Nail changes in chronic renal failure patients under haemodialysis

Background Chronic renal failure is known to cause various nail pathologies. They may be directly related to the renal condition itself or its complications or to the therapy. Objective To compare nail changes in end‐stage renal failure patients under haemodialysis with healthy persons and to study the potential relationship with various parameters in the patients. Patients and Methods The study comprised 100 patients with chronic renal failure under regular haemodialysis as well as 100 healthy control subjects of matched age and sex. Both groups were subjected to full history taking and thorough general and nail examination. Complete blood picture, liver and kidney function tests and fasting blood glucose level were investigated. Results Nail disorders were more prevalent in patients (76%) than in control group (30%). The half and half nail was the most common finding (20%) followed by – in descending manner – absent lunula, onycholysis, brittle nail, Beau's lines, clubbing, longitudinal ridging, onychomycosis, subungual hyperkeratosis, koilonychias, total leukonychia, splinter hemorrhage, pitting and pincer nail deformity. There was non‐significant correlation between nail changes and age of the patients or duration of haemodialysis. In addition, no evidence of significant relation was found between nail changes and both haemoglobin and albumin levels. Conclusion Frequent nail changes are observed on systematic nail examination of uraemic patients undergoing haemodialysis; however, the cause of them remains obscure and could not be traced to a particular abnormality in the renal condition, medication or the procedure itself and it needs further investigations.     

Nail disorders in patients with chronic renal failure and undergoing haemodialysis treatment: a case–control study

BACKGROUND: Few controlled studies have compared nail disorders in patients with chronic renal failure (CRF) and haemodialysis (HD)-dependent individuals with a healthy population. OBJECTIVE: The aim of this study was to compare the prevalence of nail disorders in patients with CRF and patients undergoing HD treatment with a healthy population, and evaluate the relationship between nail changes and various demographic, medical and laboratory parameters in these groups. METHODS: In this case-control study we recruited 73 patients affected with CRF, 77 patients undergoing regular HD and 77 healthy individuals. All patients were examined for the presence of nail disorders. Various parameters [age, gender, type of kidney disease, regular medications, duration of renal failure and HD, dialysis efficacy (Kt/v), haemoglobin, neutrophil count, calcium, phosphorus, albumin, creatinine, urea, alkaline phosphatase and parathyroid hormone (PTH) levels] of the patients were determined by multivariate analysis and compared. RESULTS: Forty-four patients (60.3%) with CRF and 48 patients (62.3%) undergoing HD treatment had at least one type of nail pathology. The most common nail alterations found in patients with CRF and those undergoing HD were absence of lunula (AL) and half-and-half nails (HHN), respectively. Prevalence of nail disorders among patients with CRF was influenced significantly by PTH level (P = 0.03). In the HD group, male sex, age above 65 years and comorbidities (diabetes mellitus, hypertension and heart failure) were significantly associated with nail pathologies. CONCLUSION: Patients with CRF and those undergoing HD therapy have higher rates of nail disorders when compared to a healthy population. Efficient HD does not improve nail changes.     

Cutaneous manifestations in patients with chronic renal failure on hemodialysis

BACKGROUND: Chronic renal failure (CRF) presents with an array of cutaneous manifestations. Newer changes are being described since the advent of hemodialysis, which prolongs the life expectancy, giving time for these changes to manifest. AIM: The aim of this study was to evaluate the prevalence of dermatologic problems among patients with chronic renal failure (CRF) undergoing hemodialysis. METHODS: One hundred patients with CRF on hemodialysis were examined for cutaneous changes. RESULTS: Eighty-two per cent patients complained of some skin problem. However, on examination, all patients had at least one skin lesion attributable to CRF. The most prevalent finding was xerosis (79%), followed by pallor (60%), pruritus (53%) and cutaneous pigmentation (43%). Other cutaneous manifestations included Kyrle's disease (21%); fungal (30%), bacterial (13%) and viral (12%) infections; uremic frost (3%); purpura (9%); gynecomastia (1%); and dermatitis (2%). The nail changes included half and half nail (21%), koilonychia (18%), onychomycosis (19%), subungual hyperkeratosis (12%), onycholysis (10%), splinter hemorrhages (5%), Mees' lines (7%), Muehrcke's lines (5%) and Beau's lines (2%). Hair changes included sparse body hair (30%), sparse scalp hair (11%) and brittle and lusterless hair (16%). Oral changes included macroglossia with teeth markings (35%), xerostomia (31%), ulcerative stomatitis (29%), angular cheilitis (12%) and uremic breath (8%). Some rare manifestations of CRF like uremic frost, gynecomastia and pseudo-Kaposi's sarcoma were also observed. CONCLUSIONS: CRF is associated with a complex array of cutaneous manifestations caused either by the disease or by treatment. The commonest are xerosis and pruritus and the early recognition of cutaneous signs can relieve suffering and decrease morbidity.     

Nail changes in patients with liver disease

Background Liver cirrhosis, hepatitis C virus (HCV) and hepatitis B (HBV) virus infections are known to be associated with different skin disorders. Nail changes are additional important criteria, which would help in identification of these systemic diseases. Objective To record the nail abnormalities in patients with liver disease which were not reported before, especially those with HCV and HBV infection. Patients and methods The study comprised 100 patients with HCV, HBV and liver cell failure, and 100 normal healthy controls. Both groups underwent full history taking and thorough general examination, complete blood picture, hepatitis B antigen, hepatitis C antibody, liver function tests, abdominal ultrasonography and PCR were performed in patients with liver disease. Full nail examination was performed. Results Nail changes were more prevalent in patient group (68%) than in the control group (35%). The nail infection, onychomycosis, was the most common finding in 18% of patients and that in controls was 10% followed by in a descending order, longitudinal striations, brittle nails, onychorrhexis, clubbing of fingers, dystrophic nails, leukonychia and longitudinal melanonychia. Conclusion Nail changes are observed with not only liver cirrhosis but also with HCV and HBV infection, and this will add additional clinical criteria for general practitioners and dermatologists to help them with diagnosis of these common systemic infections.     

Dermatologic complications in renal transplant recipients versus uraemic patients under maintenance haemodialysis treatment

One hundred and twelve renal transplant recipients and 40 patients with chronic renal failure undergoing maintenance haemodialysis were included in this study. Skin infections were the most common complication in renal transplant recipients (67.8%), with fungal infections being the most frequent (58%). Kaposi's sarcoma was found in three of our transplant patients (2.6%); no other skin tumors were observed in our cases. The second most frequent skin complication after infections was acne lesions (43.7%). On the other hand, pallor and dryness were the most common skin signs observed in uraemic patients; fungal infections were found in 15%. No skin neoplasms were found in the uraemic patients. In conclusion, skin infections and Kaposi's sarcoma are more common in renal transplant recipients than in uraemic patients under haemodialysis maintenance treatment.     

Nail changes in pemphigus vulgaris

Background The frequency and types of nail changes in pemphigus vulgaris (PV) are unclear. Aim To determine the frequency and types of nail changes, and their correlation with the number of skin and periungual bullae. Methods Seventy‐nine patients with PV, including 59 new patients and 20 patients in relapse, were entered into the study. Microscopic examination in potassium hydroxide and culture for fungus were performed on all clinically abnormal nails. Results Twenty‐five (31.6%) of 79 patients showed nail changes, with paronychia (n = 8) and onychomadesis (n = 6) being the most common. One patient in relapse had onychomycosis. The frequency of nail changes in fingers affected by periungual bullae was significantly higher than in other fingers (P < 0.05). The number of nail changes was higher in patients with a larger number of skin bullae and in those with a longer duration of disease (P < 0.05). Conclusions Nail changes in PV are common and related to the number of skin bullae and the presence of periungual bullae.     

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.     

Sirolimus-induced onychopathy in renal transplant recipients

INTRODUCTION: A large number of drugs may be responsible for the development of nail changes. Sirolimus is an immunosuppressive drug recently developed in organ transplantation. Herein, we evaluate sirolimus-induced nail abnormalities in renal transplant recipients. PATIENTS AND METHODS: The nails of 80 consecutive renal transplant recipients receiving sirolimus have been evaluated in a systematic dermatological study in 2003. The patients were mainly men (60%) with a mean age of 48 years. The mean duration of the graft was 6 years and of sirolimus treatment 18 months. Mycophenolate mofetil and steroids were combined with sirolimus in 86% of patients. RESULTS: Fifty-seven patients (74%) complained for nail alterations. The most frequent anomalies (88%) were matrix alterations including slow growth, onychomalacia, onychorrexis, and leukonychia. Nail bed alterations (onycholysis), vascular phenomenon (erythema, splinter hemorrhages), and periungual anomalies (mainly pyogenic granulomas) were observed in 42, 42 and 19% of cases respectively. One observation of type 1 photo-onycholysis was described. DISCUSSION: This study reports a new drug-induced onychopathy. Responsibility of sirolimus is highly suggested. The main pathogenesis hypothesis to explain these nail alterations is inhibition of EGF (epidermal growth factor) pathway by sirolimus.     

Finger Nail Pitting in Psoriasis and its Relation with Different Variables

Incidence of pitting, vary considerably in different types of psoriasis. In clinical practice, toe nail examination is inconvenient. There are inadequate studies which show relation of nail pitting with duration and severity of the disease. The objective was to examine the incidence of finger nail pitting in all types of cutaneous psoriasis and its relation with different variables. This is a clinico-epidemiological study. A careful clinical examination of finger nails was done in day time. Severity of disease was calculated by psoriasis area severity index (PASI). Statistical analysis was done using Microcomputer statistics software (MSTAT). In study group, 621 patients and in control group 350 people were taken. Finger nail pitting was present in 37% (total number was < 20 in 17%; 20-60 in 8% and > 60 in 12%) in study group. In control group, it was present in 10% (in all cases total number was < 20). In < 1 year duration group, pitting was present in 32% of cases, while in > 1 year duration group it was 40.5%. In mild psoriasis, pitting was present in 34.2%, while in severe cases it was 47.6%. Finger nail pitting is an important nail finding in psoriasis and its incidence increases with duration and severity of disease.     

Onychomycosis: a significant medical problem

The importance of onychomycosis is often underestimated. Far more than being a simple cosmetic problem, infected nails serve as a chronic reservoir of infection which can give rise to repeated mycotic infections of the skin. 448 patients with nail abnormalities attending Skin O. P. D of King George Hospital, Visakhapatnam during a 1 (one) year period between November'98-October'99, were subjected to detailed clinical, epidemiological study. Diagnosis was confirmed in 204 cases by direct microscopy or culture or by both. Females (51.96%) were slightly more than the males (48.04%). Majority of the cases were between 21-40 years age group. Housewives (33.33%) were most frequently affected. Trauma was a predisposing factor in 11.27% of the cases. The duration of lesions varied from 3 months to 15 years. In the majority (38.23%) it was less than one year. Candidal onychomycosis was the most prevalent clinical type (58.82%) followed by distal subungual onychomycosis (38.72%). Disease was limited only to finger nails in 57.35% and toe nails in 32.35%. Predominant isolates obtained were candida spp. (56.7%), followed by dermatophytes (38.2%) and non-dermatophyte molds (3.37%). 26.96% of the patients had experienced physical, psychosocial and occupational problems.     

Nail abnormalities in rheumatoid arthritis

Many nail abnormalities have traditionally been described in association with rheumatoid arthritis (RA), but their specificity has never been assessed in a controlled study. Our purpose was to evaluate the frequency and the specificity of nail changes associated with RA in a case-controlled study including 50 patients suffering from RA and 50 controls. For each patient, a general skin examination was performed and the 20 nails were examined. The nail features were noted and classified. Ax² test or a Fisher test was used to compare the two groups. The only nail abnormalities significantly associated with RA were longitudinal ridging on nine or 10 finger nails (29 patients in the RA group vs. three in the controls. X²: p<0.001) and clubbing on at least one nail (24 patients vs. 10.X²:p<0.01). Other nail changes were noticed but were not frequent enough to be significant. The presence of longitudinal ridging on the finger nails was significantly associated with RA.     

Diagnosis of nail psoriasis: importance of biopsy and histopathology

BACKGROUND: Involvement of the nail is quite common in psoriasis and at times may be the sole diagnostic clue. However, the histopathology of nail psoriasis has not been adequately evaluated. A confirmation of the diagnosis is required in cases suspected to have nail psoriasis in order to plan long-term therapy. OBJECTIVES: To assess the diagnostic significance and safety profile of nail biopsy in cases with nail psoriasis. METHODS: Clinical and mycological features were studied in 42 patients with nail psoriasis. Of these, 22 patients gave consent for nail biopsies to be taken and the histopathological changes were assessed. RESULTS: Males were affected more commonly (57%) with a peak incidence in the age group of 10-20 years (29%). Distal onycholysis, discoloration of nail plate, subungual hyperkeratosis and fine nail pitting were the predominant clinical features. In the 22 biopsies done, hyperkeratosis with parakeratosis (91%) was found to be the most common and hypergranulosis was the least common histological finding (36%). Clinicohistological correlation was possible only in 55% cases. Periodic acid-Schiff (PAS) staining was done for all biopsies. CONCLUSIONS: Histopathological examination of nails is a valuable diagnostic aid, especially in the absence of skin lesions. Examination of the PAS-stained sections is necessary before making a histological diagnosis of nail psoriasis because onychomycosis and psoriasis may show similar histology.     

Cutaneous clues to renal disease

The skin is the most visible and easily accessible organ of the body. For an astute clinician, the skin may function as an important diagnostic window to diseases affecting internal organs. This is especially true for the renal system. Chronic renal failure, regardless of its cause, often produces xerosis, pruritus, sallow hyperpigmentation, and nail changes. Half-and-half nails occur frequently in patients with renal failure and are formed of a white proximal nail portion and a normal pink distal end. Uremic frost can occur on the skin in patients with severe renal failure of long duration. This white coating on the skin is caused by an increased concentration of urea in the sweat. However, long before failure is manifested clinically, specific dermatologic abnormalities can provide clues to the cause of renal disease. We review here the hereditary, metabolic, and vascular disorders that affect both the kidney and skin. The dermatologic manifestations are stressed as important guides to the diagnosis of renal disease.     

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 disorders in hemodialysis patients and renal transplant recipients: a case-control study

BACKGROUND: There is one published case-control study of nail disorders in hemodialysis patients. The nail changes that occur in renal transplant recipients have not been investigated specifically. OBJECTIVE: The aim of this study was to determine prevalence rates of nail disorders in hemodialysis patients and renal transplant recipients, and to investigate whether these nail pathologies are related to hemodialysis and renal transplantation. METHODS: One hundred and eighty-two hemodialysis patients and 205 renal transplant recipients were screened for the presence of nail disorders. The findings in these groups were compared with findings in 143 healthy individuals. RESULTS: One hundred and twenty-seven patients (69.8%) in the hemodialysis group and 116 patients (56.6%) in the renal transplant recipients had at least one type of nail pathology. Absence of lunula, splinter hemorrhage, and half-and-half nails were significantly more common in the hemodialysis patients than in the renal transplant recipients. Leukonychia was significantly more frequent in the renal transplant recipients than in the hemodialysis patients and controls. CONCLUSION: Hemodialysis patients and renal transplant recipients have higher rates of nail disease than the healthy population. Renal transplantation may reduce the frequencies of splinter hemorrhage and half-and-half nails. Interestingly, leukonychia increases significantly after renal transplantation.     

Cutaneous Manifestations of Childhood Systemic Lupus Erythematosus

Abstract: We assessed the mucocutaneous signs in 57 children with classical systemic lupus erythematosus seen during a 6 year period. The female:male ratio was 4.2:1. Ages ranged from 4 to 15 years (mean 11.9 years) at the time of diagnosis. Cutaneous manifestations (77%) were the second most common finding, next to renal involvement (84%). The skin changes noted were malar rash (74%), oral ulcer (46%), vasculitis (42%), photosensitivity (40%), alopecia (32%), and discoid lupus erythematosus (LE) (19%). All 11 discoid LE patients were girls. Periungual erythema, Raynaud's phenomenon, periungual gangrene, nail involvement, and subacute LE were rare. Antinuclear antibody reaction was positive in 93% and anti-dsDNA was positive in 46%. Eight patients died, six from severe infection and two from renal failure.     

Skin disorders in peritoneal dialysis patients: An underdiagnosed subject

AIM: To examine all skin changes in peritoneal dialysis (PD) patients followed up in our unit. METHODS: Patients on PD program for at least three months without any known chronic skin disease were included in the study. Patients with already diagnosed skin disease, those who have systemic diseases that may cause skin lesions, patients with malignancies and those who did not give informed consent were excluded from the study. All patients were examined by the same predetermined dermatologist with all findings recorded. The demographic, clinical and laboratory data including measures of dialysis adequacy of patients were recorded also. Statistical Package for Social Sciences (SPSS) for Windows 16.0 standard version was used for statistical analysis. RESULTS: Among the patients followed up in our PD unit, those without exclusion criteria who gave informed consent, 38 patients were included in the study with male/female ratio and mean age of 26/12 and 50.3 ± 13.7 years, respectively. The duration of CKD was 7.86 ± 4.16 years and the mean PD duration was 47.1 ± 29.6 mo. Primary kidney disease was diabetic nephropathy in 11, nephrosclerosis in six, uropathologies in four, chronic glomerulonephritis in three, chronic pyelonephritis in three, autosomal dominant polycystic kidney disease in three patients while cause was unknown in eight patients. All patients except for one patient had at least one skin lesion. Loss of lunula, onychomycosis and tinea pedis are the most frequent skin disorders recorded in the study group. Diabetic patients had tinea pedis more frequently (P = 0.045). No relationship of skin findings was detected with primary renal diseases, comorbidities and medications that the patients were using. CONCLUSION: Skin abnormalities are common in in PD patients. The most frequent skin pathologies are onychomycosis and tinea pedis which must not be overlooked.     

Ultrasonography reveals nail thickening in patients with chronic plaque psoriasis

Nail psoriasis is usually investigated and diagnosed by clinical examination. Ultrasonography is a non-invasive imaging technique for studying soft tissue involvement. The objective of this study was to estimate nail involvement in patients with chronic plaque psoriasis by ultrasonography. Prevalence, clinical type and severity of nail involvement according to nail psoriasis and severity index (NAPSI) were investigated in 138 patients with psoriasis. The thickness of the plate and bed of the fingernails was measured in 54 patients with psoriasis, 46 healthy controls and 37 patients with chronic eczema, using an ultrasonographic system equipped with a frequency transducer of 18?MHz. The prevalence of nail psoriasis was 73?% (102 out of 138). Onycholysis and thickening of the nail plate were the most common clinical type affecting 56 and 50?% of patients, respectively; splinter haemorrhages was the less common involving 10?% of patients. The mean NAPSI score was 18.4?±?17.5 (SD; range 0–107). The thickness of fingernail plate and bed was significantly higher in patients with psoriasis with nail disease compared to healthy controls and patients with chronic eczema (p?<?0.001). There was a linear correlation between NAPSI and plate and bed nail thickness (r?=?0.52 and r?=?0.38, p?=?0.001). Increased nail plate and bed thickness was observed also in patients with psoriasis without clinically apparent nail involvement. In conclusion, thickening of the nail is a common feature of nail psoriasis also in patients without clinically apparent nail involvement.     

A comparative study of impairment of quality of life in children with skin disease and children with other chronic childhood diseases

BACKGROUND: Chronic disease can have physical and psychological effects which affect social functioning. These effects can be better understood from the perspective of parent and child by the use of health-related quality of life (HRQL) measures. Various HRQL measures are now available, of which generic health measures have been the most widely used. These permit comparison between different diseases and also the normal population. OBJECTIVES: To cross-validate a new generic HRQL proxy measure for children, the Children's Life Quality Index (CLQI), with an established speciality-specific dermatological questionnaire, the Children's Dermatology Life Quality Index (CDLQI), in a group of children with chronic skin diseases. The impairment of HRQL in the same group of children with skin disease was then compared with that associated with other common chronic childhood diseases using the CLQI. METHODS: The CDLQI was completed by 379 children aged 5-16 years with skin disease of more than 6 months' duration. Their parents (n=379) and parents of 161 children aged 5-16 years with other chronic diseases were also asked to complete a proxy measure, the CLQI. RESULTS: Using linear regression analysis, the CLQI and the CDLQI scores showed a strong linear association (rs=0.72, P<0.001) and on a Bland-Altman plot, reasonably good agreement (expressing scores out of 100, the 95% limits of agreement were from -25.5/100 to 26.7/100). In the child's opinion psoriasis and atopic dermatitis (AD) caused the greatest impairment (CDLQI scores of 30.6% and 30.5%), followed by urticaria (20%) and acne (18%). Using the generic CLQI (scored 0-36), from the parental perspective the highest score was for AD (33%), followed by urticaria (28%), psoriasis (27%) and alopecia (19%). Comparing this with children with other chronic diseases, those with cerebral palsy had the highest score (38%), followed in descending order by those with generalized AD (33%), renal disease (33%), cystic fibrosis (32%), urticaria (28%), asthma (28%) and psoriasis (27%). Diseases such as epilepsy (24%) and enuresis (24%) scored higher than diabetes (19%), localized eczema (19%), alopecia (19%) and acne (16%). CONCLUSIONS: Using the CLQI we have shown that HRQL impairment in children with chronic skin disease is at least equal to that experienced by children with many other chronic diseases of childhood, with AD and psoriasis having the greatest impact on HRQL among chronic skin disorders and only cerebral palsy scoring higher than AD. Cross-validation of the CLQI with the CDLQI in the group of children with skin disease demonstrates a strong linear association and good agreement between the two.     

Epidemiology of Chronic Paronychia in a Skin Hospital in Singapore

A retrospective epidemiologic study of 110 patients with chronic paronychia (CP) showed a female-male ratio of 2.3:1, whereas the ratio of patients attending the same clinic was 1.1:1 (p less than 0.001). The peak age range of patients with CP (40-49 years) generally was greater than that of the general dermatologic patients (20-29 years). Seventy-seven percent of the patients with CP were "manual workers," of which 48% were homemakers. Chronic paronychia was more common on the right fingers than the left fingers. The most commonly affected fingers were the right thumb (62%), followed by the right middle finger (52%), left thumb (57.6%), and left middle finger (51.5%). Mechanical trauma appears to be an important predisposing factor in CP. Sixty-two percent of 68 patients who had nail fold smears had positive findings for budding yeast cells, suggestive of candidal infection. All of the six patients for whom nail fold bacterial cultures were performed had positive results for enteric flora.