Nail Apparatus Research Articles

Dermoscopic Features of Subungual Squamous Cell Carcinoma: A Study of 44 Cases

Background: Subungual squamous cell carcinoma (SSCC) is the most frequent tumor of the nail apparatus. Its diagnosis is often missed or delayed because the clinical presentation is atypical and can mimic other conditions. Accurate diagnosis can only be made by performing an appropriate surgical biopsy, but biopsy is painful and often leaves definitive dystrophic scars. The use of dermoscopy, a noninvasive technique, has been described to be useful for the preoperative evaluation of nail diseases. Objectives: To define the different clinical and dermoscopic presentations of SSCC and to compare them with onychomatricoma-associated clinical and dermoscopic features published in our previous study. Methods: A retrospective review of 44 cases of SSCC seen in our institution over an 8-year period. Six observers scored 19 clinical criteria and 14 dermoscopic criteria as present or absent. Then, we compared those data to a previously published study about the preoperative diagnosis of onychomatricoma. Results: Only 1 dermoscopic criterion was significantly associated with SSCC compared to onychomatricoma: localized hyperkeratosis (odds ratio, OR = 6.25, p = 0.012, 95% confidence interval CI = 1.50-26.01). In contrast, parallel edges (OR = 0.03, p < 0,001, 95% CI = 0.003-0.20) and sharp demarcation of the lesion (OR = 0.24, p = 0.004, 95% CI = 0.09-0.63) can statistically significantly be considered as in favor of onychomatricoma. By contrast, we believe that the presence of unparalleled lateral edges of the nail lesion or of fuzzy edges are more in favor of SSCC. Conclusions: Dermoscopy of the nail plate and of the nail free edge in SSCC provides useful information in order to better select cases to be submitted to biopsy.

Subungual melanoma: Management in the modern era

Subungual melanoma is a rare subtype of cutaneous melanoma that arises from the structures of the nail apparatus. It presents most commonly in older patients and at an advanced stage. A retrospective review of all patients with subungual melanoma in a single institution over a 15-year period was performed. In total, 54 patients were included (26 males, average age 62.9 years), of which 28 cases involved the upper limb. Median tumour thickness was 4.5mm. Eighteen patients had lymph node metastasis at diagnosis, including 11 of 36 patients with positive sentinel lymph node biopsy. Median survival was 4.6 years. Subungual melanoma has a poor prognosis that is strongly associated with presence of nodal disease at diagnosis. Sentinel lymph node biopsy should be considered to determine stage and prognosis.

THE EXPERIENCE WITH THE APPLICATION OF THE POLYCHROMATIC INCOHERENT POLARIZED LIGHT FOR THE TREATMENT OF THE PATIENTS PRESENTING WITH ONYCHODYSTROPHIES ASSOCIATED WITH LICHEN RUBER PLANUS

This article was designed to report our original results and share the experience with the application of low-intensity polychromatic incoherent polarized radiation for the treatment of the patients presenting with onychodystrophies associated with lichen ruber planus. The clinical effectiveness of phototherapy was evaluated taking into consideration the dermatological index and dynamics of structural changes in the nail. In the patients treated by the medication therapy alone, the dermatological index reflecting the severity of the pathological process decreased by 74% within 4 months after the onset of therapy whereas it fell down by 96% on the average during the same period in the patients in whom the medication therapy was supplemented by the application of low-intensity polychromatic incoherent polarized radiation. It is concluded that the combined pharmacophysiotherapeutic method produces more pronounced effect on the ultrastructure of the nail apparatus than pharmacotherapy alone; its application is pathogenetically substantiated.

Nail Changes in Early Mycosis Fungoides

Background: Mycosis fungoides (MF) has a wide range of clinical presentations and it has been reported rarely to involve the nail apparatus. Objective: We intended to evaluate the frequency and characteristics of nail changes in patients with biopsy-proven MF. Methods: A retrospective analysis of 60 patients with MF who were evaluated at our cancer center from 2013 to 2014 was performed to identify patients with nail changes. Histological examinations of the skin around the nail apparatus were obtained from 10 patients with periungual skin erythema and scaling. Results: In 45 patients out of 60 cases, the skin around the nail apparatus was normal, and only in 5 patients of these 45 cases, nail changes were detected. These changes included leukonychia, longitudinal ridging, nail thickening, and opacity. In the remaining 15 patients, erythema and scaling was observed in periungual skin, and 13 of them demonstrated nail changes including longitudinal ridging, nail thickening, fragility of the nail plate, subungual hyperkeratosis, pigmented nail band, Beau's lines, onychomadesis, koilonychia, nail thinning, distal notching, subungual debris, leukonychia, and pitting. In biopsies of periungual skin, none of 10 cases revealed histological findings consistent with MF. Conclusions: Evidence of nail changes was observed in 18 cases (30%). The most common nail changes detected in MF patients included longitudinal ridging, nail thickening, nail fragility, and leukonychia.

Nail apparatus melanoma thickness is associated with side and age

Nail apparatus melanoma (NAM) is a rare variant of cutaneous melanoma that arises in the nail unit and typically appears as melanonychia in its early stage.1 Since the factors associated with the progression of NAM are not fully understood, 102 cases of NAM were analysed to identify clinical factors associated with Breslow's thickness. This article is protected by copyright. All rights reserved.

A Novel Apremilast Nail Lacquer Formulation for the Treatment of Nail Psoriasis.

The objective was to prepare a novel nail lacquer formulation to improve the ungual and trans-ungual delivery of apremilast for the potential treatment of nail psoriasis. Nail lacquer formulation was prepared using Eudragit® S 100 as a film-forming polymer and the mixture of ethanol, ethyl acetate, and water as a solvent system. As a result of high-throughput screening studies, dexpanthenol and salicylic acid were found to be the potential penetration enhancers. After 7days of in vitro studies, the cumulative amount of apremilast delivered by the nail lacquer formulation across the nail plate was found to be ~3-fold (0.52±0.07μg/cm2) more compared to control (nail lacquer formulation without enhancers) (0.19±0.02μg/cm2). The cumulative amount of apremilast retained in the nail plate in the case of nail lacquer formulation was 1.26±0.18μg/mg which was found to be ~2-fold more compared to control (0.57±0.07μg/mg). Human subject studies were performed on the nails of thumb and index finger of six volunteers for 15days. As a result, the cumulative amount of apremilast retained in the free distal edge of the nail plate in the case of nail lacquer was found to be ~2-fold (0.93±0.14μg/mg) more related to control (0.41±0.04μg/mg). As a conclusion, nail lacquer formulation was found to be capable of delivering a substantial amount of apremilast into the nail apparatus; thus, it can be a potential option for the treatment of nail psoriasis.

Dermoscopic evaluation of melanonychia.

The prevalence of melanonychia is approximately 1%, and it is a common symptom encountered in daily practise. However, it may also be the first symptom of melanoma of the nail apparatus. Evaluation of adult melanonychia with clinical information and clinical images is sometimes difficult for clinicians. Dermoscopic observation provides important information based on the algorithm method. Melanonychia in children requires a different approach, because dermoscopic features observed in adult nail apparatus melanoma are generally observed in benign pediatric cases.

Important malignant and new nail tumors.

The nail apparatus is an integral part of the functional unit of the digital tip. Although overall uncommon, all cells and tissues occurring in this area can give rise to neoplastic lesions. Given the special anatomical location, such tumors frequently show morphological and symptom-related differences compared to similar lesions located elsewhere on the skin. Though particularly threatening, there is often a substantial delay in the diagnosis of Bowen's disease, ungual squamous cell carcinoma, and melanoma. Nevertheless, local excision with sufficient surgical margins is usually sufficient and superior to amputation of the distal phalanx. In recent years, a number of nail-specific tumors have been described. Tumors such as onychomatricoma, onychocytic matricoma, onychocytic carcinoma, and onychopapilloma originate from the nail matrix. Onycholemmal cysts, onycholemmal horn, and the proliferating onycholemmal tumor are characteristic nail bed tumors. Onycholemmal carcinoma is a slowly growing low-grade malignancy. Using modern diagnostic methods, careful examination - including biopsy and histopathology - of nail changes not responding to conservative treatment will help identify nail-specific neoplasms and prevent the progression of malignant nail tumors.

Nail neoplasms.

Nail neoplasms include all tumors occurring in the nail or periungual apparatus tissue. While some nail tumors can be similar to tumors located on the skin, others are unique. Both benign and malignant lesions can affect the nail apparatus. In particular, early malignant tumors like melanoma and squamous cell carcinoma can present similarly to onychomycosis or benign melanonychia and frequently missed by clinicians. Therefore, physicians should be aware of nail structures and the characteristics of nail tumors. Our review covers the normal nail structure and the most common nail tumors from benign to malignant.

Management and treatment of nail melanoma.

An early and prompt nail apparatus melanoma (NAM) diagnosis is associated with less invasive surgical procedures and a better patient's prognosis. The diagnostic delay may be related both to the clinical misinterpretations and to errors in the diagnosing process. Biopsy techniques have been adequately described by nail experts, but the two main problems in the correct choice of the biopsy are probably related to the difficulty in performing surgery in the nail unit and the risk of permanent nail dystrophy. We retrospectively investigated anamnestic data and diagnostic procedures that all NAM patients referred from 1992 to January 2014, with the following objectives: 1) to evaluate the initial misdiagnoses and quantify the diagnostic delay; 2) to correlate the type of the initial biopsy with the achievement of the correct diagnosis. In our cases it was easier for a non-dermatologist to misdiagnose NAM for a benign inflammatory disease. Dermatologist instead were easier to refer patients to a tertiary center for nail diseases. In the presence of a NAM clinical and dermoscopic suspicion, longitudinal biopsy is recommended in all cases of nail pigmentation (lateral or median), that is estimated in its width as 3-6 mm, or larger than 6 mm. Regarding therapeutic surgery in our experience disarticulation compared to "functional surgical excision" did not correlate with a better prognosis.

Nail apparatus melanoma initially diagnosed as nail matrix blue nevus: a case report with dermatoscopy and dermatopathology.

We present a case of nail apparatus melanoma in a 50-year-old woman presenting as new and changing longitudinal melanonychia of the right thumb. Very heavy melanin pigmentation involving both the epidermis and dermis interfered with dermatopathological assessment, which initially leads to a diagnosis of nail matrix blue nevus. After consultation with a specialist multidisciplinary clinic the diagnosis was revised to invasive melanoma, a diagnosis consistent with the clinical and dermatoscopic assessment.

長期間にわたり経過観察した爪部malignant melanoma &lt;i&gt;in situ&lt;/i&gt;の1例

症例は25歳，女性。16歳時から右環指爪に茶色の色調変化があった。19歳で初診，色素線条は右環指中央から小指寄りに幅5 mmで，爪表面は平滑で変形もなし。明らかな染み出しはないが，micro－Hutchinson signあり。爪部母斑と考えられたが，ごく初期のmalignant melanoma（MM）in situの可能性も否定できず，定期観察を開始。1年後，線条の一部分が濃くなり，幅6 mmと太くなったが，その後1年の経過で薄くなった。3年半の経過中，常に爪の表面は平滑。一時通院を自己中断していたが，出産後から線条が濃くなり，先端に亀裂を生じたため再受診。経過，ダーモスコピー所見から，MM in situと臨床診断し，切除術を施行。病理組織学的にもMM in situであった。経過を通じ，爪部の色調の変化を観察できたMM in situの1例をダーモスコピー所見とともに文献的考察を加え報告する。

Exuberant Koenen tumors: effective treatment with amputation of the nail apparatus and reconstruction with full thickness skin grafts

Exuberant Koenen tumors: effective treatment with amputation of the nail apparatus and reconstruction with full thickness skin grafts

Acquired blue nevus of the nail bed

Blue nevi are benign proliferations of melaninproducingdendritic melanocytes located in thedermis. These nevi tend to occur mostly on the skin,predominantly on the head and neck, dorsal aspectsof the distal extremities, and the sacral area, butcan also occasionally appear on mucosal surfaces.Blue nevi of the nail apparatus are uncommon. Themajority originate in the nail matrix where there is ahigher density of melanocytes. Herein we report ona 47-year-old man with a rare common blue nevus ofthe nail bed, an area with low melanocyte density. Athorough review of the English language literaturefound no documented cases of acquired blue nevioriginating in the nailbed of the toe.

Speckled variance optical coherence tomography for the assessment of nail involvement in acrodermatitis continua of Hallopeau: A case study.

Noninvasive techniques for nail imaging would be useful for confirming diagnosis and monitoring treatment response at the microscopic level in patients with nail psoriasis. However, the use of ultrasound and high-resolution magnetic resonance imaging in nail evaluation is limited. Optical coherence tomography (OCT) produces high-resolution images of transversal tissue sections and represents an optimal approach to the study of the nail. This study used a multibeam OCT instrument to produce speckled variance OCT (SV-OCT) blood-flow images, which were used to measure the degree of change over successive scans. Nail changes, inflammation and response to therapy were evaluated in a 75-year-old female patient with psoriasis who had severe acrodermatitis continua of Hallopeau of the hands, treated for 4 weeks with 40 mg adalimumab (administered subcutaneously every other week) and 25 mg prednisone (administered orally, daily). SV-OCT provided a detailed assessment of the nail structures in relation to inflammation of psoriatic tissues. Restoration of the normal anatomy of the nail apparatus was apparent following adalimumab treatment; SV-OCT evaluation correlated with clinical appearance. SV-OCT may have a diagnostic role and provide an objective tool to assess clinical and subclinical inflammation in nail psoriasis.

Malignant Melanoma of the Nail Apparatus

Background Malignant melanoma of the nail apparatus is exceedingly rare. Increasingly, genetic studies have been employed to aid in distinguishing between malignant melanoma and benign melanocytic nevi. Methods Archived nail apparatus melanomas were analyzed by fluorescence in situ hybridization (FISH) using probes targeting the genes at 6p25 (RREB1), 11q13 (CCND1), 8q24.1 (MYC), 6q23 (MYB), 9p21 (CDKN2A) and the centromeres of chromosomes 8 (D8Z2) and 6 (D6Z1). The results were correlated with clinical and demographic information. Results Mean patient age was 57.8 years (range 23-92 years). In all, 5 of 7 (71%) cases involved the upper extremity digits. RREB1 gain was seen in all cases. CCND1 gain was seen in 6 of 7 (86%) cases, 3 of which were amplified. MYB loss and MYC gain were both seen in 5 of 7 (71%) cases. Homozygous loss of CDKN2A was not observed in any case. Two of 7 (28.6%) patients had lymph node metastasis and died of widely metastatic disease. These 2 patients harbored the most genetic aberrations: gains of RREB1, CCND1, and MYC, and MYB loss. Both benign melanocytic nevi controls showed normal FISH results. Conclusions RREB1 and CCND1 gains are common in nail apparatus melanoma as in most melanomas, and an increased number of genetic aberrations may be associated with a poorer prognosis, though the limited number of cases precludes definitive correlation. FISH appears to be a useful adjunct in the diagnosis of nail apparatus melanomas and improves diagnostic confidence even in the setting of unambiguous histomorphology.

Eficacia de las técnicas quirúrgicas más utilizadas en el tratamiento de la onicocriptosis: una revisión sistemática

BackgroundThe onychocryptosis, commonly known as ingrown toenail, is a condition of the nail apparatus in which damages the nail fold. This causes pain and inflammation and has serious alterations person's quality of life, causing inability to perform daily activities. So, is very important to choose a good treatment. Material and methodsA literature review was conducted to assess which surgical technique for the treatment of onychocryptosis was the most frequently used in the period (2007-2014), and which has lower rate of relapse and / or recurrence presented. The selection resulted in 13 articles evaluating chemical matrixectomies techniques and wedge resection technique, Suppan I or similar. ResultsThe chemical matrixectomies was the most employed techniques to treat ingrown toenails, mainly employing phenol as caustic agent. In the same way, had significantly lower rates of relapse and / or recurrence (2.02%) than wedge resection techniques or Suppan technique ConclusionsChemical matrixectomies are currently the most widely used surgical techniques, which provide good results and low recurrence rates presented, so are considered the most effective technique for the treatment of onychocryptosis.

Iontophoresis for drug delivery into the nail apparatus: exploring hyponychium as the site of delivery

In present studies, a hyponychium pathway (from ventral side of the nail plate) was investigated as a potential route of drug delivery into the nail apparatus using iontophoresis as an active physical method. In vitro transport studies were performed across the human nail plate using sodium fluorescein as a marker substrate for 24 h. After transport studies, the amount of sodium fluorescein extracted from an active diffusion area of the nail plate in case of iontophoresis was found to be ∼54-folds more to that of passive. The amount of sodium fluorescein retained in the peripheral area of the nail plate after application of iontophoresis was found to be ∼30-folds more relative to passive. Ex vivo transport studies were performed on excised human cadaver toe using terbinafine hydrochloride as a model drug for three days (8 h/day). The amount of terbinafine retained in the nail plate after application of iontophoresis (3.43 ± 1.34 µg/mg) was ∼20-folds more when compared with passive (0.17 ± 0.10 µg/mg). The amount of drug extracted from the nail bed and nail matrix was 1.73 ± 0.12 µg/mg and 0.55 ± 0.22 µg/mg, respectively. On the other hand, there was no detectable amount of terbinafine found in the nail bed and nail matrix in case of control (passive delivery). These studies show that the iontophoretic drug delivery through hyponychium region to other parts of the nail apparatus could be a potential way of onychomycosis treatment.

How effective is efinaconazole in the management of onychomycosis?

ABSTRACTIntroduction: Onychomycosis is a fungal nail infection that is difficult to treat due to poor accessibility of drugs into the nail plate. Although oral antifungals can reach the nail apparatus more readily, these therapies may not be suitable or desirable for some patients (e.g., multiple medications or immunocompromised). Efinaconazole 10% solution is a new topical antifungal recently approved and sold in Canada, the United States and Japan for the treatment of mild-to-moderate toenail onychomycosis. Efinaconazole has broad-spectrum antifungal activity against dermatophytes, nondermatophyte molds and yeasts, and high ungual penetration due to its low keratin binding properties.Areas covered: The objective of this article is to summarize recent data regarding the efficacy, safety and pharmacokinetic properties of efinaconazole in the treatment of onychomycosis.Expert opinion: Efinaconazole is a safe and effective treatment for onychomycosis that can be used in a wide range of patients due to its broad-spectrum antifungal activity andlow rate of treatment-related adverse events. When incomplete response to oral therapy or devices (e.g. laser therapy) is encountered, efinaconazole could be used in combination to improve success rates. Alternatively, efinaconazole could be used as a ‘closer’ drug, in an effort to provide cure when the initial oral or device therapy has resulted in an incomplete response.

Dermoscopic features of conjunctival, mucosal, and nail pigmentations in a case of Laugier-Hunziker syndrome.

A 23-year-old man presented with multiple lip pigmentations. Longitudinal hyperpigmented streaks on his nails, as well as an ill-defined 2×3 mm pigmented spot on his right eye were noted (Figure 1). The family history was unremarkable. He was not taking any medication. Figure 1. Clinical view of labial (A), ungual (B) and conjunctival (H) pigmentations are shown. Dermoscopic findings included reticular lines (B), globules (C), and parallel lines (D) in the labial pigmentation; brown to gray longitudinal regular lines (F, G) in ... Colonoscopy and barium radiography of intestine were unremarkable. Complete blood count, complete metabolic panel, and urinalysis were within normal limits. The patient was diagnosed with Laugier-Hunziker syndrome (LHS). Dermoscopic examination of the lip pigmentations disclosed parallel lines, reticular lines and globules. The only recognized color was brown, which had a grayish hue in some parts of the lesion. A light brown colored homogeneous pattern was observed in the conjunctival pigmentation. The pigmented nail streaks showed brown-to-gray longitudinal regular lines (Figure 1). Histopathological examination of the labial pigmentation revealed basal keratinocyte pigmentation. No increase in the melanocyte count was identified with S100 and HMB45 immunohistochemical staining. Iron accumulation was not seen with specific Perls’ stain. The histopathological findings were compatible with the diagnosis of melanotic macule. Impression cytology examination of the conjunctival pigmentation revealed melanocytes with only a mild atypia suggesting a benign nature. The patient was processed to follow-up. LHS is a rare, acquired disease characterized by hyperpigmented macules of the lips and oral mucosa along with longitudinal melanonychia. Pigmentations in other mucosal surfaces may also exist. Although this syndrome is being regarded as benign, invasive mucosal melanoma has been reported in a case of LHS [1]. Parallel ridge pattern and irregular diffuse pigmentation in acral lesions; irregular lines on a brown background and micro-Hutchinson’s sign in nail apparatus lesions [2]; and the combination of blue, gray, or white color with structureless zones in mucosal lesions are the dermoscopic findings suggestive of melanoma [3]. Little data exists regarding the dermoscopic features of conjunctival pigmentations in the literature. Atypical pigment network, irregular dots and globules, regression structures, and a blue-white veil are the dermoscopic findings reported in a case of palpebral conjunctival melanoma [4]. Dermoscopic findings may differ from usual in some pigmentation syndromes including LHS. Parallel ridge pattern has been determined in benign acral pigmentations of several LHS cases [5–7]. Although nail pigmentations in LHS have been found to demonstrate similar dermoscopic findings with that seen in ethnic type and drug induced pigmentation, which are regular linear pigmentation lines on a grayish background, micro-Hutchinson’s sign have also been reported in benign nail pigmentations of some LHS cases [2,5,8]. Parallel furrow pattern, brown and blue-gray granular pigmentation along with linear and dotted vessels on whitish pink areas are the dermoscopic findings reported in labial pigmentations of LHS cases [5]. The only LHS case with labial melanoma in the literature exhibited blue-whitish veil on dermoscopic examination [1]. Dermoscopic findings in the present case were consistent with benign nature. The dermoscopic finding of a conjunctival pigmentation in LHS is being reported for the first time by the present study. The identification of dermoscopic features of this syndrome may simplify the management of LHS. Further reports are necessary to arrive at a conclusion.