儿童纵行黑甲皮肤镜模式分析

目的了解儿童纵行黑甲的皮肤镜特点,探索通过皮肤镜模式分析诊断儿童纵行黑甲的方法。方法收集2013年6月—2015年9月就诊于首都医科大学附属北京儿童医院皮肤科的50例纵行黑甲患儿,分析其术前皮肤镜模式,对其中42例患儿行手术治疗,分析其术中皮肤镜模式。结果术前皮肤镜检查为灰色模式的8例患儿,均未行手术治疗,行手术治疗的42例患儿,术前甲板皮肤镜显示棕色条带的4例术中皮肤镜为棕色模式,组织病理证实为雀斑样痣。术前皮肤镜显示黑色条带的7例,术中表现为规则的棕色模式伴有色素球及色素斑,组织病理证实为甲母痣。术前显示规律的棕色线条组成的条带18例,术中皮肤镜为规则的棕色模式伴有色素球14例,规则棕色模式4例,组织病理分别证实为甲母痣和雀斑样痣。术前显示规律的棕色线条组成的条带伴色素球13例,术中皮肤镜为规则的棕色模式伴有色素球,组织病理证实其中12例为甲母痣,1例为黑素细胞活化。结论术前及术中皮肤镜检查及模式分析对儿童纵行黑甲的诊断具有显著意义。     

儿童Hutchinson氏征阳性纵行黑甲32例临床分析

目的了解儿童Hutchinson氏征阳性纵行黑甲的临床、皮肤镜及组织病理学特点,探索判断该类儿童纵行黑甲的性质及其管理。方法回顾性分析本科于2013年6月-2015年6月收治的Hutchinson氏征阳性纵行黑甲患儿的临床表现、皮肤镜和组织病理学特点。结果 32例患儿的平均年龄4岁6个月;男22例,女10例;平均病程2.5年。皮损部位:手指23例(其中8例发生于拇指),足趾9例,拇趾4例。Hutchinson氏征阳性部位:甲皱襞19例,甲下皮10例,二者皆有3例;黑素颗粒增多20例,色素痣12例,雀斑样痣3例。色带宽度≥3mm者22例。16例皮肤镜下见均一条带上伴规则的线状结构,12例同时伴规则线状结构和点球状结构,棕色及黑色均质模式分别为3例和1例。甲母质皮损组织病理示甲母痣27例,雀斑样痣5例。结论儿童期纵形黑甲多为黑素细胞良性增殖性病变,部分患儿需活检或手术方法确诊,以上临床特征和皮肤镜特点有助于诊断和随访。成人纵行黑甲有恶性风险的Hutchinson氏征,对儿童纵行黑甲的指导意义不明,尚需扩大样本量论证和长期随访。     

甲黑素细胞疾病的诊疗技术进展

黑甲多数是由于黑素或含铁血黄素在甲板内沉积引起。甲母痣、甲雀斑样痣、黑素瘤等甲黑素细胞疾病以及甲下出血、外伤、种族、真菌感染等多种原因均可造成黑甲［1?2］。甲黑素细胞疾病又可分为良性甲黑素细胞疾病（甲母痣、甲雀斑样痣、色素痣等）和甲黑素瘤。良性甲黑素细胞疾病无明显不良预后,但甲黑素瘤恶性程度大,且常常误诊和漏诊,临床上需要早期发现和治疗［3?4］。临床上如何不漏诊黑素瘤,同时保证良性病变不过度医疗导致指（趾）甲的损伤是甲黑素细胞疾病合理诊疗的目的。近年来,新评价体系的出现、皮肤镜的应用以及活检技术给此类疾病的诊断及治疗提供了行之有效的手段,本文就此做一综述……     

178例掌跖部位黑素细胞性皮损的皮肤镜特点

目的 探讨掌跖部位黑素细胞性皮损的皮肤镜特点。方法 回顾性分析2009年9月至2011年10月在北京大学第一医院皮肤科行皮肤镜检查的掌跖部位黑素细胞性皮损的皮肤镜图像。结果 共分析了121例患者的155个良性黑素细胞性损害,22例患者的23个黑素瘤皮损。掌跖部位良性黑素细胞性皮损中最多见的皮肤镜模式为平行沟模式（占34.2%）,其次为纤维样模式（占22.6%）,有2个（1.3%）良性皮损表现为平行脊结构。23个黑素瘤皮损中12个（52.2%）出现平行脊结构,14个（60.9%）出现弥漫不规则的色素,且后者见于所有侵袭性黑素瘤中。纤维样结构作为肢端色素痣常见的一种良性皮肤镜模式,亦见于39.1%的黑素瘤中。结论 皮肤镜在区分掌跖部位良性黑素细胞痣和黑素瘤方面有一定价值     

纵行黑甲243例临床及病理分析

目的分析纵行黑甲的临床和病理特点。方法回顾性分析243例纵行黑甲切除/活检术患者的临床表现及组织病理学特点。结果 243例患者中,甲黑素细胞活化113例,甲母痣(良性黑素细胞增生)62例,甲黑素瘤42例,其他26例。甲黑素瘤临床表现多样,可以为褐色、黑色或不均一条带,第一指(趾)甲为最常见的甲黑素瘤发病部位,而多个甲受累为甲黑素瘤的保护因素。结论对纵行黑甲应仔细评估,临床评估有疑问或皮损变化的情况下,应及时进行指甲活检以除外甲黑素瘤。     

黑甲的诊断与治疗

黑甲主要表现为甲板内纵行的黑色或棕色条带。甲下出血、感染、药物、良性黑素细胞增生以及黑素瘤等多种原因均可造成黑甲的出现,其中临床预后最差也最值得临床医生关注的就是甲单位的黑素瘤。如何将甲良性病变与甲黑素瘤区分开来,避免甲黑素瘤的误诊、漏诊,是临床医生诊断的重点与难点。近年来,皮肤镜的应用以及相关活检技术给黑甲的诊断及早期治疗提供了行之有效的手段。     

22例甲下黑素瘤临床及组织病理学分析

目的:探讨甲下黑素瘤的临床及组织病理学特点。方法:回顾分析西京医院皮肤科2003—2009年间诊断的22例甲下黑素瘤患者临床及组织病理学特点。结果:全部患者均为成人,其中男9例,女13例。发生于拇指9例,示指5例,发生于第一趾4例,发生于其他指(趾)4例。16例出现甲周皮肤颜色变黑,10例表现为甲板毁损或溃疡、结节性损害,6例为单纯甲黑线或黑甲。组织病理资料分析结果表明10例为原位黑素瘤,12例为浸润性黑素瘤。结论:甲下黑素瘤好发于成年人,尤其是中老年患者,拇指、示指以及第一趾是其好发部位。早期甲下黑素瘤表现为皮损较宽、颜色不均的甲黑线或弥漫性黑甲,晚期甲下黑素瘤累及甲周皮肤,或形成结节溃疡性损害。甲下原位黑素瘤表现为甲母质或甲床部位单个黑素细胞增生,黑素细胞位置较高(基底层以上),核染色质深,细胞树突明显,合成颗粒较粗大的黑素。甲下浸润性黑素瘤累及真皮内,呈浸润性生长,细胞异形性明显。     

甲真菌病皮肤镜表现及模式分析北大核心CSCD

目的 探讨皮肤镜下甲真菌病的特征性表现及模式。方法 对2017年2 - 7月在安徽宣城市人民医院内分泌皮肤科病区住院的患者进行甲真菌直接镜检,阳性者诊断为甲真菌病,对病甲拍摄皮肤镜照片,分析甲真菌病的皮肤镜下特征及皮肤镜模式。结果 共调查205例患者634个病甲。甲板特征中大理石样浑浊区300个（47.3%）、色素沉着196个（30.9%）、出血碎片116个（18.3%）、甲剥离84个（13.2%）。远端侧位型和全甲毁损型病甲大理石样浑浊区、色素沉着、甲剥离的出现频率差异均有统计学意义（χ2值分别为42.09、31.23、18.19,均P 〈 0.01）。210个（33.1%）甲增厚,168个（26.5%）甲下角蛋白及碎屑沉积。全甲毁损型病甲甲增厚和甲下角蛋白及碎屑沉积的比例均显著高于远端侧位型病甲（χ^2值分别为44.3和18.52,均P 〈 0.01）。甲周皮肤干燥脱屑在全甲毁损型病甲中的比例高于远端侧位型（χ^2 = 16.07,P 〈 0.01）。634个病甲中,短刺状模式141个（22.2%）、纵向条纹模式210个（33.1%）、线状边缘模式202个（31.9%）、远端不规则中断模式193个（30.4%）。结论 大理石样混浊区、甲下角蛋白及碎屑沉积、甲周皮肤干燥脱屑是甲真菌病皮肤镜下主要特征性表现,短刺状模式、纵向条纹模式、线状边缘模式、远端不规则中断模式是甲真菌病皮肤镜下特征性模式。     

甲真菌病的皮肤镜特征研究

目的 观察甲真菌病的皮肤镜表现特征.方法 对2018年7月—2020年7月于河北医科大学第一医院就诊的132例甲真菌病患者的临床资料及皮肤镜表现进行回顾性研究.结果 共回顾分析132例甲真菌病患者的388个病甲,皮肤镜表现为锯齿状边缘177个(45.62%)、纵向条纹150个(38.66%)、锥形甲角化107个(27....     

甲真菌病和甲银屑病的皮肤镜特征分析

【摘要】 目的 分析甲真菌病和甲银屑病的皮肤镜特征。方法 2017年3月至2018年3月在湖北襄阳市中心医院皮肤科收集就诊的甲真菌病和甲银屑病患者各128例,对病甲皮肤镜图像进行比较。计数资料比较采用χ2检验和Fisher精确检验分析。结果 甲真菌病出现7种皮肤镜模式,分别为锯齿状边缘69例（53.91%）、纵行条纹72例（56.25%）、锥形甲角化30例（23.44%）、甲板增厚21例（16.41%）、甲黑点5例（3.91%）、甲剥离26例（20.31%）和甲变色23例（17.97%）。其中,锯齿状边缘和纵行条纹在远端侧位甲下型甲真菌病中出现的频率明显高于其他3种亚型,差异有统计学意义（均P＜0.001）,锥形甲角化在全甲毁损型甲真菌病中出现的频率明显高于其他3种亚型,差异有统计学意义（χ2 = 42.020,P＜0.001）,甲板增厚、甲黑点、甲剥离和甲变色在4种甲真菌病临床亚型中的分布差异无统计学意义（均P＞0.05）。甲银屑病出现7种皮肤镜模式,分别为点蚀征61例（47.66%）、油滴征41例（32.03%）、裂片形出血41例（32.03%）、甲床毛细血管扩张23例（17.97%）、甲板增厚20例（15.63%）、甲剥离20例（15.63%）和甲变色13例（10.16%）,其中油滴征在寻常性和关节病性银屑病中出现的频率明显高于其他两种亚型（P = 0.019）,甲床毛细血管扩张在脓疱性银屑病中出现的频率明显高于其他3种亚型（P = 0.047）,点蚀征、裂片形出血、甲板增厚、甲剥离和甲变色在4种银屑病临床亚型中的分布差异无统计学意义（均P＞0.05）。结论 甲真菌病皮肤镜下特征包括锯齿状边缘、纵行条纹、锥形甲角化和甲黑点,银屑病甲皮肤镜下特征包括点蚀征、油滴征、裂片形出血和甲床毛细血管扩张,二者同时出现的镜下表现包括甲板增厚、甲剥离和甲变色。     

Key point in dermoscopic differentiation between early nail apparatus melanoma and benign longitudinal melanonychia

Longitudinal melanonychia presents in various conditions including neoplastic and reactive disorders. It is much more frequently seen in non-Caucasians than Caucasians. While most cases of nail apparatus melanoma start as longitudinal melanonychia, melanocytic nevi of the nail apparatus also typically accompany longitudinal melanonychia. Identifying the suspicious longitudinal melanonychia is therefore an important task for dermatologists. Dermoscopy provides useful information for making this decision. The most suspicious dermoscopic feature of early nail apparatus melanoma is irregular lines on a brown background. Evaluation of the irregularity may be rather subjective, but through experience, dermatologists can improve their diagnostic skills of longitudinal melanonychia, including benign conditions showing regular lines. Other important dermoscopic features of early nail apparatus melanoma are micro-Hutchinson's sign, a wide pigmented band, and triangular pigmentation on the nail plate. Although there is as yet no solid evidence concerning the frequency of dermoscopic follow up, we recommend checking the suspicious longitudinal melanonychia every 6 months. Moreover, patients with longitudinal melanonychia should be asked to return to the clinic quickly if the lesion shows obvious changes. Diagnosis of amelanotic or hypomelanotic melanoma affecting the nail apparatus is also challenging, but melanoma should be highly suspected if remnants of melanin granules are detected dermoscopically.     

Dermoscopic examination of nail pigmentation

BACKGROUND: Diagnosis of longitudinal melanonychia is usually difficult, and neither a single clinical criterion nor a combination of symptoms currently can be used to clearly distinguish malignant from benign bandlike pigmented nail lesions. Biopsy is painful and often leaves definitive dystrophic scars. OBJECTIVES: To describe and evaluate dermoscopic patterns associated with longitudinal nail pigmentation. PATIENTS AND METHODS: A total of 148 unselected consecutive cases of longitudinal melanonychia were included over a period of 4 years (20 melanoma, 37 nevi, 16 drug-induced nail pigmentation, 45 nail apparatus lentigo of various types, 8 ethnic-type nail pigmentation, and 22 subungual hemorrhages). All patients were recruited from the dermatology unit outpatient clinic of the H?tel Dieu de Lyon. All cases were photographed in vivo under oil immersion (dermoscopy). Patterns were recorded prior to final pathologic diagnosis. An independent biostatistics unit performed statistical evaluation using 7 semiologic patterns. RESULTS: Melanoma cases were significantly associated with a brown coloration of the background and the presence of irregular longitudinal lines (P =.001). Blood spots were mostly observed in subungual hemorrhages (P =.001); however, their presence could not rule out melanoma. Micro-Hutchinson sign was observed only in melanoma, but its rare occurrence did not allow any statistical evaluation of its specificity. Nail apparatus nevi were significantly associated with a brown coloration of the background and the presence of regular lines (P =.001). Nail apparatus lentigo, ethnic-type pigmentation, and drug-induced pigmentation were significantly associated with homogeneous longitudinal thin gray lines and gray coloration of the background (P =.001). Microscopic longitudinal grooves were unspecific, occurred in several conditions, and were associated with any type of ungual discoloration. CONCLUSIONS: We believe that dermoscopic examination of the nail plate in cases of longitudinal melanonychia provides useful information that could help clinicians to more accurately decide if a nail apparatus biopsy should be performed; however, histopathologic diagnosis remains the gold standard in doubtful cases.     

Dermoscopy of subungual haemorrhage: its usefulness in differential diagnosis from nail‐unit melanoma

Background Subungual haemorrhages are characterized by well‐circumscribed dots or blotches with a red to red–black pigmentation, but some cases can be difficult to distinguish from subungual melanoma by the naked eye alone. Dermoscopy has proven to be a useful, noninvasive tool in the diagnosis of pigmented lesions in the nail; however, few dermoscopic studies of subungual haemorrhages have been reported. Objectives To investigate characteristic dermoscopic patterns of subungual haemorrhages, and to find distinctive features that can differentiate them from nail‐unit melanomas. Methods Patients with a confirmed diagnosis of either subungual haemorrhage or nail‐unit melanoma at a tertiary university hospital were included in the study. Clinical features and dermoscopic patterns were evaluated. Results Sixty‐four patients with a total of 90 lesions of subungual haemorrhage were enrolled in the study. The majority of cases (84%) showed combinations of more than one colour, while 16% had only one colour. The most common colour of the subungual haemorrhages was purple–black, in 37% of cases. A homogeneous pattern was observed in 92% of cases, globular patterns in 42% and streaks in 39%. Peripheral fading and periungual haemorrhages were found in 54% and 22% of cases, respectively. Destruction or dystrophy of the nail plate was observed in 16% of cases. In the 16 cases of nail‐unit melanomas, Hutchinson sign, longitudinal irregular bands or lines, triangular shape of bands, vascular pattern, and ulcerations were found in 100%, 81%, 25%, 6% and 81% of cases, respectively. In contrast, these features were not found in subungual haemorrhages. Conclusions Dermoscopy provides valuable information for the diagnosis of subungual haemorrhage and aids in the differential diagnosis from nail‐unit melanoma.     

Pigmented lesions of the nail unit: clinical and histopathologic features

Probably the most common reason to perform biopsy of the nail unit is for the evaluation of irregular pigmentation, especially longitudinal melanonychia or pigmented bands. When narrow and solitary, these are usually the product of melanocytic activation/hypermelanosis, lentigines, or melanocytic nevi. Multiple pigmented bands are generally a benign finding, the result of melanocytic activation, as seen in racial pigmentation in darker-skinned patients, for example. In the context of an irregular, broad, heterogeneous or "streaky" band, the chief concern is the exclusion of subungual melanoma. Before assessing the histologic features of any such entities, it is important to understand the normal nail anatomy and melanocytic density of nail unit epithelium, as well as the type of specimen submitted, and whether it is adequate to undertake a proper histologic evaluation. The criteria for diagnosis and prognosis of melanoma of the nail unit are still evolving, and a variety of factors must be weighed in the balance to make a correct diagnosis. The importance of the clinical context cannot be overemphasized. There are also nonmelanocytic conditions to be considered that may produce worrisome nail discoloration, such as subungual hemorrhage, squamous cell carcinoma, and pigmented onychomycosis.     

The rare occurrence of three subungual melanomas in one patient

Subungual melanoma commonly presents with solitary longitudinal melanonychia. Herein, we report the case of a patient with subungual melanoma who developed involvement of three digits by three independent primary melanomas. A 98-year-old male patient presented with a two-year history of longitudinal melanonychia on three different fingernails. Histopathologically, all three lesions were proved to be melanoma. To our knowledge, this is the first reported case in which three subungual melanomas developed in one patient. Our case indicates that that not all examples of multiple longitudinal melanonychia represent benign lesions.     

Melanonychia striata: clarifying behind the Black Curtain. A review on clinical evaluation and management of the 21st century

Melanonychia striata is characterized by a tan, brown, or black longitudinal streak within the nail plate that runs from the proximal nail fold to the distal part of the nail plate. Melanonychia striata is due to increased activity of melanocytes or melanocytic hyperplasia in the nail matrix with subsequently increased melanin deposition in the nail plate. The most common cause of melanonychia striata associated with melanocytic activation is ethnic melanonychia which occurs in dark-skinned individuals. Other causes of melanonychia striata related to melanocytic activation include pregnancy, chronic local trauma, infections, medications, dermatological disorders, endocrine disorders, alkaptonuria, hemochromatosis, porphyria, graft-vs-host disease, Peutz-Jeghers syndrome, and Laugier-Hunziker syndrome. Causes of melanonychia striata associated with melanocytic hyperplasia include nail matrix melanocytic nevus, nail lentigo, and nail apparatus/subungual in situ and invasive melanoma. In most cases, melanonychia striata is a benign condition, especially in children. Consequently, most investigators advocate a wait-and-see approach. Nail apparatus/subungual melanoma should be suspected if there is an abrupt onset after middle age, personal or family history of melanoma, rapid growth, darkening of a melanonychia band, pigment variegation, blurry lateral borders, irregular elevation of the surface, a bandwidth >3 mm, proximal widening, associated nail plate dystrophy, single rather than multiple digit involvement, and periungual spread of pigmentation onto the adjacent cuticle and/or proximal and/or lateral nail folds (Hutchinson sign). Prolonged follow-up is mandatory for early detection of possible malignant changes.     

Dermoscopy provides useful information for the management of melanonychia striata

The diagnosis of melanonychia striata is often difficult, and a biopsy of the nail matrix is required in doubtful cases. However, dermoscopic examination of the nail plate offers interesting information in order to better select the cases in which pathologic examination is indicated. In the case of brown longitudinal pigmentation with parallel regular lines, the diagnosis of nail apparatus melanocytic nevus could be made. On the other hand, the presence of a brown pigmentation overlaid by longitudinal lines irregular in their thickness, spacing, color, or parallelism is highly in favor of a melanoma. Gray homogeneous lines are observed in case of lentigo, lentiginoses, ethnic or drug-induced pigmentations, and in post-traumatic pigmentations. Blood spots are characterized by their round-shaped proximal edge and their filamentous distal edge and are highly suggestive of subungual hemorrhages. Dermoscopic examination of the free edge of the nail plate gives information on the lesion location; pigmentation of the dorsum of the nail plate is in favor of a proximal nail matrix lesion, whereas pigmentation the lower part of the nail edge is in favor of a lesion of the distal matrix.     

Automated evaluation system of dermoscopic images of longitudinal melanonychia: Proposition of a discrimination index for detecting early nail apparatus melanoma

The prognosis of nail apparatus melanoma is generally poor because of difficulty in early stage diagnosis. Most nail apparatus melanomas occur as longitudinal melanonychia, and criteria and algorithms for dermoscopy diagnosis of longitudinal melanonychia have only recently been proposed. However, as with any clinical diagnosis, the diagnosis based on dermoscopy is to some extent subjective. Our goal is to develop an automated dermoscopic screening system for longitudinal melanonychia and to propose a novel objective and quantitative index for discriminating early nail apparatus melanoma from benign longitudinal melanonychia including melanocytic nevus. We propose an automatically calculated index representing degrees of color variegation in dermoscopic images of longitudinal melanonychia. Dermoscopy images of six cases of early stage nail apparatus melanoma and 25 cases of benign longitudinal melanonychia were analyzed with our screening system and a threshold of melanoma discrimination index was determined. This single melanoma discrimination index diagnosed early nail apparatus melanoma with 100% sensitivity and 92% specificity. The automatically calculated index proposed in the present study is valuable for managing longitudinal melanonychia. The results suggest that the degree of color variegation is essentially different between early nail apparatus melanoma and benign longitudinal melanonychia including melanocytic nevus of the nail apparatus.