Nails in systemic disease

Nail plate and nail unit abnormalities may be helpful as diagnostic tools or as a part of the puzzle for confirmation of systemic disease. There are specific and nonspecific nail signs, which can be seen involving one or more nails, that occur simultaneously or secondary to systemic disease. Occasionally these clues can be diagnostic, while most are nonspecific reaction patterns. Nail changes occur in the nail plate as a result of nail matrix abnormalities caused by systemic disease and other systemic insults such as reactions to medications. In this article we review some of the more common nail signs that can be used to help diagnose systemic disease.     

Consensus on melanonychia nail plate dermoscopy

This statement, focused on melanonychia and nail plate dermoscopy, is intended to guide medical professionals working with melanonychia and to assist choosing appropriate management for melanonychia patients. The International Study Group on Melanonychia was founded in 2007 and currently has 30 members, including nail experts and dermatopathologists with special expertise in nails. The need for common definitions of nail plate dermoscopy was addressed during the Second Meeting of this Group held in February 2008. Prior to this meeting and to date (2010) there have been no evidence-based guidelines on the use of dermoscopy in the management of nail pigmentation.     

Mohs Surgery in Patients Immunobullous Diseases: Should Prednisone be Increased Prior to Surgery?

Background: Mohs surgery is one of the most effective treatment options for skin cancers as it offers one of the highest chances for cure. Mohs surgery is a precise technique that removes a layer at a time. Although this may be advantageous, this treatment method is difficult in patients with immunobullous diseases. Currently the guidelines for Mohs surgery do not discuss the premanagement of immunobullous patients about to undergo Mohs surgery. Objective: To advocate for increasing prednisone dose in patients with immunobullous disease prior to undergoing Mohs surgery. Case Report: The authors present a case of an excision of a squamous cell carcinoma from a 94-year-old woman with a history of pemphigus vulgaris using Mohs micrographic surgery. Conclusion: Current preoperative guidelines for Mohs surgery do not address the issue of altering steroid medications for patients with immunobullous disease prior to the procedure. The authors suggest that patients with a history of immunobullous disease undergoing Mohs micrographic surgery should have an increase in steroid dose prior to surgery.A 94 year-old Caucasian woman with no prior history of A skin cancer presented for evaluation of a crusting Plaque on her mid-back that had been present for six months. The patient’s past medical history was significant for pemphigus vulgaris for the last 20 years for which she was on prednisone 2.5mg daily. The patient reported no allergies. She denied smoking and denied alcohol use. Review of systems was unremarkable and physical examination revealed a well-developed, well-nourished woman. Upon complete skin examination, the mid-back presented with a 5x4cm erythematous, waxy, and crusty plaque (Figure 1). The surrounding areas of skin were examined and no other suspicious lesions were noted. The lesion was biopsied and a diagnosis of squamous cell carcinoma (SCC) was established. Open in a separate windowFigure 1Left upper back—preoperativeOn the scheduled day of surgery, the patient did have a new oral ulcer on her left buccal mucosa. The patient did not exhibit any other active lesions. However, during curettage and the incision, her skin became positive for Nikolsky’s sign and the epidermis sloughed off immediately (Figure 2). The squamous cell carcinoma was then excised with wider margins using Mohs micrographic surgery (MMS) in one stage. Open in a separate windowFigure 2Left upper back—intraoperativeFurthermore, closing the lesion was very difficult (Figure 3). The defect was repaired utilizing 3-0 Vicryl and 4-0 Nylon, which were placed from opposite edges of the defect spanning the width of the opening to minimize tension at the wound edges. During microscopic examination of the frozen section, it was difficult to assess if the margins were still positive for cancer because the epidermis was not present anymore. A compression dressing consisting of xeroform was used to avoid the use of adhesive tape on surrounding tissue that had become prone to blistering. The authors’ goal was to avoid adhesives altogether, since they further traumatize the fragile skin. The patient returned for her two-week follow up for suture removal and was diagnosed with methicillin-resistant Staphylococcus aureus (MRSA) infection. This was subsequently cultured and treated with doxycycline. The patient returned one week thereafter for suture removal and healed well with no other complications. Open in a separate windowFigure 3Left upper back—postoperative     

Coronary artery spasm following coronary artery bypass grafting. Treatment with intracoronary ISDN followed by systemic intravenous nifedipine infusion

Coronary artery spasm following coronary artery bypass grafting (CABG) has been described previously. The cause and underlying risk factors are mainly speculative and treatment therefore symptomatic. We present the successful management of this condition by administration of an intravenous Nifedipine infusion after intracoronary Isosorbide dinitrate (ISDN) had failed to relieve the spasm.     

The Role of Biological Agents in the Treatment of Nail Psoriasis

Nail psoriasis affects up to 90% of patients with psoriasis in their lifetime and is seen in 80% of patients with psoriatic arthritis. These changes of nail psoriasis often cause significant pain, psychological effects, and result in restrictions of daily activities. In patients with nail psoriasis, the choice of effective therapy is limited and depends on various factors, including the severity of the disease, the ability of patients to tolerate treatment, and their ability to pay (insurance) for what are, in some cases, expensive treatments. In recent years, biological therapies have proved effective in improving nail psoriasis, have generally proved to be well tolerated and require minimal patient monitoring. In the right situation, therefore, the use of biological agents is justified in patients with psoriatic nail disease.     

Nail damage from gel polish manicure

Manicures can result in nail damage via instrumentation, nail polish, nail polish removers, and artificial nails. We report nail weakness, brittleness, and thinning in five subjects after the application of a new manicure system called gel polish and removal with acetone and manual peeling. All subjects complained that the polish was very difficult to remove and that their nails became much thinner after the procedure. Pseudoleukonychia and onychoschizia lamellina were noted on examination. One subject underwent ultrasound and reflectance confocal microscopy (RCM) measurements of nail plate before and after the gel polish application, which showed thinned nail plate (0.063 vs. 0.050 cm and 0.059 vs. 0.030 cm, respectively). Overall, we call attention to the adverse effects of gel polish manicures in five subjects. In addition, our case illustrates potential utility of ultrasound and RCM in measuring nail plate thickness.