Common nail disorders

Brittle nail, simple chronic paronychia, and onycholysis represent three of the most prevalent nail disorders. Brittle nails are characterized by increased fragility of the nail plate due to damage to the nail matrix or changes to nail plate cohesion, caused by internal and/or external factors. Simple chronic paronychia represents an inflammatory process of the lateral and/or proximal nail folds of the fingernails or toenails often preceded by damage to the cuticle. Onycholysis describes the detachment of the nail plate from its nail bed, often attributable to dermatologic conditions, infections, drug therapy, or trauma.     

Green Nail Syndrome Treated with the Application of Tobramycin Eye Drop

Green nail syndrome (chromonychia) is a nail disorder characterized by onycholysis and green-black discoloration of the nail bed. This condition is often associated with chronic paronychia. Pseudomonas aeruginosa is the most commonly identified organism in cultures from the affected area. Despite the various treatment options available, removal of the nail is still necessary in many cases. A 35-year-old man presented with dark-greenish discoloration of the nail plate and onycholysis on the left thumbnail. He had been treated with oral antifungal and antibiotic agents for several months; however, the lesion showed no improvement. The diagnosis of green nail syndrome was established after a positive bacterial culture, and on the basis of the antibiotic sensitivity test result, tobramycin eye drop (Tobrex®) was then prescribed. Three weeks later, the nail discoloration almost vanished but the onycholysis remained. Herein, we recommend the application of tobramycin eye drop as an easy and safe treatment option for green nail syndrome.     

Nail diseases related to nail cosmetics

The use of nail care products and procedures to beautify and groom the nails is extremely common. Unfortunately, when improperly used, nail cosmetics can lead to nail diseases, such as paronychia, onycholysis, and brittle nails. Understanding the pathophysiology behind these conditions is an essential step toward better treatment and future prevention allowing patients to enjoy nail adornments while maintaining healthy nails.     

Evaluation and treatment of nail disorders utilizing practical nail surgical techniques

Nail disorders frequently seen in daily practice may be inflammatory, infectious, tumoral, traumatic, or cicatricial. Surgical correction of the most common disorders is reviewed here. Treatment of the different types of ingrown nails as representative of the inflammatory diseases, the peculiarities in the treatment of an acute or a chronic hematoma, management of infectious diseases like chronic and acute paronychia, and different surgical techniques to treat a nail tumor depending where the problem is located, trying to prevent permanent postsurgical dystrophies are discussed.     

[Translated article] Nail Psoriasis

Nail involvement in psoriasis is common. It is seen in up to 80% of patients with psoriatic lesions and may be the only manifestation in 6% of cases. Nail psoriasis is correlated with more severe disease, characterized by earlier onset and a higher risk of psoriatic arthritis. Accordingly, it can also result in significant functional impairment and reduced quality of life. Psoriasis involving the nail matrix causes pitting, leukonychia, red lunula and nail dystrophy, while nail bed involvement causes splinter hemorrhages, onycholysis, oil spots (salmon patches), and subungual hyperkeratosis. Common evaluation tools are the Nail Psoriasis Severity Index (NAPSI), the modified NAPSI, and the f-PGA (Physician's Global Assessment of Fingernail Psoriasis). Treatment options include topical therapy, intralesional injections, and systemic and biologic agents. Treatment should therefore be assessed on an individualized basis according to the number of nails involved, the part of the nail or nails affected, and the presence of concomitant nail and/or joint involvement.     

Psoriasis ungueal

Nail involvement in psoriasis is common. It is seen in up to 80% of patients with psoriatic lesions and may be the only manifestation in 6% of cases. Nail psoriasis is correlated with more severe disease, characterized by earlier onset and a higher risk of psoriatic arthritis. Accordingly, it can also result in significant functional impairment and reduced quality of life. Psoriasis involving the nail matrix causes pitting, leukonychia, red lunula and nail dystrophy, while nail bed involvement causes splinter hemorrhages, onycholysis, oil spots (salmon patches), and subungual hyperkeratosis. Common evaluation tools are the Nail Psoriasis Severity Index (NAPSI), the modified NAPSI, and the f-PGA (Physician's Global Assessment of Fingernail Psoriasis). Treatment options include topical therapy, intralesional injections, and systemic and biologic agents. Treatment should therefore be assessed on an individualized basis according to the number of nails involved, the part of the nail or nails affected, and the presence of concomitant nail and/or joint involvement.     

Docetaxel-induced nail dystrophy

A 73-year-old man with metastatic prostate cancer treated with weekly docetaxel chemotherapy for 5 months developed an acute nail dystrophy restricted to the fingernails. This was characterized by onycholysis, subungual haemorrhage and acute paronychia, progressing to a subungual abscess of the right index finger. Nail bed hyperaemia and haemosiderin-like nail bed discoloration were present. Nail plate avulsion was performed to decompress the acutely painful subungual abscess. The right thumb, middle finger and left index finger demonstrated early, proximal white subungual collections of pus obscuring the lunula (onychophosis). Central nail plate fenestrations with a surgical drill led to exudation of purulent material. Cultures of the subungual abscess material yielded mixed organisms, possibly related to administration of flucloxacillin for 1 week prior to presentation. The patient completed a further two courses of docetaxel without sequelae, and the nail dystrophy appears to be resolving. Docetaxel-induced nail changes are a common adverse effect, occurring in 30-40% of patients. Mild changes do not usually warrant the discontinuation of treatment.     

Prevalence, severity and clinical features of psoriasis in fingernails and toenails in adult patients: Italian experience

Background Psoriasis is a chronic inflammatory skin disease affecting 2.0–6.5% of the European population. Although the most striking clinical features of psoriasis involve the skin, other organs including nails and joints may be affected in a substantial proportion of patients. Literature reports nail involvement in 10–56% of psoriatic patients, with common physical and social impairment. However, the precise prevalence of specific clinical features of nail psoriasis is somewhat under‐reported. Objectives Our cross‐sectional study aimed at describing the prevalence and the clinical features of nail involvement in adult psoriatic patients in a psoriasis referral centre in northern Italy. Methods A total of 178 (124 men, 54 women) consecutive adult patients (≥18 years old) with psoriasis were included. Psoriasis Area and Severity Index (PASI) and Nail Psoriasis Severity Index (NAPSI) scores were calculated for each patient. Relevant medical history was recorded. Results Nail involvement was present in 137 (99 men, 38 women) patients (76.9%). The most common nail abnormality was onycholysis, followed by crumbling, subungual hyperkeratosis, pitting and discoloration. Pitting and onycholysis were the most prevalent patterns observed in fingernails, whereas onycholysis and crumbling were the most frequent changes detected in toenails. The most frequently and severely affected nails were the fourth fingernail and the first toenail. The average PASI score was higher in individuals with nail involvement (12.0 vs. 8.7, P = 0.06). Nail changes were present in 85.7% of patients with psoriatic arthritis. Conclusions Our study confirms that nail involvement may be overlooked in psoriasis patients. Different psoriatic patterns in the nail affect specific digits more frequently.     

Nail involvement in leprosy

Leprosy, a disease caused by Mycobacterium leprae, primarily affects the skin and nerves, but the nails are also involved in as many as 3 out of 4 patients .The factors that trigger nail changes in leprosy are numerous and include repeated trauma, neuropathy, vascular impairment, infections, lepra reactions, and the drugs used to manage the disease. The changes most often reported include subungual hematomas, onycholysis, onychauxis, onychogryphosis, pterygium unguis, and onychoheterotopia, most of which can be attributed to nerve damage and trauma. Furthermore, the acro-osteolysis that occurs in the advanced stages of the disease may present with brachyonychia, racquet nails, or even anonychia. Infections of the nail bed leading to paronychia and onychomycosis should also be taken into account in leprosy. Other typical changes include longitudinal striae, pitting, macrolunula, Terry nails, leukonychia, hapalonychia, and Beau lines. In this review, we describe the principal nail changes associated with leprosy. These changes, which are highly varied and diverse in origin, are in fact a reflection of the significant morbidity caused by M. leprae infection.     

Paronychia – a manifestation of pemphigus vulgaris

Involvement of the nail unit in pemphigus vulgaris is thought to be uncommon. However, trachyonychia, nail atrophy, onychomadesis, omcholysis, nail lied erosion, onychosehizia, subungual haemorrhage, nail pitting, nail plate discoloration, cross-ridging of nail plate, Beau's line and paronychia have been reported.’^1–9 These manifestations may he due either to secondary extension of the India adjacent to the nail or primary involvement of the nail bed, nail matrix and nail fold.⁴ We report four patients with pemphigus vulgaris who developed paronychia with a corresponding exacerbation of their cutaneous lesions. Nail fold biopsy and direct immunofluorescence revealed features of pemphigus vulgaris. Treatment with immunosuppressive agents showed simultaneous improvement of both cutaneous and nail lesions.     

Nail changes in childhood psoriasis: a study from Kuwait

Psoriasis is a widespread skin disorder in which nail involvement can be seen in up to two-thirds of those affected. Childhood psoriasis is a distinct entity and the literature focused on nail changes associated with childhood psoriasis is scant. Our objectives were to evaluate the frequency of nail involvement in childhood psoriatic patients, assess the types of nail changes in childhood psoriasis, and compare our clinical findings with the few reports available in the literature. Two hundred and one consecutive new patients with childhood (age < or = 16 years) psoriasis of both sexes were selected for the study of nail changes. The diagnosis of psoriasis was made on clinical grounds. Each patient underwent a thorough dermatologic examination with special attention paid to the nail changes. If a clinical suspicion of fungal infection of the nails existed, further mycologic investigations were performed. We found the prevalence of nail changes to be 37.81% (boys > girls) in children who had psoriasis. Nail pitting was found to be the most common manifestation (61.84%) followed by onycholysis (30.26%), subungual hyperkeratosis (13.16%), and discoloration of the nail plate (7.90%). Nail involvement had no relationship to the type of psoriasis, patient's sex, or duration or extent of disease.     

Nail features in Langerhans cell histiocytosis

We report the case of an infant who presented with isolated cutaneous manifestations of Langerhans cell histiocytosis before the evolution of systemic features. In the transition period, at 9 months of age, nail unit changes became prominent, and persisted throughout the duration of systemic treatment. A change in clinical features coincided with a course of systemic gamma-interferon, which was given because immune paresis was suspected. Nail unit changes are rare in Langerhans cell histiocytosis. and this case illustrates the range of findings, including paronychia, nail fold destruction, onycholysis with subungual expansion, and nail plate loss. The significance of these changes as a prognostic indicator is controversial.     

Nail involvement in pemphigus vulgaris

BACKGROUND: Involvement of the nail unit in pemphigus vulgaris (PV) is thought to be rare. OBJECTIVES: To determine the frequency of nail changes among patients with PV. METHODS: Nail changes were recorded in patients with PV and were analysed retrospectively. Biopsies were taken from the nail bed and nail matrix for histological and immunofluorescence observations. Microscopic (potassium hydroxide) examination and fungal culture were performed. RESULTS: Nail changes were present in 30 of 64 (47%) patients with PV. Sixteen patients had onychomycosis and 14 had nail changes due to PV. These included onychomadesis, discoloration, deformity, onychorrhexis, onycholysis, subungual haemorrhage, subungual hyperkeratosis and paronychia. Onychomycosis affected fingernails and toenails, but changes due to PV occurred only in fingernails, most commonly on the thumb and index finger. No connection was found between the patient's occupation and nail involvement, and there was no correlation with the severity or duration of PV. In a control group of 64 patients of similar sex and age, only two had non-specific fingernail changes. CONCLUSIONS: Nail changes in PV may be more frequent than previously thought.     

Nail involvement in histiocytosis X. A 12-year retrospective study

A retrospective study of nail involvement was made in 15 cases of histiocytosis X (HX). These included seven cases of Letterer-Siwe (LS) disease, four cases of Hand-Schüller-Christian disease, and four cases of eosinophilic granuloma seen at Ramathibodi Hospital, Bangkok, Thailand, during the years 1970 to 1981. Nail involvement was found in three patients with LS disease, two of whom showed fingernail and toenail dystrophy with onycholysis and subungual hyperkeratosis. Paronychial erythema and swelling with small pustules underneath some nails were seen in both of the latter patients. The remaining patient showed subungual purpura of all fingernails and toenails with slight thickening of some fingernails. The nail changes in one patient responded well to cytotoxic therapy but recurred when the disease progressed. Nail involvement seems to be one of the unfavorable prognostic signs in HX.     

Current and future nail research - areas ripe for study.

This discussion examines five common topics that affect nails adversely, onychomycosis, brittle nails, developmental nail disorders, chronic paronychia and onycholysis. What is known about these processes, what areas of research, old and new, might lead to improved understanding of the underlying basis of the problems and what prospects the future might hold are considered.     

Nail changes during childhood

Nail changes occur frequently in adults, but are relatively rare in children. There are, however, certain nail changes that emerge particularly during childhood. Ingrown nails, onychoschizia, congenital slanted alignment of the large toenail, and psoriasiform nail dystrophies can be frequently observed in toddlers and in schoolchildren the syndrome of an ingrown nail, nail artifacts, periungual warts or fibromas, trachyonychia, and nail mycoses. Connatal nail changes can appear as isolated events or together with other symptoms whereas acquired nail changes are caused by infections, traumatic injuries, or tumors, in conjunction with skin diseases or general illnesses, or even develop spontaneously.     

拔甲联合甲旁真皮-脂肪瓣填塞术治疗7例双侧重度卷曲型嵌甲

【摘要】 目的 探讨拔甲联合甲旁真皮-脂肪瓣填塞术治疗双侧重度卷曲型嵌甲的临床效果。方法 回顾性分析2018年1月至2020年1月就诊的7例双侧重度卷曲型嵌甲患者的临床资料,男3例,女4例,年龄25 ~ 49岁,平均35岁。采用拔甲联合甲旁真皮-脂肪瓣填塞术进行门诊手术治疗。结果 7例患者术后切口均为一期愈合,无感染。术后1~ 2周疼痛全部缓解。随访12 ~ 24个月,新生甲板均长出,无卷曲畸形,甲沟无红肿,无甲沟炎复发,患者均对疗效满意。结论 拔甲联合甲旁真皮-脂肪瓣填塞术治疗双侧重度卷曲型嵌甲临床效果良好。     

Treatment of common nail disorders

Treatment of nail diseases is not always easy; topical treatment is often ineffective because the nail plate is not penetrated by topical drugs, and the nail matrix is located under the proximal nail fold. The most frequent nail disorders are nail psoriasis and onychomycosis. In these cases, systemic treatment is often necessary to cure the nail changes. Systemic treatment with steroids is mandatory for patients with nail lichen planus because the disease may cause definitive destruction of the nail matrix. Environmental nail abnormalities are frequent and include nail brittleness, onycholysis, and chronic paronychia. Preventive measures should always be associated with treatment in these cases.     

PATHOLOGY OF THE FINGER NAIL IN PSORIASIS

Summary.— Psoriasis of the finger nail produces metaplastic change of the nail matrix and nail bed to skin-like epithelium, following which the histological changes are essentially similar to those seen in the skin. The resulting lesions of the finger nail are of 2 types: (1) Nail plate abnormalities, the nature of which depends upon the site and the duration of disease in the matrix; (2) Nail bed abnormalities, consisting of onycholysis, subungual keratosis and splinter haemorrhages.