an update on the status of nail disorders.
We have reviewed the new nail disorders described
recently and advances made in the diagnosis and
therapy of nail disorders over the last few years.
NEW ENTITIES DESCRIBED
In this section, we present the recently described new
nail disorders and reports of uncommon involvement
of nail unit by common cutaneous dermatoses. We
should be aware of these rare occurrences so that the
diagnosis is not missed.
New disorders
Lateral ingrowth of nail plate or onychocryptosis is a well-known and studied nail disease process.
Retronychia is a new entity occurring as a rare
complication of onychomadesis. Retronychia stands
for the proximal ingrowth of the nail plate into the
nail matrix. Berker. et al[1] for the first time reported
19 patients of retronychia and the details of all the
cases were presented and discussed at European
Nail Society meeting (2007). The mean age of the
patients was 39 years, with female preponderance
(16/19). All the patients presented with complaints
of proximal nail fold paronychia. The cardinal sign
seen on examination was the elevation of the proximal
nail plate beneath the proximal nail fold such that it
was higher than the distal nail plate. In most of the
patients, the nail showed yellowish discoloration due
to the nail plate thickening. Granulation tissue was
seen in the proximal nail fold in one-third of the cases
and was most marked at the junction of the lateral and
proximal nail folds. Big toe was affected in 16 of 19
subjects, whereas in three cases, hand was affected
(thumb alone in two cases, thumb and index finger
in one case). Around half of the patients reported an
episode of trauma as the precipitating event.
Authors proposed that retronychia results due to the
malalignment of the nail plate following its detachment from the matrix. The detached nail plate is pushed
upward into the matrix and the new nail plate grows
beneath it, further pushing the old nail plate upward.
Subsequently, two to four new nail plates may get
sandwiched beneath the old nail plate in the proximal
nail fold. This malalignment most commonly occurs
as a result of repeated distal trauma from the footwear
which pushes the nail plate proximally and upward.
Definitive treatment is the total nail plate avulsion
which leads to subsidence of nail fold inflammation.
The new nail plate growth is often normal and the
recurrences are not seen as in lateral ingrowth of nail
plate. Wortsman et al.[2] reported a case of triple finger
retronychia resulting from trauma and the diagnosis
was established using 3D ultrasonography (USG).
Worn down nail syndrome, also known as bidet nails,
was first reported by Baran and Moulin.[3] They
reported three unrelated women who had nail disorder
characterized by a triangular defect of the fingernails
with its base at the free edge of the nail. All these
females had obsession for genital hygiene and nail
changes were the result of excessive rubbing of nails
against the porcelain of bidet while cleaning their
genital area. Piraccini et al.[4] reported this nail disorder
in 14 of their patients and Patrizi et al.[5] described it as
a tic disorder in an 8-year-old girl child. The child had
habit of scratching the school desk with his nails and
finger tips. In this disorder, there is triangular thinning
and erythema of the distal nail plate. On dermoscopy,
dilated capillaries and pinpoint hemorrhage can be
seen. Nails improve once the behavior is changed.
Lacquer nail described by Rigopoulos et al.[6] has
significant overlap with worn down nail syndrome.
Lacquer nail are the result of excessive rubbing of
nail plate with nail filers provided with the topical
antifungal nail lacquers.
Hair growth at ectopic sites like glans penis[7] and
oral cavity[8] has been reported before. Onycotrychia has been recently described by Ferreira et al.[9] as
a growth of hair follicle longitudinally underneath
the nail plate. Their patient presented with single
longitudinal brownish ridge of the right thumb nail
plate evolving for last three months. The ridge started
under the cuticle and in the distal third, it formed
a hyperpigmented band. Nail biopsy revealed the
presence of hair structure in the nail bed in contact
with the nail plate. Immunocytochemistry with
keratin 9 better defined the nail structure. Cerman[10] have reported onycotrychia in 16-month-old child
as an isolated abnormality. Child presented with
longitudinal black streak underneath the nail plate of
second right toe. The nail plate was not affected unlike
the case reported by Ferreira et al. Authors could not
provide a satisfactory explanation for the occurrence
of this anomaly.
Nail degloving was recently described by Baran and
Perrin having three main clinical presentations and
multiple etiologies.[11] First is the typical thimbleshaped
nail shedding in which the walls of the thimble
are composed of the skin of the distal digit including
the nail plate (circumferential skin shedding). Second,
a partially sloughed-off nail plate with its surrounding
tissue composes nail degloving. In third presentation, shedding is restricted to the entire nail apparatus and
its components (matrix, nail bed, hyponychium, and
ventral aspect of the proximal nail fold) while the
surrounding epidermis of the distal digit is spared.
Various causes of nail degloving syndrome include
trauma, toxic epidermal necrolysis, and digital
gangrene. Lichen planus can rarely present with nail
degloving type of involvement.[11]
Common disorders—uncommon site
Seborrheic keratosis (SKs) is a common benign
epithelial cell tumor which commonly occurs in
head and neck area and upper trunk. Bon-Mardion
et al.[12] for the first time have reported SKs involving
the nail bed. Their case was a 58-year-old man who
had 1-year history of nail involvement in the form
of longitudinal leukoxanthonychia. Dermoscopic
examination showed longitudinal leukoxanthonychia
with filiform hemorrhages and milia-like cysts.
Histopathological examination revealed typical
findings of SKs. So, SKs should be included in the
differentials of leukoxanthonychia which includes
squamous-cell carcinoma, subungual warts-induced
lesion, onychomatricoma, and onychopapilloma.
Fixed drug eruption (FDE) is a common pattern of
cutaneous drug reaction reported with a variety
of drugs. Drug reaction occurs within 30 minutes
to 8 hours of drug administration. The sites most
commonly involved are mucosa and the limbs. Benton
and McGibbon[13] have reported a case of FDE with
amoxicillin-clavulanic acid in a 75-year-old man who
presented with painful periungual and subungual
erythema. On examination, circumscribed macules of
erythema involving the paronychial fold and the nail
bed were seen.
Pyogenic granuloma commonly involves the nail
folds presenting as a bleeding exophytic growth.
Rarely, it can present in the nail bed and then it
has to be differentiated from amelanotic subungual
melanoma.[14] There is a single report of subungual
pyoderma gangrenosum.[15]
NEW DIAGNOSTIC IN NAIL
Diagnosis of nail disorders is based mainly on clinical
examination, but some nail disorders need a further
workup to establish the diagnosis and/or plan the
treatment. Nail scraping is most commonly performed
laboratory test in the clinical setting. Nail biopsies are occasionally done for the diagnosis of nail bed
and matrix disorders but they are time consuming,
unpleasant to the patient, and result in scarring and
disfigurement of the nail. Nail apparatus has been
deprived of investigative medical imaging until
recently when there has been a growing interest in
noninvasive techniques which could supplement
the clinical examination of the nails. This includes
USG, magnetic resonance imaging (MRI), optical
coherence tomography (OCT), confocal laser scanning
microscopy (CLSM), and improvised dermoscopy
instruments.
Since onychomycosis (OM) is the most common
nail disorder accounting for around 50% of total nail
disease patients,[16] we have dealt with new advances
in its diagnosis separately.
ADVANCES IN MEDICAL IMAGING OF NAIL
Ultrasound
Nail unit is well suited for USG study as it consists
of well-defined tissues of different densities.[17] USG of
nail requires a high-resolution ultrasound machines
and high-frequency ultrasound probe. This modality
is available since long time, but is finding place in
the diagnosis of nail disorders only recently probably
because of greater availability of machines with high
resolution. USG is a good tool to diagnose cystic tumors
of nail unit including myxoid cyst, synovial cyst, and
collections like subungual hematoma or abscess. USG
is not a good tool for the diagnosis of solid tumors
like melanoma and squamous-cell carcinoma as they
appear as nonspecific hypoechoic areas.[17]
Wortsman et al.[18] presented the ultrasonographic
findings in retronychia nails in which the distance
between the nail plate origin and distal interphalangeal
(DIP) joint is reduced, proximal nail fold is thickened
and hypoechoic, and sometimes multiple nail plates
embedded into the proximal nail fold can be visualized.
Blood flow in the nail unit can be studied with color
Doppler and power angio. These techniques are useful
in the diagnosis of vascular tumors like glomus tumor.
Imaging of vascular lesions can be further enhanced
by means of using contrast media.
Newer technique called real-time compound spatial
imaging is evolving.[19] It provides instantaneous
integration of several overlapping ultrasound scans taken at different angles to produce a compound image
with better information content.
Magnetic resonance imaging
High-resolution MRI provides an accurate analysis of
the nail apparatus with detection of even 1 mm lesions.
Use of MRI for nail disorders started in 1990s with the
availability of small surface coils, mainly devoted to
the diagnosis of glomus tumor.[20,21] Nail unit tumors
have atypical presentations as the lesion in nail matrix
present with secondary nail plate changes and nail
bed tumors are obscured by the nail plate. MRI has
been used mainly for the diagnosis of nail unit tumors,
glomus tumor being the commonest indication.
Indications for MRI in relation to nail pathologies are
still evolving.[22] Other indications include myxoid
cyst, implantation epidermoid cyst, ganglion cyst
onychomatricoma, exostosis, and osteochondromas.
Optical coherence tomography
OCT works in analogy to USG; the infrared light
reflected from the skin is measured and the intensity
is imaged as a function of position. The OCT probe
is applied directly to the nail, scanning lasts for few
seconds, and does not cause discomfort to the subject
studied. This technique provides images of tissue
pathology in situ with a high axial resolution.[23]
Mogensen et al.[24] found OCT technique to have
low coefficients of variation compared with 20 Hz
USG in measurements of nail plate thickness. Ayden
et al.[25] recently reported OCT to provide higher
resolution changes compared with nail USG in nail
psoriasis. Abuzahra et al.[26] detected fungal elements
noninvasively in vivo using OCT in 10 patients with
histologically proven OM. Fungal elements were
detectable as highly scattering elongated structures
inside the nail plate, in the middle of the areas of
homogeneous decrease in signal intensity.
Confocal laser scanning microscopy
CLSM is a new noninvasive diagnostic tool which
is becoming increasingly popular. It can visualize
cell structures of the skin up to a depth of 300 μm in vivo. It is based on the principal of increasing optical
resolution and contrast of a micrograph by using
point illumination and a spatial pinhole to eliminate
out-of-focus light in specimens that are thicker than
the focal plane. It also enables the reconstruction
of three-dimensional structures from the obtained
images. Researchers have found it to be faster and more accurate than the conventional microscope used
in potassium hydroxide (KOH) preparations in the
diagnosis of OM.[27,28]
Dermatoscopy
Dermatoscopy is also known as dermoscopy and
epiluminescence microscopy. It is the examination
of skin using dermatoscope and is mainly used for
distinguishing pigmented benign and malignant
lesions. In nail unit, it is mainly used for patients
presenting with melanonychia. Park et al.[29] have
introduced a handy portable hand-held digital
dermoscope (USB Microscope M2, Scalar Corporation,
Tokyo, Japan) which can be used to study the nail
fold capillary changes while sitting in a high-volume
outpatient setting. It has the advantages of obtaining
microscopic images on a computer monitor in real
time; this makes the system more practical than other
conventional dermoscopy systems using a camera
that requires the development process. In addition,
it has a polarizing light mode that minimizes the
light reflection from the stratum corneum caused by
the difference in the reflective index between the air
and the stratum corneum. Thus, it does not require
mineral oil or other immersion agents to reduce the
light reflection.
ADVANCES IN DIAGNOSIS OF ONYCHOMYCOSIS
OM is a common problem, accounting for up to half of
all diseases of the nail, with an estimated prevalence
of 10% of the general population and approaching
60% in the elderly.[30,31] Hay and Baran[32] have revised
its classification because of the recognition of new
pathways of nail infection, new pathogens and
variations in the appearance of diseased infected nail.
KOH preparation and culture together have been
considered as the gold standard test for OM diagnosis.[33]
Nail sampling is done by means of curettage. In a
study by Semer et al.,[34] they compared sampling
by means of nail drilling vis-a-vis curettage. They
found that culture sensitivity was significantly
higher when sampling was done by means of drilling
technique as compared with conventional curettage
technique. Direct microscopic examination using
KOH preparation has low sensitivity. Fungal culture
technique has high false-negative rate, requires long
incubation period, risk of obscuration by bacterial
overgrowth, and contamination with foreign material.
Periodic acid-Schiff (PAS) staining is a good diagnostic tool for the diagnosis of OM but probably less utilized
by the dermatologist. Recently, it has been considered
as the gold standard for the diagnosis of OM by
some authors and is beginning to supplant KOH and
culture in the diagnosis of OM.[35,36] Wilsmann et al.[37]
found histopathological staining to have highest
sensitivity (82%), followed by culture (53%) and KOH
preparation (48%). The results with PAS staining
are faster compared with culture. It should be the
preferred diagnostic tool, especially in cases where the
diagnosis of OM is not certain and in those already on
antifungal treatment.
Diagnosis of OM caused by non-dermatophyte molds
is challenging, requiring more stringent criteria
than that of dermatophytes. Based on the available
data in literature, Gupta et al.[38] concluded that at
the moment, traditional mycology remains the gold
standard for diagnosing non-dermatophyte mold OM.
This includes obtaining positive results from KOH and
culture. Repeated isolations (2 or 3) in the absence of
a dermatophyte increase the probability of accurate
identification of the causative non-dermatophyte
mold. Still, there is controversy over the number of
inocula required to confirm the causative diagnosis.
Histopathology can be of assistance in establishing
the penetration of the non-dermatophyte mold into
the nail plate; however, this method does not provide
identification of the organism.
Development of newer techniques like polymerase
chain reaction (PCR),[39] OCT,[26] flow cytometry,[40,41]
and immunohistochemistry[42] for the diagnosis of OM
is underway. The routine use is impractical at present
because of some limitations. Litz and Cavagnolo[39]
have devised a quick inexpensive PCR test to detect
dermatophyte DNA in nail specimens. They compared
their PCR with KOH, fungal culture, and PAS staining.
A total of 559 nail specimens were tested and PAS,
PCR, KOH, and culture were positive in 54%, 37%,
40%, and 22% of specimens, respectively. PCR was
negative in all non-dermatophyte and yeast isolates.
PCR is specific, requires no morphologic expertise,
has relatively good sensitivity, and gives faster results.
This molecular approach is developing and with wider
availability, it may prove to be a useful tool in future.
OTHER ADVANCES IN NAIL DISORDER DIAGNOSIS
Nail biopsy is sometimes done to diagnose those
conditions which are not clear on clinical examination or history alone. As nail is a highly vascular structure,
bleeding from biopsy site is difficult to manage. Hwa
et al.[43] reported easy control of post-biopsy bleeding
using gelatin sponge saturated with aluminium
chloride.
While doing nail procedures, digital block using plain
lidocaine is the most common mode of administering
anesthesia. Many authors have reported safe use of
lidocaine-epinephrine mixture for digital block in good
number of patients.[44-46] They did not observe digital
necrosis in any of their patients, rather there were
added advantages of combining with epinephrine.
Epinephrine facilitates faster onset of anesthesia,
prolonged post-procedure pain relief, and lesser
amount of local anesthetic required without much
need of tourniquet placement to control bleeding.
So, lidocaine with epinephrine can be used for giving
digital block, but caution should be exercised in
patients with peripheral vascular diseases.
NEW THERAPEUTICS IN NAIL
In this section, new advances are discussed in the
management of OM, inflammatory disorders of nail,
surgical treatment of nail disorders, and various other
new approaches in the treatment of nail disorders.
New in onychomycosis treatment
OM is a common disorder caused by dermatophytes,
non-dermatophyte molds, and yeasts. It is managed
with topical and systemic antifungal therapy. At
present, oral terbinafine is considered the treatment of
choice for OM caused by dermatophytes.[47,48] Ciclopirox
and amorolfine are the two topical compounds used
for mild to moderate OM or as an adjunct to systemic
therapy. With standard therapies, response rate is
less than 50%.[49] There is a continuing search for a
convenient, cost-effective agent with high and longlasting
cure rates. Currently, many new therapies
for OM are under investigation which includes new
azoles, improvement of existing topical treatments
through addition of ungual penetration enhancers and
new topical drugs with better nail permeation. Several
means to enhance ungual penetration are under
investigation.[50] This includes the following:
I. Physical enhancers - transungual laser therapy,
electrokinetic transungual system iontophoretic
application of terbinafine gel;
II. Chemical enhancers - NM100060, econazole 5%/
SEPA18% nail lacquer, nanoemulsion (NB-002),
IDP-108, Ciclopoli™ 8% nail polish, AN-2690.
New triazole drugs (second generation triazoles) under
trial for the treatment of OM include pramiconazole,
posaconazole, ravuconazole, and albaconazole.[50]
Voriconazole has high antifungal activity against
dermatophytes as well as non-dermatophytes but its
use is mainly directed to invasive fungal infections
in immunocompromised individuals. Echinocandins
and sordarins are two new groups of antifungals
which are effective against azole-resistant fungi, but
they are also under development for mainly invasive
fungal infections.
Besides the topical and systemic medical therapy,
investigators are devising new means of treatment of
OM
- Photodynamic therapy (PDT) - Cases resistant
to standard antifungal therapy and those who
cannot take oral antifungals have been treated
with photodynamic therapy.[51-53] Watanabe et al.[51]
treated two with 20% solution of aminolevulinic
acid (ALA) as photo sensitizer and irradiated
with pulsed laser light at a wavelength of 630 nm
at 100 J/cm2 using an excimer-dye laser. Both
the patient had complete clearance after 6 and 7
weekly sittings. Similar results have been reported
by other authors.[52,53]
- Dual wavelength device – uses optical energy for
the treatment of OM.[54]
- Ultraviolet C (UVC) irradiation an in vitro study
indicate that germicidal UVC irradiation may be a
less invasive treatment option for onychomycosis,
when the appropriate consideration is given to
safety.[55]
These devices provide a non-drug approach and are
undergoing testing for the treatment of OM.
With the currently available treatment options,
recurrences are common occurring in 10 to 53% of
cases.[56,57] Sigurgeirsson et al.[58] studied the utility of
topical amorolfine nail lacquer (ANL) for prevention
of recurrence. The patients who were cured of
confirmed OM were divided into two groups. One
group applied ANL 2 weekly and the other group
did not receive any treatment. Recurrence occurred
more quickly in the untreated group and at end point,
70.8% remained cured in treated group, while 50% in
the untreated group. Author concluded that ANL can
serve as a good prophylactic tool to prevent recurrence
of OM. However, in another long-term follow-up
study, recurrence rate was not found to be related to
presence of predisposing factors, use of nail lacquer as
a prophylactic treatment, and the dermatophyte strain
isolated.[59]
Non-dermatophyte OM is less common, incidence
ranging from 1.45% to 17.6%.[60] Epidemiologically,
the top five organisms in terms of published
confirmed isolations worldwide are (in descending
order) Scopulariopsis brevicaulis, Fusarium species,
Aspergillus species, Scytalidium dimidiatum, and
Acremonium species.[38] Non-dermatophyte show a
poor response to topical as well as systemic antifungal
therapy. Gupta et al[38] reviewed various studies on
treatment of non-dermatophytes. Oral terbinafine and
itraconazole have greatest amount of efficacy data.
Both have shown efficacy in treating S. brevicaulis
and Aspergillus species infections. A smaller amount
of data supports the use of oral fluconazole and
ketoconazole for treating S. brevicaulis. Griseofulvin
should not be used for treating non-dermatophyte
(NDM) OM. Topical ciclopirox may be effective
in treating S. brevicaulis and Acremonium species
infections. Systemic and/or topical therapy combined
with periodic chemical or surgical nail debridement/
avulsion may be the best option in the management of
non-dermatophyte mold OM.
New in inflammatory disorders of nail
Treatment of nail psoriasis has received little
attention compared with cutaneous psoriasis despite
the significant burden it places on patients as a
result of functional impairment of manual dexterity,
pain, and psychological stress. Also, the treatment
response of nail psoriasis is slow and incomplete.
Sanchez–Regana et al.[61] retrospectively reviewed
the data of 84 psoriasis patients who had received
classical systemic therapy (acitretin, methotrexate,
cyclosporin, photo (chemo) therapy) or biologics
(infliximab, efalizumab, etanercept, adalimumab)
for moderate to severe skin disease or psoriatic
arthritis and had concomitant significant nail
involvement. The author found that the NAPSI score
fell significantly with all classical treatments (except
NBUVB) as well as with the biological treatments.
Among all the classical treatments, cyclosporine
produced the highest improvement. In the biological
treatment group, infliximab and adalimumab lead to
significantly greater improvement at 12 and 24 weeks.
The author did not find relation between response to
treatment and type of nail involvement (matrix, bed,
mixed). Also, the percentage of improvement in the NAPSI score was significantly greater with biological
treatments compared with classical treatment.
Many new topical formulations and combinations
have been tried for the treatment of nail psoriasis.[62,63]
Pulsed dye Laser (PDL) has been used to treat psoriatic
plaques, and recently, PDL has been shown to improve
nail psoriasis as well.[64]
Chronic paronychia is a common problem among the
females which is multifactorial in origin. Initially, it
was attributed to fungal infection primarily, but now
the role of irritants and allergens in its development
and propagation has been realized. Rigopoulos et al.[65]
compared the response of chronic paronychia in 45
patients treated with tacrolimus or betamethasone-
17-valereate or emollients. Treatment was given
for three weeks and patients were followed up for
further 6 weeks. Both betamethasone and tacrolimus
groups achieved statistically significantly greater
improvement when compared with the emollient
group. This study stresses the importance of treatment
with anti-inflammatory agents in addition to antifungal
therapy in chronic paronychia patients.
New in surgical management of nail disorders
Ingrown toe nail, also known as onychocryptosis, is
a common nail disorder. It is managed with either
conservative approach or by surgical treatment,
depending upon the clinical presentation and severity.
Conservative approaches include antibiotics, silver
nitrate cautery, proper nail trimming techniques,
and flexible tube splinting (sleeve method). New
non-surgical techniques using VHO-osthold nail
brace,[66] resin splint,[67] super-elastic wire[68] have been
described. All these techniques are based on same
principle that is to keep the lateral nail plate pulled
by making use of some equipment, so that it does not
impinge into the lateral nail fold. Advantages of these
techniques are that they are easy and faster to perform,
good for elderly and diabetic individuals in whom
surgery may otherwise be contraindicated, and lastly
the nail anatomy remains unaltered. Disadvantages are
that basic pathology is not corrected and recurrences
can occur on removing the equipment, patient has to
take care of device, and his activities may be limited
because of it.
Ozdil et al. have described a new non-surgical
procedure called angle correction technique in
eight patients with ingrown toe nail.[69] The major principal of the technique is to correct the dome shape
(convexity) of the nail by reducing its thickness 50 to
75%.
Different techniques of surgery for ingrown toe nail
include Winograd method, whole nail plate avulsion,
Emmert procedure, ablation of the nail matrix using
phenol or sodium hydroxide or Lasers, and Zadik’s
procedure. Payvandi et al.[70] compared Winograd and
sleeve methods for the treatment of ingrown toe nails in
100 patients. They found that the participants treated
with sleeve method experienced shorter surgery
duration, less work day loss, and the recurrence rate
were similar in two groups.
Pincer nail kind of deformity has been treated by
nail plate avulsion followed by complete destruction
of nail matrix by either chemical cautery or surgical
matricectomy or laser. Ghaffarpour et al.[71] has
described a new nail-saving surgical technique for
correction of pincer nail deformity. The technique is
a combination of nail bed cutting and splinting. First
nail plate is removed, fibrous nail bed excised, and
then widened. Remaining nail bed is sutured to the
margins and then splint is applied, which ensure that
the new nail growth is not deformed.
Glomus tumor has to be surgically excised. Roan
et al.[72] have reported a new surgical approach for
removing glomus tumor with nil recurrences and good
cosmetic results. Author recommends cutting into the
nail plate and nail bed over the tumor together without
separating the nail plate from the nail bed. The tumor
pops out when the nail plate and nail bed are split and
then nail plate is sutured without the need of nail bed
repair. This is easy to perform, gives good cosmetic
results, and there were no recurrence in 17 reported
patients.
OTHER ADVANCES
Pachyonychia congenita (PC) is a rare autosomaldominant
keratin disorder caused by dominant negative
mutations in keratin genes KRT6A/B, KRT16, or KRT17.
It is characterized by painful plantar keratoderma and
hypertrophic nail dystrophy. It is notoriously difficult
to manage and systemic retinoids have been the main
stay of therapy. But because of the rarity of the disorder,
the optimum use of retinoids is not described. Gruber
et al.[73] surveyed 30 patients of PC who had received
oral retinoids (acitretin/isotretinoin 10-50 mg/day for 1-240 months). Nail changes ameliorated in 14% while
79% did not experience any nail change. In 50% cases,
there was thinning of plantar hyperkeratosis and 33%
had decreased plantar pain. Most of the patients (83%)
discontinued retinoids because of the adverse effects.
Risk benefit analysis favored low dose (≤25 mg/d) for
longer period (>5 months) compared with higher dose
(>25 mg/day) given for shorter period (≤5 months).
The data indicate that acitretin may have a slight edge
over isotretinoin in treating PC.
Sirolimus (rapamycin) is an mTOR inhibitor and
mainly used presently in organ transplant recipient
patients. Hickerson et al.[74] have treated keratinocyte
cell line with mTOR inhibitors and this lead to
decreased expression of K6a. Three PC patients given
oral rapamycin had subjective improvement and
change in callus character. Further research including
topical formulations is warranted in this regard.
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- Cerman AA. Subungual ectopic hair. J Eur Acad Dermatol Venereol 2011;25:1115-6.
- Baran R, Perrin C. Nail degloving, a polyetiologic condition with 3 main patterns: A new syndrome. J Am Acad Dermatol 2008;58:232-7.
- Bon-Mardion M, Poulalhon N, Balme B, Thomas L. Ungualseborrheic keratosis. J Eur Acad Dermatol Venereol 2010;24:1102-4.
- Benton EC, McGibbon D. Subungual fixed drug eruption. Br J Dermatol 2010;162:1397-8.
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- Holzberg M. Glomus tumor of the nail: A ‘redherring’ clarified by magnetic resonance imaging. Arch Dermatol 1992;128:160-2.
- Matloub HS, Muoneke VN, Prevel CD, Sanger JR, Yousif NJ. Glomus tumor imaging: Use of MRI for localization of occult lesions. J Hand Surg Am 1992;17:472-5.
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- Mogensen M, Thomsen JB, Skovgaard LT, Jemec GB. Nail thickness measurements using optical coherence tomography and 20-MHz ultrasonography. Br J Dermatol 2007;157:894-900.
- Aydin SZ, Ash Z, Del Galdo F, Marzo-Ortega H, Wakefield RJ, Emery P, et al. Optical coherence tomography: A new tool to assess nail disease in psoriasis? Dermatology 2011;222:311-3.
- Abuzahra F, Spöler F, Först M, Brans R, Erdmann S, Merk HF, et al. Pilot study: Optical coherence tomography as a noninvasive diagnostic perspective for real time visualisation of onychomycosis. Mycoses 2010;53:334-9.
- Kaufman G, Horwitz BA, Duek L, Ullman Y, Berdicevsky I. Infection stages of the dermatophyte pathogen Trichophyton: Microscopic characterization and proteolytic enzymes. Med Mycol 2007;45:149-55.
- Hongcharu W, Dwyer P, Gonzalez S, Anderson RR. Confirmation of onychomycosis by in vivo confocal microscopy. J Am Acad Dermatol 2000;42:214-6.
- Park JH, Lee DY, Cha HS, Koh EM. Handheld portable digital dermoscopy: Routine outpatient use for evaluating nail-fold capillary changes in autoimmune connective tissue diseases. J Eur Acad Dermatol Venereol 2009;23:207.
- Ghannoum MA, Hajjeh RA, Scher R, Konnikov N, Gupta AK, Summerbell R, et al. A large-scale North American study of fungal isolates from nails: The frequency of onychomycosis, fungal distribution, and antifungal susceptibility patterns. J Am Acad Dermatol 2000;43:641-8.
- Gupta AK, Jain HC, Lynde CW, Macdonald P, Cooper EA, Summerbell RC. Prevalence and epidemiology of onychomycosis in patients visiting physicians’ offices: A multicenter canadian survey of 15,000 patients. J Am Acad Dermatol 2000;43:244-8.
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- Weinberg JM, Koestenblatt EK, Tutrone WD, Tishler HR, Najarian L. Comparison of diagnostic methods in the evaluation of onychomycosis. J Am Acad Dermatol 2003;49:193-7.
- Reisberger EM, Abels C, Landthaler M, Szeimies RM. Histopathological diagnosis of onychomycosis by periodic acid– Schiff-stained nail clippings. Br J Dermatol 2003;148:749-54.
- Wilsmann-Theis D, Sareika F, Bieber T, Schmid-WendtnerMH, Wenzel J. New reasons for histopathologicalnail-clipping examination in the diagnosis of onychomycosis. J Eur Acad Dermatol Venereol 2011;25:235-7.
- Gupta AK, Drummond-Main C, Cooper EA, Brintnell W, Piraccini BM, Tosti A. Systematic review of nondermatophyte mold onychomycosis: Diagnosis, clinical types, epidemiology, and treatment. J Am Acad Dermatol 2011. [In Press]
- Litz CE, Cavagnolo RZ. Polymerase chain reaction in the diagnosis of onychomycosis: A large, single-institute study. Br J Dermatol 2010;163:511-4.
- Kaya TI, Eskandari G, Guvenc U, Gunes G, Tursen U, Burak Cimen MY, et al. CD4+CD25+ Treg cells in patients with toenail onychomycosis. Arch Dermatol Res 2009;301:725-9.
- Feuilhade de Chauvin M. New diagnostic techniques. J Eur Acad Dermatol Venereol 2005;19 (Suppl 1):20-4.
- Arrese JE, Quatresooz P, Piérard-Franchimont C, Piérard GE. [Nail histomycology. Protean aspects of a human fungal bed]. Ann Dermatol Venereol 2003;130:1254-9.
- Hwa C, Kovich OI, Stein JA. Achieving hemostasis after nail biopsy using absorbable gelatin sponge saturated in aluminum chloride. Dermatol Surg 2011;37:368-9.
- Altinyazar HC, Demirel CB, Koca R, Hosnuter M. Digital block with and without epinephrine during chemical matricectomy with phenol. Dermatol Surg 2010;36:1568-71.
- Sonmez A, Yaman M, Ersoy B, Numanodlu A. Digital blocks with and without adrenalin: A randomised-controlled study of capillary blood parameters. J Hand Surg EurVol 2008;33:515-8.
- Firoz B, Davis N, Goldberg LH. Local anesthesia using buffered 0.5% lidocaine with 1:200,000 epinephrine for tumors of the digits treated with Mohs micrographic surgery. J Am Acad Dermatol 2009;61:639-43.
- Gianni C. Update on antifungal therapy with terbinafine. G Ital Dermatol Venereol 2010;145:415-24.
- Finch JJ, Warshaw EM. Toenail onychomycosis: Current and future treatment options. Dermatol Ther 2007;20:31-46.
- Epstein E. How often does oral treatment of toenail onychomycosis produce a disease-free nail? An analysis of published data. Arch Dermatol 1998;134:1551-4.
- Kumar S, Kimball AB. New antifungal therapies for the treatment of onychomycosis. Expert Opin Investig Drugs 2009;18:727-34.
- Watanabe D, Kawamura C, Masuda Y, Akita Y, Tamada Y, Matsumoto Y. Successful treatment of toenail onychomycosis with photodynamic therapy. Arch Dermatol 2008;144:19-21.
- Sotiriou E, Koussidou-Eremonti T, Chaidemenos G, Apalla Z, Ioannides D. Photodynamic therapy for distal and lateral subungual toenail onychomycosis caused by Trichophyton rubrum: Preliminary results of a single-centre open trial. Acta Derm Venereol 2010;90:216-7.
- Piraccini BM, Rech G, Tosti A. Photodynamic therapy of onychomycosis caused by Trichophyton rubrum. J Am Acad Dermatol 2008;59(5 Suppl):S75-6.
- Landsman AS, Robbins AH, Angelini PF, Wu CC, Cook J, Oster M, et al. Treatment of mild, moderate, and severe onychomycosis using 870- and 930-nm light exposure. J Am Podiatr Med Assoc 2010;100:166-7.
- Dai T, Tegos GP, Rolz-Cruz G, Cumbie WE, Hamblin MR. Ultraviolet C inactivation of dermatophytes: Implications for treatment of onychomycosis. Br J Dermatol 2008;158:1239-46.
- Scher RK, Tavakkol A, Sigurgeirsson B, Hay RJ, Joseph WS, Tosti A, et al. Onychomycosis: Diagnosis and definition of cure. J Am Acad Dermatol 2007;56:939-44.
- Gupta AK, Lynch LE. Onychomycosis: Review of recurrence rates, poor prognostic factors, and strategies to prevent disease recurrence. Cutis 2004;74(1 Suppl):10-5.
- Sigurgeirsson B, Olafsson JH, Steinsson JT, Kerrouche N, Sidou F.Efficacy of amrolfine nail lacquer for the prophylaxis of onychomycosis over 3 years. J Eur Acad Dermatol Venereol 2010;24:910-5.
- Piraccini BM, Sisti A, Tosti A. Long-term follow-up of toenail onychomycosis caused by dermatophytes after successful treatment with systemic antifungal agents. J Am Acad Dermatol 2010;62:411-4.
- Tosti A, Piraccini BM, Lorenzi S. Onychomycosis caused by nondermatophytic molds: Clinical features and response to treatment of 59 cases. J Am Acad Dermatol 2000;42:217-24.
- Sánchez-Regaña M, Sola-Ortigosa J, Alsina-Gibert M, Vidal-Fernández M, Umbert-Millet P. Nail psoriasis: A retrospectivestudy on the effectiveness of systemic treatments (classical and biological therapy). J Eur Acad Dermatol Venereol 2011;25:579-86.
- Sánchez Regaña M, MárquezBalbás G, Umbert Millet P. Nail psoriasis: A combined treatment with 8% clobetasolnail lacquer and tacalcitol ointment. J Eur Acad Dermatol Venereol 2008;22:963-9.
- Cannav ò SP, Guarneri F, Vaccaro M, Borgia F, Guarneri B. Treatment of psoriatic nails with topical cyclosporin: A prospective, randomized placebo-controlled study. Dermatology 2003;206:153-6.
- Oram Y, Karincaoğlu Y, Koyuncu E, Kaharaman F. Pulsed dye laser in the treatment of nail psoriasis. Dermatol Surg 2010;36:377-81.
- Rigopoulos D, Gregoriou S, Belyayeva E, Larios G, Kontochristopoulos G, Katsambas A. Efficacy and safety of tacrolimus ointment 0.1% vs. betamethasone 17-valerate 0.1% in the treatment of chronic paronychia: An unblinded randomized study. Br J Dermatol 2009;160:858-60.
- Harrer J, Schöffl V, Hohenberger W, Schneider I. Treatment of ingrown toenails using a new conservative method: Aprospective study comparing brace treatment with Emmert’s procedure. J Am Podiatr Med Assoc 2005;95:542-9.
- Matsumoto K, Hashimoto I, Nakanishi H, Kubo Y, Murao K, Arase S. Resin splint as a new conservative treatment for ingrown toenails. J Med Invest 2010;57:321-5.
- Moriue T, Yoneda K, Moriue J, Matsuoka Y, Nakai K, Yokoi I, et al. A simple therapeutic strategy with super elastic wire for ingrown toenails. Dermatol Surg 2008;34:1729-32.
- Ozdil B, Eray IC. New method alternative to surgery for ingrown nail: Angle correction technique. Dermatol Surg 2009;35:990-2.
- Peyvandi H, Robati RM, Yegane RA, Hajinasrollah E, Toossi P, Peyvandi AA, et al. Comparison of two surgical methods (Winograd and sleeve method) in the treatment of ingrown toenail. Dermatol Surg 2011;37:331-5.
- Ghaffarpour G, Tabaie SM, Ghaffarpour G. A new surgical technique for the correction of pincer-nail deformity: Combination of splint and nail bed cutting. Dermatol Surg 2010;36:2037-41.
- Roan TL, Chen CK, Horng SY, Hsieh JH, Tai HC, Hsieh MH, et al. Surgical technique innovation for the excision of subungual glomus tumors. Dermatol Surg 2011;37:259-62.
- Gruber R, Edlinger M, Kaspar RL, Hansen CD, Leachman S, Milstone LM, et al. An appraisal of oral retinoids in the treatment of pachyonychiacongenita. J Am Acad Dermatol 2011. [In Press]
- Hickerson RP, Leake D, Pho LN, Leachman SA, Kaspar RL. Rapamycin selectively inhibits expression of an induciblekeratin (K6a) in human keratinocytes and improves symptoms in pachyonychiacongenita patients. J Dermatol Sci 2009;56:82-8.
Copyright 2011 - Indian Journal of Dermatology, Venereology, and Leprology
Indian Journal of Dermatology, Venereology, and Leprology, Vol. 77, No. 6, September-October, 2011, pp. 631-539
Editorial
What's new in nail disorders?
Sunil Dogra, Savita Yadav
Department of Dermatology, Venereology and Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
Correspondence Address:
Dr. Sunil Dogra,
Department of Dermatology, Venereology and Leprology
Postgraduate Institute of Medical Education and Research
Chandigarh-160 012, India.
E-mail: sundogra@hotmail.com
Code Number: dv11199
DOI:
10.4103/0378-6323.86469
Nails have a functional as well as aesthetic importance. Though it is a small structural and anatomical unit, it is
affected by a variety of disorders. Major advances have
occurred in skin and hair disorders at a fast pace over
the last two decades. Nail has received little attention
compared with other dermatological disorders. Nail
disorders are rarely medically serious, but provide
insight into various systemic disorders. Nail diseases
can lead to impairment of hand function, difficulty
in walking, and cosmetic disfigurement. This article
provides an update on the status of nail disorders.
We have reviewed the new nail disorders described
recently and advances made in the diagnosis and
therapy of nail disorders over the last few years.
NEW ENTITIES DESCRIBED
In this section, we present the recently described new
nail disorders and reports of uncommon involvement
of nail unit by common cutaneous dermatoses. We
should be aware of these rare occurrences so that the
diagnosis is not missed.
New disorders
Lateral ingrowth of nail plate or onychocryptosis is a well-known and studied nail disease process.
Retronychia is a new entity occurring as a rare
complication of onychomadesis. Retronychia stands
for the proximal ingrowth of the nail plate into the
nail matrix. Berker. et al[1] for the first time reported
19 patients of retronychia and the details of all the
cases were presented and discussed at European
Nail Society meeting (2007). The mean age of the
patients was 39 years, with female preponderance
(16/19). All the patients presented with complaints
of proximal nail fold paronychia. The cardinal sign
seen on examination was the elevation of the proximal
nail plate beneath the proximal nail fold such that it
was higher than the distal nail plate. In most of the
patients, the nail showed yellowish discoloration due
to the nail plate thickening. Granulation tissue was
seen in the proximal nail fold in one-third of the cases
and was most marked at the junction of the lateral and
proximal nail folds. Big toe was affected in 16 of 19
subjects, whereas in three cases, hand was affected
(thumb alone in two cases, thumb and index finger
in one case). Around half of the patients reported an
episode of trauma as the precipitating event.
Authors proposed that retronychia results due to the
malalignment of the nail plate following its detachment from the matrix. The detached nail plate is pushed
upward into the matrix and the new nail plate grows
beneath it, further pushing the old nail plate upward.
Subsequently, two to four new nail plates may get
sandwiched beneath the old nail plate in the proximal
nail fold. This malalignment most commonly occurs
as a result of repeated distal trauma from the footwear
which pushes the nail plate proximally and upward.
Definitive treatment is the total nail plate avulsion
which leads to subsidence of nail fold inflammation.
The new nail plate growth is often normal and the
recurrences are not seen as in lateral ingrowth of nail
plate. Wortsman et al.[2] reported a case of triple finger
retronychia resulting from trauma and the diagnosis
was established using 3D ultrasonography (USG).
Worn down nail syndrome, also known as bidet nails,
was first reported by Baran and Moulin.[3] They
reported three unrelated women who had nail disorder
characterized by a triangular defect of the fingernails
with its base at the free edge of the nail. All these
females had obsession for genital hygiene and nail
changes were the result of excessive rubbing of nails
against the porcelain of bidet while cleaning their
genital area. Piraccini et al.[4] reported this nail disorder
in 14 of their patients and Patrizi et al.[5] described it as
a tic disorder in an 8-year-old girl child. The child had
habit of scratching the school desk with his nails and
finger tips. In this disorder, there is triangular thinning
and erythema of the distal nail plate. On dermoscopy,
dilated capillaries and pinpoint hemorrhage can be
seen. Nails improve once the behavior is changed.
Lacquer nail described by Rigopoulos et al.[6] has
significant overlap with worn down nail syndrome.
Lacquer nail are the result of excessive rubbing of
nail plate with nail filers provided with the topical
antifungal nail lacquers.
Hair growth at ectopic sites like glans penis[7] and
oral cavity[8] has been reported before. Onycotrychia has been recently described by Ferreira et al.[9] as
a growth of hair follicle longitudinally underneath
the nail plate. Their patient presented with single
longitudinal brownish ridge of the right thumb nail
plate evolving for last three months. The ridge started
under the cuticle and in the distal third, it formed
a hyperpigmented band. Nail biopsy revealed the
presence of hair structure in the nail bed in contact
with the nail plate. Immunocytochemistry with
keratin 9 better defined the nail structure. Cerman[10] have reported onycotrychia in 16-month-old child
as an isolated abnormality. Child presented with
longitudinal black streak underneath the nail plate of
second right toe. The nail plate was not affected unlike
the case reported by Ferreira et al. Authors could not
provide a satisfactory explanation for the occurrence
of this anomaly.
Nail degloving was recently described by Baran and
Perrin having three main clinical presentations and
multiple etiologies.[11] First is the typical thimbleshaped
nail shedding in which the walls of the thimble
are composed of the skin of the distal digit including
the nail plate (circumferential skin shedding). Second,
a partially sloughed-off nail plate with its surrounding
tissue composes nail degloving. In third presentation, shedding is restricted to the entire nail apparatus and
its components (matrix, nail bed, hyponychium, and
ventral aspect of the proximal nail fold) while the
surrounding epidermis of the distal digit is spared.
Various causes of nail degloving syndrome include
trauma, toxic epidermal necrolysis, and digital
gangrene. Lichen planus can rarely present with nail
degloving type of involvement.[11]
Common disorders—uncommon site
Seborrheic keratosis (SKs) is a common benign
epithelial cell tumor which commonly occurs in
head and neck area and upper trunk. Bon-Mardion
et al.[12] for the first time have reported SKs involving
the nail bed. Their case was a 58-year-old man who
had 1-year history of nail involvement in the form
of longitudinal leukoxanthonychia. Dermoscopic
examination showed longitudinal leukoxanthonychia
with filiform hemorrhages and milia-like cysts.
Histopathological examination revealed typical
findings of SKs. So, SKs should be included in the
differentials of leukoxanthonychia which includes
squamous-cell carcinoma, subungual warts-induced
lesion, onychomatricoma, and onychopapilloma.
Fixed drug eruption (FDE) is a common pattern of
cutaneous drug reaction reported with a variety
of drugs. Drug reaction occurs within 30 minutes
to 8 hours of drug administration. The sites most
commonly involved are mucosa and the limbs. Benton
and McGibbon[13] have reported a case of FDE with
amoxicillin-clavulanic acid in a 75-year-old man who
presented with painful periungual and subungual
erythema. On examination, circumscribed macules of
erythema involving the paronychial fold and the nail
bed were seen.
Pyogenic granuloma commonly involves the nail
folds presenting as a bleeding exophytic growth.
Rarely, it can present in the nail bed and then it
has to be differentiated from amelanotic subungual
melanoma.[14] There is a single report of subungual
pyoderma gangrenosum.[15]
NEW DIAGNOSTIC IN NAIL
Diagnosis of nail disorders is based mainly on clinical
examination, but some nail disorders need a further
workup to establish the diagnosis and/or plan the
treatment. Nail scraping is most commonly performed
laboratory test in the clinical setting. Nail biopsies are occasionally done for the diagnosis of nail bed
and matrix disorders but they are time consuming,
unpleasant to the patient, and result in scarring and
disfigurement of the nail. Nail apparatus has been
deprived of investigative medical imaging until
recently when there has been a growing interest in
noninvasive techniques which could supplement
the clinical examination of the nails. This includes
USG, magnetic resonance imaging (MRI), optical
coherence tomography (OCT), confocal laser scanning
microscopy (CLSM), and improvised dermoscopy
instruments.
Since onychomycosis (OM) is the most common
nail disorder accounting for around 50% of total nail
disease patients,[16] we have dealt with new advances
in its diagnosis separately.
ADVANCES IN MEDICAL IMAGING OF NAIL
Ultrasound
Nail unit is well suited for USG study as it consists
of well-defined tissues of different densities.[17] USG of
nail requires a high-resolution ultrasound machines
and high-frequency ultrasound probe. This modality
is available since long time, but is finding place in
the diagnosis of nail disorders only recently probably
because of greater availability of machines with high
resolution. USG is a good tool to diagnose cystic tumors
of nail unit including myxoid cyst, synovial cyst, and
collections like subungual hematoma or abscess. USG
is not a good tool for the diagnosis of solid tumors
like melanoma and squamous-cell carcinoma as they
appear as nonspecific hypoechoic areas.[17]
Wortsman et al.[18] presented the ultrasonographic
findings in retronychia nails in which the distance
between the nail plate origin and distal interphalangeal
(DIP) joint is reduced, proximal nail fold is thickened
and hypoechoic, and sometimes multiple nail plates
embedded into the proximal nail fold can be visualized.
Blood flow in the nail unit can be studied with color
Doppler and power angio. These techniques are useful
in the diagnosis of vascular tumors like glomus tumor.
Imaging of vascular lesions can be further enhanced
by means of using contrast media.
Newer technique called real-time compound spatial
imaging is evolving.[19] It provides instantaneous
integration of several overlapping ultrasound scans taken at different angles to produce a compound image
with better information content.
Magnetic resonance imaging
High-resolution MRI provides an accurate analysis of
the nail apparatus with detection of even 1 mm lesions.
Use of MRI for nail disorders started in 1990s with the
availability of small surface coils, mainly devoted to
the diagnosis of glomus tumor.[20,21] Nail unit tumors
have atypical presentations as the lesion in nail matrix
present with secondary nail plate changes and nail
bed tumors are obscured by the nail plate. MRI has
been used mainly for the diagnosis of nail unit tumors,
glomus tumor being the commonest indication.
Indications for MRI in relation to nail pathologies are
still evolving.[22] Other indications include myxoid
cyst, implantation epidermoid cyst, ganglion cyst
onychomatricoma, exostosis, and osteochondromas.
Optical coherence tomography
OCT works in analogy to USG; the infrared light
reflected from the skin is measured and the intensity
is imaged as a function of position. The OCT probe
is applied directly to the nail, scanning lasts for few
seconds, and does not cause discomfort to the subject
studied. This technique provides images of tissue
pathology in situ with a high axial resolution.[23]
Mogensen et al.[24] found OCT technique to have
low coefficients of variation compared with 20 Hz
USG in measurements of nail plate thickness. Ayden
et al.[25] recently reported OCT to provide higher
resolution changes compared with nail USG in nail
psoriasis. Abuzahra et al.[26] detected fungal elements
noninvasively in vivo using OCT in 10 patients with
histologically proven OM. Fungal elements were
detectable as highly scattering elongated structures
inside the nail plate, in the middle of the areas of
homogeneous decrease in signal intensity.
Confocal laser scanning microscopy
CLSM is a new noninvasive diagnostic tool which
is becoming increasingly popular. It can visualize
cell structures of the skin up to a depth of 300 μm in vivo. It is based on the principal of increasing optical
resolution and contrast of a micrograph by using
point illumination and a spatial pinhole to eliminate
out-of-focus light in specimens that are thicker than
the focal plane. It also enables the reconstruction
of three-dimensional structures from the obtained
images. Researchers have found it to be faster and more accurate than the conventional microscope used
in potassium hydroxide (KOH) preparations in the
diagnosis of OM.[27,28]
Dermatoscopy
Dermatoscopy is also known as dermoscopy and
epiluminescence microscopy. It is the examination
of skin using dermatoscope and is mainly used for
distinguishing pigmented benign and malignant
lesions. In nail unit, it is mainly used for patients
presenting with melanonychia. Park et al.[29] have
introduced a handy portable hand-held digital
dermoscope (USB Microscope M2, Scalar Corporation,
Tokyo, Japan) which can be used to study the nail
fold capillary changes while sitting in a high-volume
outpatient setting. It has the advantages of obtaining
microscopic images on a computer monitor in real
time; this makes the system more practical than other
conventional dermoscopy systems using a camera
that requires the development process. In addition,
it has a polarizing light mode that minimizes the
light reflection from the stratum corneum caused by
the difference in the reflective index between the air
and the stratum corneum. Thus, it does not require
mineral oil or other immersion agents to reduce the
light reflection.
ADVANCES IN DIAGNOSIS OF ONYCHOMYCOSIS
OM is a common problem, accounting for up to half of
all diseases of the nail, with an estimated prevalence
of 10% of the general population and approaching
60% in the elderly.[30,31] Hay and Baran[32] have revised
its classification because of the recognition of new
pathways of nail infection, new pathogens and
variations in the appearance of diseased infected nail.
KOH preparation and culture together have been
considered as the gold standard test for OM diagnosis.[33]
Nail sampling is done by means of curettage. In a
study by Semer et al.,[34] they compared sampling
by means of nail drilling vis-a-vis curettage. They
found that culture sensitivity was significantly
higher when sampling was done by means of drilling
technique as compared with conventional curettage
technique. Direct microscopic examination using
KOH preparation has low sensitivity. Fungal culture
technique has high false-negative rate, requires long
incubation period, risk of obscuration by bacterial
overgrowth, and contamination with foreign material.
Periodic acid-Schiff (PAS) staining is a good diagnostic tool for the diagnosis of OM but probably less utilized
by the dermatologist. Recently, it has been considered
as the gold standard for the diagnosis of OM by
some authors and is beginning to supplant KOH and
culture in the diagnosis of OM.[35,36] Wilsmann et al.[37]
found histopathological staining to have highest
sensitivity (82%), followed by culture (53%) and KOH
preparation (48%). The results with PAS staining
are faster compared with culture. It should be the
preferred diagnostic tool, especially in cases where the
diagnosis of OM is not certain and in those already on
antifungal treatment.
Diagnosis of OM caused by non-dermatophyte molds
is challenging, requiring more stringent criteria
than that of dermatophytes. Based on the available
data in literature, Gupta et al.[38] concluded that at
the moment, traditional mycology remains the gold
standard for diagnosing non-dermatophyte mold OM.
This includes obtaining positive results from KOH and
culture. Repeated isolations (2 or 3) in the absence of
a dermatophyte increase the probability of accurate
identification of the causative non-dermatophyte
mold. Still, there is controversy over the number of
inocula required to confirm the causative diagnosis.
Histopathology can be of assistance in establishing
the penetration of the non-dermatophyte mold into
the nail plate; however, this method does not provide
identification of the organism.
Development of newer techniques like polymerase
chain reaction (PCR),[39] OCT,[26] flow cytometry,[40,41]
and immunohistochemistry[42] for the diagnosis of OM
is underway. The routine use is impractical at present
because of some limitations. Litz and Cavagnolo[39]
have devised a quick inexpensive PCR test to detect
dermatophyte DNA in nail specimens. They compared
their PCR with KOH, fungal culture, and PAS staining.
A total of 559 nail specimens were tested and PAS,
PCR, KOH, and culture were positive in 54%, 37%,
40%, and 22% of specimens, respectively. PCR was
negative in all non-dermatophyte and yeast isolates.
PCR is specific, requires no morphologic expertise,
has relatively good sensitivity, and gives faster results.
This molecular approach is developing and with wider
availability, it may prove to be a useful tool in future.
OTHER ADVANCES IN NAIL DISORDER DIAGNOSIS
Nail biopsy is sometimes done to diagnose those
conditions which are not clear on clinical examination or history alone. As nail is a highly vascular structure,
bleeding from biopsy site is difficult to manage. Hwa
et al.[43] reported easy control of post-biopsy bleeding
using gelatin sponge saturated with aluminium
chloride.
While doing nail procedures, digital block using plain
lidocaine is the most common mode of administering
anesthesia. Many authors have reported safe use of
lidocaine-epinephrine mixture for digital block in good
number of patients.[44-46] They did not observe digital
necrosis in any of their patients, rather there were
added advantages of combining with epinephrine.
Epinephrine facilitates faster onset of anesthesia,
prolonged post-procedure pain relief, and lesser
amount of local anesthetic required without much
need of tourniquet placement to control bleeding.
So, lidocaine with epinephrine can be used for giving
digital block, but caution should be exercised in
patients with peripheral vascular diseases.
NEW THERAPEUTICS IN NAIL
In this section, new advances are discussed in the
management of OM, inflammatory disorders of nail,
surgical treatment of nail disorders, and various other
new approaches in the treatment of nail disorders.
New in onychomycosis treatment
OM is a common disorder caused by dermatophytes,
non-dermatophyte molds, and yeasts. It is managed
with topical and systemic antifungal therapy. At
present, oral terbinafine is considered the treatment of
choice for OM caused by dermatophytes.[47,48] Ciclopirox
and amorolfine are the two topical compounds used
for mild to moderate OM or as an adjunct to systemic
therapy. With standard therapies, response rate is
less than 50%.[49] There is a continuing search for a
convenient, cost-effective agent with high and longlasting
cure rates. Currently, many new therapies
for OM are under investigation which includes new
azoles, improvement of existing topical treatments
through addition of ungual penetration enhancers and
new topical drugs with better nail permeation. Several
means to enhance ungual penetration are under
investigation.[50] This includes the following:
I. Physical enhancers - transungual laser therapy,
electrokinetic transungual system iontophoretic
application of terbinafine gel;
II. Chemical enhancers - NM100060, econazole 5%/
SEPA18% nail lacquer, nanoemulsion (NB-002),
IDP-108, Ciclopoli™ 8% nail polish, AN-2690.
New triazole drugs (second generation triazoles) under
trial for the treatment of OM include pramiconazole,
posaconazole, ravuconazole, and albaconazole.[50]
Voriconazole has high antifungal activity against
dermatophytes as well as non-dermatophytes but its
use is mainly directed to invasive fungal infections
in immunocompromised individuals. Echinocandins
and sordarins are two new groups of antifungals
which are effective against azole-resistant fungi, but
they are also under development for mainly invasive
fungal infections.
Besides the topical and systemic medical therapy,
investigators are devising new means of treatment of
OM
- Photodynamic therapy (PDT) - Cases resistant
to standard antifungal therapy and those who
cannot take oral antifungals have been treated
with photodynamic therapy.[51-53] Watanabe et al.[51]
treated two with 20% solution of aminolevulinic
acid (ALA) as photo sensitizer and irradiated
with pulsed laser light at a wavelength of 630 nm
at 100 J/cm2 using an excimer-dye laser. Both
the patient had complete clearance after 6 and 7
weekly sittings. Similar results have been reported
by other authors.[52,53]
- Dual wavelength device – uses optical energy for
the treatment of OM.[54]
- Ultraviolet C (UVC) irradiation an in vitro study
indicate that germicidal UVC irradiation may be a
less invasive treatment option for onychomycosis,
when the appropriate consideration is given to
safety.[55]
These devices provide a non-drug approach and are
undergoing testing for the treatment of OM.
With the currently available treatment options,
recurrences are common occurring in 10 to 53% of
cases.[56,57] Sigurgeirsson et al.[58] studied the utility of
topical amorolfine nail lacquer (ANL) for prevention
of recurrence. The patients who were cured of
confirmed OM were divided into two groups. One
group applied ANL 2 weekly and the other group
did not receive any treatment. Recurrence occurred
more quickly in the untreated group and at end point,
70.8% remained cured in treated group, while 50% in
the untreated group. Author concluded that ANL can
serve as a good prophylactic tool to prevent recurrence
of OM. However, in another long-term follow-up
study, recurrence rate was not found to be related to
presence of predisposing factors, use of nail lacquer as
a prophylactic treatment, and the dermatophyte strain
isolated.[59]
Non-dermatophyte OM is less common, incidence
ranging from 1.45% to 17.6%.[60] Epidemiologically,
the top five organisms in terms of published
confirmed isolations worldwide are (in descending
order) Scopulariopsis brevicaulis, Fusarium species,
Aspergillus species, Scytalidium dimidiatum, and
Acremonium species.[38] Non-dermatophyte show a
poor response to topical as well as systemic antifungal
therapy. Gupta et al[38] reviewed various studies on
treatment of non-dermatophytes. Oral terbinafine and
itraconazole have greatest amount of efficacy data.
Both have shown efficacy in treating S. brevicaulis
and Aspergillus species infections. A smaller amount
of data supports the use of oral fluconazole and
ketoconazole for treating S. brevicaulis. Griseofulvin
should not be used for treating non-dermatophyte
(NDM) OM. Topical ciclopirox may be effective
in treating S. brevicaulis and Acremonium species
infections. Systemic and/or topical therapy combined
with periodic chemical or surgical nail debridement/
avulsion may be the best option in the management of
non-dermatophyte mold OM.
New in inflammatory disorders of nail
Treatment of nail psoriasis has received little
attention compared with cutaneous psoriasis despite
the significant burden it places on patients as a
result of functional impairment of manual dexterity,
pain, and psychological stress. Also, the treatment
response of nail psoriasis is slow and incomplete.
Sanchez–Regana et al.[61] retrospectively reviewed
the data of 84 psoriasis patients who had received
classical systemic therapy (acitretin, methotrexate,
cyclosporin, photo (chemo) therapy) or biologics
(infliximab, efalizumab, etanercept, adalimumab)
for moderate to severe skin disease or psoriatic
arthritis and had concomitant significant nail
involvement. The author found that the NAPSI score
fell significantly with all classical treatments (except
NBUVB) as well as with the biological treatments.
Among all the classical treatments, cyclosporine
produced the highest improvement. In the biological
treatment group, infliximab and adalimumab lead to
significantly greater improvement at 12 and 24 weeks.
The author did not find relation between response to
treatment and type of nail involvement (matrix, bed,
mixed). Also, the percentage of improvement in the NAPSI score was significantly greater with biological
treatments compared with classical treatment.
Many new topical formulations and combinations
have been tried for the treatment of nail psoriasis.[62,63]
Pulsed dye Laser (PDL) has been used to treat psoriatic
plaques, and recently, PDL has been shown to improve
nail psoriasis as well.[64]
Chronic paronychia is a common problem among the
females which is multifactorial in origin. Initially, it
was attributed to fungal infection primarily, but now
the role of irritants and allergens in its development
and propagation has been realized. Rigopoulos et al.[65]
compared the response of chronic paronychia in 45
patients treated with tacrolimus or betamethasone-
17-valereate or emollients. Treatment was given
for three weeks and patients were followed up for
further 6 weeks. Both betamethasone and tacrolimus
groups achieved statistically significantly greater
improvement when compared with the emollient
group. This study stresses the importance of treatment
with anti-inflammatory agents in addition to antifungal
therapy in chronic paronychia patients.
New in surgical management of nail disorders
Ingrown toe nail, also known as onychocryptosis, is
a common nail disorder. It is managed with either
conservative approach or by surgical treatment,
depending upon the clinical presentation and severity.
Conservative approaches include antibiotics, silver
nitrate cautery, proper nail trimming techniques,
and flexible tube splinting (sleeve method). New
non-surgical techniques using VHO-osthold nail
brace,[66] resin splint,[67] super-elastic wire[68] have been
described. All these techniques are based on same
principle that is to keep the lateral nail plate pulled
by making use of some equipment, so that it does not
impinge into the lateral nail fold. Advantages of these
techniques are that they are easy and faster to perform,
good for elderly and diabetic individuals in whom
surgery may otherwise be contraindicated, and lastly
the nail anatomy remains unaltered. Disadvantages are
that basic pathology is not corrected and recurrences
can occur on removing the equipment, patient has to
take care of device, and his activities may be limited
because of it.
Ozdil et al. have described a new non-surgical
procedure called angle correction technique in
eight patients with ingrown toe nail.[69] The major principal of the technique is to correct the dome shape
(convexity) of the nail by reducing its thickness 50 to
75%.
Different techniques of surgery for ingrown toe nail
include Winograd method, whole nail plate avulsion,
Emmert procedure, ablation of the nail matrix using
phenol or sodium hydroxide or Lasers, and Zadik’s
procedure. Payvandi et al.[70] compared Winograd and
sleeve methods for the treatment of ingrown toe nails in
100 patients. They found that the participants treated
with sleeve method experienced shorter surgery
duration, less work day loss, and the recurrence rate
were similar in two groups.
Pincer nail kind of deformity has been treated by
nail plate avulsion followed by complete destruction
of nail matrix by either chemical cautery or surgical
matricectomy or laser. Ghaffarpour et al.[71] has
described a new nail-saving surgical technique for
correction of pincer nail deformity. The technique is
a combination of nail bed cutting and splinting. First
nail plate is removed, fibrous nail bed excised, and
then widened. Remaining nail bed is sutured to the
margins and then splint is applied, which ensure that
the new nail growth is not deformed.
Glomus tumor has to be surgically excised. Roan
et al.[72] have reported a new surgical approach for
removing glomus tumor with nil recurrences and good
cosmetic results. Author recommends cutting into the
nail plate and nail bed over the tumor together without
separating the nail plate from the nail bed. The tumor
pops out when the nail plate and nail bed are split and
then nail plate is sutured without the need of nail bed
repair. This is easy to perform, gives good cosmetic
results, and there were no recurrence in 17 reported
patients.
OTHER ADVANCES
Pachyonychia congenita (PC) is a rare autosomaldominant
keratin disorder caused by dominant negative
mutations in keratin genes KRT6A/B, KRT16, or KRT17.
It is characterized by painful plantar keratoderma and
hypertrophic nail dystrophy. It is notoriously difficult
to manage and systemic retinoids have been the main
stay of therapy. But because of the rarity of the disorder,
the optimum use of retinoids is not described. Gruber
et al.[73] surveyed 30 patients of PC who had received
oral retinoids (acitretin/isotretinoin 10-50 mg/day for 1-240 months). Nail changes ameliorated in 14% while
79% did not experience any nail change. In 50% cases,
there was thinning of plantar hyperkeratosis and 33%
had decreased plantar pain. Most of the patients (83%)
discontinued retinoids because of the adverse effects.
Risk benefit analysis favored low dose (≤25 mg/d) for
longer period (>5 months) compared with higher dose
(>25 mg/day) given for shorter period (≤5 months).
The data indicate that acitretin may have a slight edge
over isotretinoin in treating PC.
Sirolimus (rapamycin) is an mTOR inhibitor and
mainly used presently in organ transplant recipient
patients. Hickerson et al.[74] have treated keratinocyte
cell line with mTOR inhibitors and this lead to
decreased expression of K6a. Three PC patients given
oral rapamycin had subjective improvement and
change in callus character. Further research including
topical formulations is warranted in this regard.
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