Lateral Nail Folds Research Articles

Hutchinson's Nail Sign

A 37-year-old man presented with a brownish-black nail on the great toe of the right foot. A darkly pigmented linear patch had started to form within the toenail 4 years earlier and had widened and darkened over time. Two months before the current presentation, the dark pigment had begun to involve the hyponychium and the proximal and lateral nail folds. The patient's personal and family medical histories were otherwise unremarkable. The results on routine laboratory testing were within normal limits. An incisional biopsy of the nail matrix showed atypical melanocytes and inflammatory cells along the basal layer of the epidermis, . . .

Immunohistochemical Study of Specialized Nail Mesenchyme Containing Onychofibroblasts in Transverse Sections of the Nail Unit

In the frozen longitudinal section of the nail unit, CD10 was previously found in nail mesenchymal cells beneath nail matrix, and we proposed calling the nail mesenchymal cells onychofibroblasts. In this study, to further characterize nail mesenchyme containing onychofibroblasts, we examined the expression of several mesenchymal markers immunohistochemically in transverse paraffin sections of the nail unit. CD10 was strongly expressed in the nail mesenchyme containing onychofibroblasts beneath the nail matrix. However, CD10 was not observed in dermal fibroblasts and surrounding extracellular matrix of the lateral nail fold (LNF), except around blood vessels and eccrine structures. In addition, versican was expressed diffusely in the nail mesenchyme containing onychofibroblasts in contrast to the dermis of LNF. Fibrillin, which is a major component of elastic fiber in the dermis, was expressed very weakly on the nail mesenchyme below the nail matrix but was expressed strongly in the dermis of LNF. These findings support the existence of specialized nail mesenchyme containing onychofibroblasts that is distinguished from the dermis of LNF.

The mucocutaneous and systemic phenotype of dermatomyositis patients with antibodies to MDA5 (CADM-140): A retrospective study

Dermatomyositis (DM) is a multisystem autoimmune disease, in which serologic evidence of immune responses to disease-specific antigenic targets is found in approximately 50% to 70% of patients. Recently, melanoma differentiation-associated gene 5 (MDA5) has been identified as a DM-specific autoantigen that appears to be targeted in patients with DM and mild or absent muscle inflammation and with an increased risk of interstitial lung disease. We wished to understand the role of MDA5 in DM skin inflammation by testing it to determine if a specific cutaneous phenotype is associated with MDA5 reactivity. We retrospectively screened plasma from 77 patients with DM in the outpatient clinics at the Stanford University Department of Dermatology in California. We found that 10 (13%) patients had circulating anti-MDA5 antibodies, and had a characteristic cutaneous phenotype consisting of skin ulceration, tender palmar papules, or both. Typical areas of skin ulceration included the lateral nailfolds, Gottron papules, and elbows. Biopsy specimens of the palmar papules showed a vasculopathy characterized by vascular fibrin deposition with variable perivascular inflammation. Patients with anti-MDA5 antibodies also had an increased risk of oral pain and/or ulceration, hand swelling, arthritis/arthralgia, and diffuse hair loss. Consistent with previous reports, these patients had little or no myositis and had increased risk of interstitial lung disease. This study was conducted at a tertiary referral center. Multiple associations with MDA5 antibodies were tested retrospectively on a relatively small cohort of 10 anti-MDA5-positive patients. We suggest that MDA5 reactivity in DM characterizes a patient population with severe vasculopathy.

Scarring alopecia associated with the epidermal growth factor receptor inhibitor erlotinib

To the Editor: Erlotinib (Tarceva; Genentech, South San Francisco, CA) is an oral anticancer agent that blocks the function of the epidermal growth factor receptor (EGFR) and has been approved by the US Food and Drug Administration for the treatment of non–small cell lung and pancreatic cancers. Therapy is frequently complicated by multiple cutaneous adverse effects ranging from follicular papulopustular (“acneiform”) eruptions, xerosis, nail changes (including paronychia and pyogenic granulomas in the lateral nail folds), and hair texture changes.

Changes in the nail unit in patients with secondary lymphoedema identified using clinical, dermoscopic and ultrasound examination

Secondary lymphoedema is characterized by lymphatic stasis that is often the result of a lymph node lesion. At advanced stages it may cause trophic changes in the skin. However, the presence of changes in the nail unit has not been reported to date. The aim of this study was to determine the presence of nail abnormalities in cases of secondary lymphoedema. This was a prospective study, conducted on patients with unilateral secondary lymphoedema. A comparative clinical and dermoscopic examination and 20-MHz high-resolution ultrasound imaging of the affected limb and the contralateral limb were performed. Thirty-three patients were included. On physical examination, hyperkeratosis of the lateral nail folds, friability of the nail surface, 'ragged' proximal nail folds and cuticle and apparent leuconychia were observed more frequently on the lymphoedematous limb. The ultrasound study of the nails of the thumb and the big toe did not reveal any differences in thickness of the different structures of the nail between the lymphoedema side and the opposite side. The nail matrix was longer on the lymphoedema side. Our study showed mild changes in the nail unit compatible with the xerosis often associated with severe lymphoedema. However, the study also showed frequent evidence of 'ragged' cuticles, which in these patients at high risk of erysipelas are entry points for bacteria. This should be taken into account when counselling patients with limb lymphoedema in order to prevent erysipelas.

Is There a Relationship Between Forefoot Alignment and Ingrown Toenail? A Case-Control Study

Biomechanical imbalance between the hallux and the second toe and external compression of the lateral nail fold are proposed as the main reasons for ingrown toenail. Therefore, any anatomical predisposition facilitating this compression may play a role in the occurrence of ingrown toenail. The purpose of this study is to investigate the relationship between forefoot alignment and ingrown toenail. The authors retrospectively reviewed radiographs of 81 patients with ingrown toenails and compared them with 100 healthy subjects regarding forefoot alignment. Hallux valgus angle (HVA), intermetatarsal angle (IMA), and interphalangeal angle (IPA) were measured, and feet were classified according to digital formula as Egyptian, Greek, and square. The mean HVA was 14.5° ± 5.0° in the case group and 13.2° ± 5.9° in the control group. The mean IMA was 9.1° ± 2.5° in the case group and 8.6° ± 3.1° in the control group. The mean IPA was 11.9° ± 4.1° in the case group and 12.0° ± 5.1° in the control group. There was no statistically significant difference between the groups regarding HVA, IMA, or IPA (P = .123, P = .198, and P = .925, respectively). The distribution of foot types between groups was also similar (P = .967). This study has failed to demonstrate any abnormality in forefoot alignment in patients with symptomatic ingrowing toenails, and it is suggested that treatment should not be based on the correction of the anatomy if no abnormality exists.

Nutrition and nail disease

The nail is a specialized keratinous skin appendage that grows approximately 2 to 3 mm per month, with complete replacement achieved in 6 to 9 months. Although this structure can be easily overlooked, nail disorders comprise approximately 10% of all dermatologic conditions. This contribution first provides an overview on the basic anatomy of the nail that will delineate between the nail unit (eg, hyponychium, nail bed, proximal nail fold, and matrix) and anatomic components not part of the nail unit (eg, lateral nail folds, nail plate, and eponychium). The function of each nail structure will also be presented. The chemical profile of the normal nail plate is reviewed with a discussion of its keratin content (hair type keratin vs epithelial type keratin), sulfur content, and mineral composition, including magnesium, calcium, iron, zinc, sodium, and copper. The remainder will focus on nail manifestations seen in states of malnutrition. Virtually every nutritional deficiency can affect the growth of the nail in some manner. Finally, the discussion will include anecdotal use of nutritional and dietary supplements in the setting of brittle nail syndrome as well as a brief overview of biotin and its promising utility in the treatment of nail disorders.

Pincer nail deformity associated with an arteriovenous fistula for hemodialysis

bed and lateral nail folds, resulting in paronychia with painful swelling, hemorrhage and pus discharge (Figure 2). Pus culture grew abundant Staphylococcus aureus. Her right hand also appeared swollen and congested, and the affected nails displayed leukonychia. The distal nail plate was sent for pathologic examination, which revealed subungual hyperkeratosis with parakeratosis and focal plasma globules. No fungi were identified by periodic acid-Schiff stain. The arteriovenous fistula (AVF) in the right arm and forearm was markedly engorged with strong pulsation and thrill. An X-ray of the hands revealed no obvious bony hypertrophy. The patient was advised to elevate her right arm to reduce venous hypertension. Pain and paronychia improved after symptomatic treatment with a short course of antibiotics and prednisolone (20 mg/day). Evaluation by a cardiovascular surgeon regarding possible revision of vascular shunt was suggested to the patient, but she opted to continue with supportive treatment. Case report A 51-year-old female piano teacher presented with a 3-month history of progressive deformity of the nails of the right hand, associated with painful erythematous swelling of the lateral nail folds. Her medical history was significant for hypertension, hyperlipidemia, diabetes mellitus and end-stage renal disease. She had been undergoing hemodialysis for the past 8 years. She was taking nifedipine, valsartan, doxazosin and fluvastatin. The patient noticed progressive thickening and increased transverse curvature of multiple nail plates, which started with the right thumb and index finger (Figure 1). The distal nail rounded up and pinched deeply into the nail

Periungual lesions in pyoderma gangrenosum

Pyoderma gangrenosum (PG) is a progressive cutaneous necrosis of unknown origin. We report a case of PG presenting with periungual lesions. A 57-year-old woman was on treatment with ciclosporin A for PG. During tapering of the ciclosporin A dose, proliferating periungual lesions developed on the third and fourth finger of the left hand, the fourth finger of the right hand, and on the right great toe and the left fifth toe. All lesions appeared within a 4-week period. These abnormalities were ulcerated, involved about one-third of the distal part of the lateral nail folds including the part of nail fold bordering on the free edge of the nails, and were very painful. The skin biopsy was consistent with that seen in PG. Increasing the ciclosporin A dose led to significant improvement in the periungual lesions within the next few weeks and complete resolution within 6 months.

Acquired digital fibrokeratoma associated with ciclosporin treatment

Conflict of interest: none declared. Ciclosporin (CsA) is the favoured drug for immunosuppressive treatment in recipients of organ transplants. The principal adverse reactions to CsA treatment are renal dysfunction, tremor, hirsutism, hypertension and gingival overgrowth. We report a case of acquired digital fibrokeratoma (ADFK) and concomitant gingival overgrowth secondary to CsA treatment in a renal‐transplant recipient. A 39‐year‐old Chinese woman presented with two gradually enlarging tumours on the left great toe and with gingival overgrowth, which had been present for 2 years. The patient had received a renal transplant 6 years previously and was taking CsA. Physical examination found two solitary, skin‐coloured, firm tumours under the lateral nail folds of the left great toe. One of the tumours was verrucous and slightly erosive and about 12 × 8 × 7 mm3 in size. The other was a tall finger‐like protrusion with a hyperkeratotic surface, about 4 × 3 × 6 mm3 in size (Fig. 1). Diffuse waxy nodules and masses were present on the upper and lower gingiva (Fig. 2).

Nail alterations in 250 infant patients: a clinical study

To investigate the frequency and the nature of nail alterations in infants. A total of 250 infant patients from newborn to 2 years of age were evaluated from the outpatient clinics of paediatrics and dermatology departments, Fatih University Hospital. The nail alterations were documented. The data were presented as percentages, and for categorical comparisons, Chi-squared or Fisher's Exact test were used. P < 0.05 was considered statistically significant. Of the 250 infant patients, nail alterations were seen in only 17 (6.8%). Most of the patients had toe nail involvement. In 12 of 17 (70.6%) infants, there was one type of nail alteration; in 4 of 17 (23.5%) infants, there was two type of nail alterations; and in 1 of 17 (5.9%) infants, there was three type of nail alterations. The most frequent diagnosis was onychoschizia in 6 of 17 (2.4%) and congenital hypertrophy of the lateral nail fold together with ingrown nail in 6 (2.4%) infants. Because nail alterations could be a manifestation of systemic or dermatologic diseases in infants, fingernail and toenail examination should be a part of the paediatric dermatology examination.

Surgical Treatment of Ingrown Toenail without Matricectomy

BACKGROUND Partial excision of the nail matrix (matricectomy) is generally considered necessary in the surgical treatment of ingrown toenail. Recurrences may occur, however, and poor cosmetic results are frequently observed. OBJECTIVE The objective is to present a new surgical procedure for ingrown toenail with complete preservation of the nail matrix. METHODS Twenty-three patients with ingrown toenail were included in this study. The surgical excision was performed 1 week after the completion of treatment of the initial infection. A large volume of soft tissue surrounding the nail plate was removed under local anesthesia. No matrix excision was performed. RESULTS Short-term results were excellent. No recurrences or severe complications were observed during the minimum 12-months follow-up period. Cosmetic results were remarkable. CONCLUSIONS Ingrown toenail results from the compression of the lateral nail folds on the nail plate. This study shows that ingrown toenail can be surgically treated without matricectomy. A large volume of soft tissue surrounding the nail plate should be removed to decompress the nail and reduce inflammation. Cosmetic results are excellent and superior to the classical Emmert plasty. Postoperative nail dystrophies and spicule formation are not observed. The main advantage of this surgical approach is the complete preservation of the anatomy and function of the nail to improve both therapeutic and cosmetic results.

Surgical Treatment of Ingrown Toenail without Matricectomy

Partial excision of the nail matrix (matricectomy) is generally considered necessary in the surgical treatment of ingrown toenail. Recurrences may occur, however, and poor cosmetic results are frequently observed. The objective is to present a new surgical procedure for ingrown toenail with complete preservation of the nail matrix. Twenty-three patients with ingrown toenail were included in this study. The surgical excision was performed 1 week after the completion of treatment of the initial infection. A large volume of soft tissue surrounding the nail plate was removed under local anesthesia. No matrix excision was performed. Short-term results were excellent. No recurrences or severe complications were observed during the minimum 12-months follow-up period. Cosmetic results were remarkable. Ingrown toenail results from the compression of the lateral nail folds on the nail plate. This study shows that ingrown toenail can be surgically treated without matricectomy. A large volume of soft tissue surrounding the nail plate should be removed to decompress the nail and reduce inflammation. Cosmetic results are excellent and superior to the classical Emmert plasty. Postoperative nail dystrophies and spicule formation are not observed. The main advantage of this surgical approach is the complete preservation of the anatomy and function of the nail to improve both therapeutic and cosmetic results.

Nail biology and nail science

The nail plate is the permanent product of the nail matrix. Its normal appearance and growth depend on the integrity of several components: the surrounding tissues or perionychium and the bony phalanx that are contributing to the nail apparatus or nail unit. The nail is inserted proximally in an invagination practically parallel to the upper surface of the skin and laterally in the lateral nail grooves. This pocket-like invagination has a roof, the proximal nail fold and a floor, the matrix from which the nail is derived. The germinal matrix forms the bulk of the nail plate. The proximal element forms the superficial third of the nail whereas the distal element provides its inferior two-thirds. The ventral surface of the proximal nail fold adheres closely to the nail for a short distance and forms a gradually desquamating tissue, the cuticle, made of the stratum corneum of both the dorsal and the ventral side of the proximal nail fold. The cuticle seals and therefore protects the ungual cul-de-sac. The nail plate is bordered by the proximal nail fold which is continuous with the similarly structured lateral nail fold on each side. The nail bed extends from the lunula to the hyponychium. It presents with parallel longitudinal rete ridges. This area, by contrast to the matrix has a firm attachment to the nail plate and nail avulsion produces a denudation of the nail bed. Colourless, but translucent, the highly vascular connective tissue containing glomus organs transmits a pink colour through the nail. Among its multiple functions, the nail provides counterpressure to the pulp that is essential to the tactile sensation involving the fingers and to the prevention of the hypertrophy of the distal wall tissue, produced after nail loss of the great toe nail.

Chronic paronychia: different causes and their treatment

Chronic paronychia is an inflammatory disorder that usually involves fingernails of adult women, affecting the proximal and/or lateral nail folds. It is a multifactorial disorder and, depending on the major etiological factor, can be classified into different types that will be discussed in this review. Besides the use of drugs, management of chronic paronychia requires avoidance of wet environments, chronic microtraumas and contact with irritants or allergens for at least 1–2 months after the cuticle has been restored and the condition has resolved. Clinical appearance of the periungual tissues and nails are important guidelines for treatment.

Squamous cell carcinoma of the lateral nail fold

The digital nail complex is occasionally involved by squamous cell carcinoma. The published literature has either been indiscriminating of the site of origin of this tumour within the nail complex or has concentrated attention on the nail bed as the site of pathology. Tumours originating in the lateral nail fold can be clearly differentiated from those of the nail bed itself. This study identifies six cases of squamous cell carcinoma arising in the lateral nail fold. While surgical convention remains to amputate the digital tip for squamous cell carcinoma of any part of the nail complex, the dermatological literature identifies that local surgery can be curative for these tumours, when presenting early and without bone involvement, although offering no discussion of reconstruction. Reconstruction is desirable and methods of achieving this following local excision of lateral nail fold tumours are illustrated in this series.

Reconstruction of the Great Toe Ski-Slope, Sunken-Nail Deformity with a Buried Adipofascial Flap

Development of a ski-slope deformity following loss of the great toe nail plate is a problematic condition with few conservative or surgical options available. The condition becomes more difficult to treat when the distal, medial, and lateral labial nail folds are hypertrophied, creating the appearance of a sunken nail. We present a case of ski-slope, sunken-nail deformity following multiple attempts at chemical nail matrixectomy. The patient's persistent pain and deformity were managed through 1) nail plate avulsion and complete surgical excision of the germinal nail matrix, 2) remodeling of the distal phalanx, and 3) elevation of an adipofascial flap from the plantar tuft of the great toe, which was brought from plantar to dorsal and interposed between the dorsal aspect of the distal phalanx and the overlying nail bed in buried fashion. The combination of these procedures elevated the nail bed, which restored normal architecture to the great toe and relieved the pain associated with the chronic deformity. This case demonstrates a potential complication of a commonly performed procedure and a salvage technique useful for dealing with the resultant ski-slope, sunken-nail deformity.

Periungual lipoma: About three cases

Lipomas are one of the most common benign soft tissue tumors. The usual development sites are the neck, the torso, and the legs. Lipomas of the nail unit are extremely rare. Only five cases have been reported up to now, four in subungual locations and one in the lateral nail fold. We report three cases of peri-ungual lipomas, one on the digit and two on the toes. Two of them exhibited the histological features of perisudoral lipomas.

Gouty Tophi

BACKGROUND Digital lesions can have a broad differential diagnosis. Squamous cell carcinoma (SCC), the most common digital malignant neoplasm, must be excluded as the cause of persistent digital lesions causing nail dystrophy. OBJECTIVE To describe a patient with a periungual hyperkeratotic lesion on the left fifth digit which, upon initial dermatopathologic examination, appeared to be a malignancy. However, on further biopsy, the lesion proved to be a gouty tophus. METHODS Case report and literature review. RESULTS An 84-year-old white man presented with a hyperkeratotic papule on the lateral proximal nail fold of the left fifth digit, which resulted in nail dystrophy for 1 year. Similar lesions were present on several other digits which did not affect the nail plate. Initial biopsy was consistent with actinic keratosis and was treated with cryotherapy. When the lesion persisted, repeat biopsy was performed, demonstrating fragments of squamous epithelium with focal atypia and an infiltrative growth pattern. SCC could not be excluded and the patient was referred for Mohs micrographic surgery (MMS) consultation. An excisional biopsy was performed and a white chalky material was observed at the base of the defect. Histopathology confirmed a gouty tophus. The patient was referred to his primary care physician and was treated with allopurinol. CONCLUSION This is the first report of gouty tophus of the periungual region presenting as a hyperkeratotic lesion. Initial clinical diagnosis favored SCC and histologic evidence suggested a possible early SCC. This lesion can be confused with digital squamous cell carcinoma. The presence of pseu- docarcinomatous hyperplasia may complicate accurate diagnosis.

Surgical Pearl: Hemostat-assisted nail avulsion revisited

J Am Acad Dermatol 2001;45:943-4.