Nail Morphology Research Articles

Osteoid osteoma of the distal thumb phalanx: A case report

Osteoid osteomas of the hand are uncommon. Particularly, location in the thumb and involvement of the distal phalanx are very rarely reported. Long diagnostic delay and inadequate treatment are typical, since clinical features may mimic other causes more frequently found in the same site (post-traumatic, infective, rheumatic, neoplastic conditions, regional pain syndrome) and even the nail morphology may be altered, as in the reported case (watch-glass deformity). A case of an osteoid osteoma of the distal thumb phalanx in a 27-year-old man is presented, along with its clinical, radiographic and CT findings. In the Authors' opinion, curettage should be considered the treatment of choice.

Treatment of Chronic Idiopathic Onychodystrophy with Intake of Carotene-rich Food.

Onychodystrophy refers to the various abnormalities in nail morphology due to changes in the attachment of the nail plate, changes in nail surface or color. The treatment principle of onychodystrophy largely relies on the discovery and verification of the cause. However, preventive treatment methods offer little help to the patient due to poor compliance, and the effect of corticosteroid is only temporary. To evaluate the clinical efficacy of carotene-rich food intake in chronic idiopathic onychodystrophy. Ten patients with chronic idiopathic onychodystrophy were recommended to drink one or two cups of carrot juice daily. Patients showed improvement of onychodystrophy after drinking carrot juice twice a day for at least 4 weeks. No specific adverse effects were noted. Since there are no reliable treatment methods for chronic idiopathic onychodystrophy, we suggest a simple and compliant treatment method consisting of taking carotene-rich food, such as carrot juice, for patients with chronic idiopathic onychodystrophy.

Clinical pitfalls: a painful nail enlargement

Editor Alterations in the structure and appearance of the nail unit may be seen in association with a variety of dermatological disorders.1 Because of the limited number of reaction patterns associated with the nail unit, many of the changes that are seen, such as onycholysis, pitting and subungual hyperkeratosis, are not specific. However, certain clinical findings, especially when present in combination, may be highly suggestive of a specific diagnosis or may assist in limiting the differential diagnosis. A 63-year-old woman was referred for the evaluation of a painful enlargement and severe third left finger nail deformity of 2 months’ duration. The lesion started at the dorsal side of the proximal nail fold and migrated distally toward the hyponychium. Clinically, there was a greenish-blue discoloration associated to severe onychodystrophy, massive subungual hyperkeratosis causing uplifting of the nail plate and partially onycholysis at the distal phalanx (fig. 1). Advanced subungual hyperkeratosis resulting in uplifting of the nail plate with distal nail bed, ‘oil spot’ involvement of nearly the entire nail bed and hyponychial involvement. The woman was otherwise in good general health, and there was no involvement of other skin areas. A fungal infection of the area was excluded by examination of a potassium hydroxide preparation. Complete general physical and mucocutaneous examination was done. Laboratory evaluation was within normal limits. The patient refused the nail biopsy. The risk of scarring and injuring the nail matrix was unacceptable to her. Ultrasonography (US; fig. 2) with very high frequency transducers (Esaote AU-4 Idea Biomedica, Genoa, Italy) of the distal interphalangeal joint showed well-defined thickness of the nail matrix and nail bed. Hand X-ray film revealed acral lamellar periostitis; both were suggestive of the diagnosis of nail psoriasis. Keratolytic agents and topical Calcipotriol/betamethasone dipropionate were administered. After 2 weeks of treatment, there was a clear improvement confirming the clinical and imaging diagnosis. Real-time US using 13-MHZ linear probe; sonographic longitudinal section of the distal interphalangeal joint showed well-defined thickness of the nail matrix and nail bed, with slight eye catching signal at power Doppler, together with superficial soft tissue thickening at the distal phalanx. Nail psoriasis can create diagnostic difficulties and may remain undiagnosed for a long time. It occurs in 10% to 50% of psoriasis patients, particularly those with arthritis, and about 1% to 5% of patients manifest nail changes alone.2 This is the category of patients in whom the clinician faces a formidable diagnostic challenge because psoriatic nail disease resembles other causes of dystrophic nails. Nail morphology in psoriasis depends upon the anatomical location of the disease process.3 The chief complaint of patients with psoriasis is the unsightliness of nails. They also battle lowered self-esteem, feelings of being socially isolated, and the stress associated with the unpredictable intervals of flaring disease and spontaneous remissions leading to significant disfigurement and disability. It is an often persistent disease and frequently refractory to treatment. Topical treatments are barely effective, and possible side-effects of systemic treatments limit their usefulness in uncomplicated nail psoriasis.4 The diagnosis of nail psoriasis is usually straightforward when characteristic nail findings coexist with cutaneous psoriasis.5 Diagnostic difficulty arises when nail disease occurs as an isolated finding. Ungueal psoriasis and onychomycosis, especially distal subungual onychomycosis, are often indistinguishable by clinical examination alone. In our patient, the personal and family history, clinical examination, the X-ray film, dermatological sonography and a strict clinical follow-up led us to make the right diagnosis, thereby avoiding the biopsy. Dermatological sonography of soft tissues should be done more widely for the evaluation of nail psoriasis.6 This art requires a great deal of training and experience to be practical, and sometimes, it can substitute the microscopic examination.7,8 Advancements in technology will improve the correlation of clinical findings with high frequency ultrasound findings in the assessment of several skin diseases. Many thanks to Dr Stefania Cigna and Dr Frank Iacobellis, Assistant Clinical Professor of Dermatology, New York Presbyterian Hospital and the Stanford Weill Cornell Medical School for their technical and linguistic assistance.

Nail thickness measurements using optical coherence tomography and 20-MHz ultrasonography

Nail diseases are often troubling to the patient and may present a diagnostic challenge to the dermatologist. Biopsies from the nail may be required although often perceived uncomfortable by the patient and potentially scarring. Noninvasive technologies are therefore of particular interest in the study of nails. Optical coherence tomography (OCT) is an optical imaging modality which may provide improved data. This study evaluates nail morphology and thickness in OCT images in comparison with high-frequency ultrasound (HFUS) imaging of the nail. Ten healthy volunteers were recruited for imaging and nail measurements; OCT and HFUS images were compared qualitatively. Nail thickness measurements with four different techniques were compared: ultrasound, OCT, polarization-sensitive (PS) OCT and callipers. The OCT system was developed at Risoe National Laboratory, Denmark. A commercially available 20-MHz ultrasound system (Dermascan; Cortex Technology, Hadsund, Denmark) was used. In standard OCT the nail plate appeared as a layered structure containing a varying number of horizontal homogeneous bands of varying intensity and thickness. PS-OCT images of the nail plate also showed a layered structure. The refractive index of the nail was 1.47 +/- 0.09. OCT and PS-OCT had low coefficients of variation, 6.31 and 6.53, respectively, compared with other methods: HFUS 12.70 and callipers 14.03. PS-OCT has to our knowledge not been applied to OCT analysis of the nail, and offers some advantages in separation of the nail bed from the nail plate.

Do fungi play a role in psoriatic nails?

Onychomycosis is the most common disease of the nails and constitutes about a half of all nail abnormalities. Some factors like increasing age, male sex, repeated nail damage, genetic predispositions and underlying conditions, such as diabetes, immunodeficiency or peripheral arterial disease may predispose to develop onychomycosis. It is also suggested that abnormalities in nail morphology are the predisposing factors to onychomycosis. Psoriasis is one of the most common reasons of disturbed nail morphology and the spectrum of nail changes in psoriasis is very wide. Thus, there were suggestions that dystrophic nails in psoriatic patients lose their natural preventing barrier and therefore are more predisposed to fungal infection. This paper summarizes the knowledge about prevalence of onychomycosis among psoriatic patients and contains a literature review concerning this problem. Most authors report that the prevalence of onychomycosis in psoriatic patients is not higher than that in control population. However, especially yeasts and maybe moulds, probably as concomitant pathogens, are more often isolated from psoriatic patients than from non-psoriatic population. In reasonable cases, the mycological examination is required, especially when the clinical picture of the nails suggests the presence of fungal infection. In these cases, antifungal treatment may be beneficial for psoriatic patients.

Patients at risk of onychomycosis – risk factor identification and active prevention

The aims of this workshop were to identify risk factors for onychomycosis and to reach consensus on the management of high-risk groups to allow the development of guidelines to help doctors recognize risk factors that complicate treatment. Previous Trichophyton rubrum infection, older age, abnormal nail morphology, immunodeficiency and genetic factors were identified as risk factors for initial infections. Risk factors for recurrence (relapse and re-infection) are largely the same. The experts agreed that the prevention of onychomycosis and its recurrence should be based on the correct treatment of tinea pedis, screening family members and adequate patient education. In addition, generic management recommendations for each high-risk group were discussed: * Immunosuppressed patients Usual dose and treatment length not appropriate Follow-up required Beware of drug interactions * Diabetics Prophylactic foot care combined with nail treatment Good opportunity for patient education, footwear, foot care, etc. Beware of drug interactions * Psoriatics and patients with abnormal nails Dermatophyte eradication does not restore normal nails * Children High failure rate possibly due to compliance problems.

Topical antifungal drugs for the treatment of onychomycosis: an overview of current strategies for monotherapy and combination therapy

Onychomycosis is a relatively common disease accounting for up to 50% of all nail disorders and its prevalence rises with age. As onychomycosis is an important medical disorder affecting both patient's health and quality of life, it requires prompt and effective treatment. Topical antifungal nail lacquers have been formulated to provide efficient delivery to the nail unit. As both amorolfine and ciclopirox have proved useful as monotherapy for onychomycosis that does not involve the nail matrix area, the purpose of this article is to check if, when combined with oral agents, the effectiveness and scope of treatment can be improved further. Combining data for mycological cure with clinical success (nail morphology) provides a more exacting efficacy measure. Clinical investigations have shown that the combination of oral therapies with antifungal nail lacquer can confer considerable advantage over monotherapy with either drug type. The improved effectiveness and economic advantages of combined topical/oral therapies benefit both patients and health providers; these treatment regimens therefore have an important role to play in the modern management of onychomycosis.

Dolichonychia in women with Marfan syndrome.

Dolichonychia refers to nails that are elongated and slender. This nail morphology has been described in single case reports of patients with Ehlers-Danlos syndrome, hypohidrotic ectodermal dysplasia, and Marfan syndrome. The length and width of fingernails were measured in patients with Marfan syndrome and in individuals without the syndrome. A fingernail index was calculated for each person. A non-parametric sign test was used to compare the mean fingernail index of patients with Marfan syndrome and control subjects. The fingernail index ranged from 0.92 to 1.52 in patients with Marfan syndrome and from 0.77 to 1.30 in control individuals. The median fingernail index in women with Marfan syndrome (1.455) was significantly greater than the median fingernail index in women control subjects (1.080) (P = 0.035). Dolichonychia, defined as a fingernail index greater than or equal to 1.30, was present in six of eight (75%) of women with Marfan syndrome as compared with only one of 40 (2.5%) of women control subjects. Dolichonychia is a physical finding present in some patients with Marfan syndrome. The detection of long narrow fingernails in women should suggest the possibility of Marfan syndrome.

Nail morphology studies as assessments for onychomycosis treatment modalities

The purpose of this investigation was to study the morphology of the human nail treated with chemical penetration enhancers (CPE), bioadhesives and surface modifiers for assessment of topical treatment modalities for onychomycosis. CPEs, including dimethyl sulfoxide (DMSO) and urea were applied to human nail samples. Additional samples were treated with surface modifiers, tartaric acid (TTA) and phosphoric acid gel (PA). Other nail specimens were subjected to the bioadhesive polymers Carbopol® 971P and Klucel® MF. Atomic force microscopy (AFM), scanning electron microscopy (SEM) and polarized light microscopy (PLM) were utilized to visualize nail morphology and topographical changes of the human nail samples subjected to the various chemical agents. AFM, SEM and PLM micrographs revealed changes in topography to the dorsal layer when CPEs and surface modifiers were applied. Roughness scores as determined by nanoscope™ iiia software indicated a 2-fold increase when the dorsal nail layer was subjected to PA versus the control (147.8 vs. 85.0 nm, respectively). In contrast, when carbomer 971P was applied to the dorsal surface, roughness scores decreased significantly (44.6 vs. 85.0 nm, respectively). AFM, SEM and PLM studies of the human nail subjected to various chemical agents may be useful in the design and formulation of novel drug delivery systems for the topical treatment of onychomycosis. The AFM studies offer both a qualitative and quantitative assessment for nail treatment opportunities.

加齢による爪の成分と形態の変化

In contrast to the abundant researchs as to the aging symptoms of skin, very little is known about those of nails, beyond the decline in the rate of growth and the appearance of vertical lines. However, many women want their nails to be kept in a healthy and fresh condition, as well as their skin, particularly facial skin. To satisfy this demand, it is necessary to understand various symptoms of nail which appear with aging and elucidate the mechanisms of the changes.A study was conducted, therefore, in which the changes in nail caused by aging were investigated using SEM. The lipid content in nail was measured by GC, GC-MS, or HPLC, and the moisture content absorbed, the water holding capacity and the strength of nail were determined.It was found that the nails of people over about ten years showed an increase in the desquamation of corneocytes on the nail surface, a reduction in the content of intercellular lipids such as cholesterol and cholesteryl sulfate, and a decrease in moisture absorption and water holding capacity. Nails in which the lipids was removed using acetone showed a decrease in strength against breaking. The structure and moisture absorption function of such nails were similar to those of aged nails. A correlation was also observed between the content of cholesterol in nail and the moisture absorption function.From the above findings, it is shown that the decrease in the content of intercellular lipids affects the changes in the morphology and properties of nails seen with aging. Consequently, as in skin care, the healthy condition of nails is considered to be maintained by the supply of moisturizing substances, particularly intercellular lipids.

The nails in adult type 1 pityriasis rubra pilaris: A comparison with Sézary syndrome and psoriasis

The fingernails of twenty-four patients with classical adult (type 1) pityriasis rubra pilaris were examined for changes in nail morphology and a comparison was made with the fingernail morphology of twenty-seven consecutive psoriatic patients with nail changes. Distal yellow-brown discoloration, subungual hyperkeratosis, nail plate thickening, and splinter hemorrhages indicate a diagnosis of type 1 pityriasis rubra pilaris rather than psoriasis, while onycholysis (particularly marginal), salmon patches, small pits, and larger indentations of the nail plate indicate a diagnosis of psoriasis. Histology demonstrated that a nail biopsy would be a useful diagnostic procedure if nails were involved in isolation but provided no additional diagnostic features to those found from biopsy specimens of involved skin in the two conditions. The similarity in nail morphology between the type 1 pityriasis rubra pilaris patients and five patients with chronic erythroderma resulting from Sézary syndrome indicated that these changes may represent a nonspecific reaction pattern that may result from prolonged erythema of the proximal nail bed and matrix. The rough nails (trachyonychia) described in advanced Sézary syndrome were not observed in any of our patients.

The importance of nail morphology in the differential diagnosis of pityriasis rubra pilaris, psoriasis and chronic erythroderma

The importance of nail morphology in the differential diagnosis of pityriasis rubra pilaris, psoriasis and chronic erythroderma

Treatment of the Ingrown Toenail: And a New Anesthetic Method

The present study evaluated the properties of nails, frequency of ingrown nails in patients with type 2 diabetes mellitus (DM), risk factors for developing ingrown nails, and effect of diabetic polyneuropathy and vasculopathy on the development and outcome of ingrown nails. Our 6-month epidemiologic prospective study included 300 patients with type 2 DM attending a DM outpatient clinic for routine examinations. The general characteristics and foot changes of the study population were investigated. Diabetic polyneuropathy and vasculopathy were evaluated using a biothesiometer, monofilament tests, and arterial Doppler ultrasonography. The frequency of ingrown nails was 13.6%. Multivariate analysis with logistic regression showed that body mass index (odds ratio [OR] 1.077, 95% confidence interval [CI] 1.007 to 1.15; p = .03), previous trauma (OR 2.828, 95% CI 1.017 to 7,867, p = .042), a weak dorsalis pedis pulse (OR 2.72, 95% CI 1.17 to 6.30, p = .02), trimming type (OR 2.3, 95 CI 1.06 to 4.98), p = .35), onychogryphosis (OR 9.036, 95% CI 2.34 to 34.87, p = .001), and subungual hyperkeratosis (OR 4.3, 95% CI 1.99 to 9.3, p = .001) were predictive variables for ingrown nails in our population. The incidence of onychomycosis was significantly greater in patients with ingrown nails (p = .032) than in patients without ingrown nails. The nail curvature ratio was greater in the patients with ingrown nails than in the group with normal nails. Arterial Doppler ultrasound examinations showed peripheral arterial disease in 19 patients (46.9%) with ingrown nails. The prevalence of ingrown nails was greater in the patients with DM than in the healthy population. Our results indicate that nail type, nail morphology, and diabetic vasculopathy affect the formation and evolution of ingrown nails.