Diagnostic significance of nailfold bleeding in scleroderma spectrum disorders

BACKGROUND

The early detection of scleroderma spectrum disorders (SSD) is important.

OBJECTIVE

Our purpose was to determine the prevalence of nailfold bleeding in SSD.

METHODS

We examined patients for nailfold bleeding in the following three groups: (1) 81 patients with SSD including 50 patients with scleroderma, 10 with mixed connective tissue disease, and 21 with Raynaud's phenomenon having specific antinuclear antibody (ANA); (2) 99 patients with other connective tissue diseases or primary Raynaud's phenomenon; and (3) 200 patients with common skin diseases.

RESULTS

The frequency of nailfold bleeding was significantly higher in SSD (75.3%) than in other connective tissue diseases (12.1%) and in controls (3.0%). The presence of nailfold bleeding in two or more fingers showed a 98.3% specificity for SSD. Among the patients with SSD, the incidence of nailfold bleeding in scleroderma, mixed connective tissue disease, and Raynaud's phenomenon with specific ANA was similar. Nailfold bleeding strongly correlated with the presence of anticentromere antibody.

CONCLUSION

The presence of nailfold bleeding is useful for the early detection of SSD.

Cutaneous alterations in patients with chronic renal failure

The purpose of this study was to evaluate the prevalence of dermatologic problems among patients with chronic renal failure (CRF) undergoing hemodialysis or peritoneal dialysis. One-hundred and two patients with CRF were examined for the presence of cutaneous alterations. All patients examined had at least one cutaneous lesion. The most prevalent findings were alterations in the cutaneous pigmentation. Of particular interest was an increased prevalence of hyperpigmented macules on the palms and soles. Other manifestations, seen particularly in the hemodialysis group, included the half-and-half nail, pruritus, and keratotic pits of the palms and soles. Infectious processes were more prevalent in the group undergoing peritoneal dialysis. This study showed that all patients with CRF have some type of cutaneous alteration and that the type of dialysis could have some influence upon the incidence of these changes.

How common are benign subungual naevi?

The differentiation of subungual haematoma from benign and malignant nevoid lesions is a common clinical problem. To determine the incidence of benign subungual naevi in the general population, the digits of the hands and feet of 1000 white patients were examined. These were consecutive patients presenting to hospital for problems unrelated to the finger or toe-nail. Eight patients were found to have pigmented subungual lesions. All proved to be haematoma, although there was no history of injury. Benign subungual naevi are rare in caucasians, so subungual nevoid lesions should be regarded as malignant until proved otherwise.

Superficial mycoses in Saudi Arabia

Between June 1988 and December 1990, 1018 cases of superficial mycoses were investigated. Diagnosis was confirmed by microscopic examination in 503 cases and the causal agent was isolated in 490 cases. Tinea capitis accounted for 47.7% (92.5% in children below 10 years of age). The frequency of other clinical types in descending order was pityriasis versicolor 25.8%, tinea corporis 9%, onychomycosis 5.8%, tinea pedis 4%, intertrigo 3.9% and tinea cruris 2.8%. Erythrasma was encountered three times and mixed piedra and trichomycosis axillaris once. Microsporum canis was the commonest aetiological agent, responsible for 46.9% of ringworm infections. Malassezia furfur was the next most common agent (26.5%) followed by Candida albicans (8.6%) and Trichophyton violaceum (8.2%). Other species were found less frequently. T.simii was isolated from four cases of tinea cruris and one each of tinea capitis and tinea corporis, and Piedraia hortae and Trichosporon beigelii from a case of mixed piedra infection.

[Onychomycosis. Clinico-epidemiological mycological and therapeutic aspects]

Onychomycosis is the most frequent cause of nail disease. Dermatophytic and Candida onychomycosis have a similar frequency (54% and 45%), while only in 1% they are caused by molds. Tinea unguium equally affects both sexes and is mainly observed in the first toenail. T. rubrum is the fungus responsible in 87% of dermatophytosis. The ungual candidosis is three times more frequent on the hands in women and is due to C. albicans in 99% of the cases. Both types of onychomycosis are observed in children. Clinical diagnosis of onychomycosis based on direct KOH examination. Treatment includes the removal of the infested keratin and use of local or systemic antimycotics, such as griseofulvin, ketoconazole and itraconazole.

A rapidly growing pigmented nail streak resulting in diffuse melanosis of the nail. A possible sign of subungual melanoma in situ

Subungual melanomas are one of the most common types of malignant melanoma among the Japanese population. Although most pigmented nail streaks are benign and remain unchanged in their color and shape for a long time, rarely are they precursor lesions of subungual melanomas i.e., a rapid growing pigmented nail streak resulting in diffuse melanosis of the nail is thought to be an early stage of subungual melanoma in situ. We found four patients with these changes: three of these patients were children. The lesions occurred on the right index finger, right thumb, left middle finger, and right great toe, respectively. A slightly haphazard combination of colors ranging from dark brown to black, the important characteristic of subungual melanoma in situ, was observed in two cases. In the remaining two cases, although the haphazard combination of colors was not distinctive, many fine, dark longitudinal lines were seen within diffuse, light-brownish pigmentation. Serial histologic examination of the excised tissue specimens showed great proliferation of vacuolated melanocytes with variable nuclear atypicality along the entire basal layer in all cases. These histologic changes were compatible with those of atypical melanocytic hyperplasia or intraepidermal melanoma (in situ melanoma), which is an early lesion of subungual melanoma. An adult case is thought to be a definite example of a subungual melanoma in situ. We also made the diagnosis of melanoma in situ in the remaining three cases of children with rapidly growing pigmented nail streaks because their histopathologic features were distinguishable from those of the adult case. However, there remains some hesitation about this because invasive subungual melanoma is rare in children.

Koilonychia of the toenails in children

Two hundred twenty-four children were examined for koilonychia of the toenails. Koilonychia was encountered in 55 out of 171 (32%) kibbutz children compared with 9 out of 53 (17%) of urban children (p less than 0.046). The most likely explanation for the increased prevalence of koilonychia in kibbutz children is habitual minor trauma associated with barefoot walking and frequent water immersion.

Clinical observations on nail changes in psoriasis

410 cases of psoriasis [282 males (68%) and 127 females (31%)] were interviewed and examined to study the nail changes. The prevalence of nail changes was 78.0% (males = females). Common changes were pitting (67.5%) and onycholysis (67.2%). Dystrophy of varying degrees occurred in 35.0%, subungual hyperkeratosis in 24.7%, discoloration in 18.4%, loss of nails in 2.8% and pustulation in 1.3%. Pitting and onycholysis was the most common combination (45.6%). Nail changes were significantly more common in patients who have moderate to severe psoriasis as compared with patients with mild psoriasis; in patients who have psoriasis for greater than 5 years as compared with patients who have psoriasis for less than 5 years; and in patients older than age 50 as compared with those aged less than 50. A definite correlation was found between the prevalence of nail changes and the presence of scalp and periungual psoriasis, and the presence of joint involvement.

Laugier-Hunziker syndrome

The Laugier-Hunziker syndrome represents a rare acquired pigmentary disorder of the lips, oral mucosa, and nails. We report the first case of this syndrome to be recognized in the United States and review other causes of hyperpigmentation in these locations.

Hendersonula toruloidea and Scytalidium hyalinum infections in London, England

In a survey of 399 patients with superficial fungal lesions who had been born outside Western Europe, 32 cases of Hendersonula toruloidea infection and 11 cases of Scytalidium hyalinum infection were diagnosed. The hyphae of these two non-dermatophytes in skin were indistinguishable from each other but could be distinguished from those of dermatophytes. Both the non-dermatophyte infections were limited to the palms, soles, two webs and nails. The geographical origins of the infected patients were analysed and it appeared that S. hyalinum infection was geographically more limited than H. toruloidea infection.

Incidence of brittle nails

Only few reports exist about the occurrence of brittle nails. We examined 1,584 persons with respect to the incidence of this anomaly. The patients were from five different groups: outpatients of a dental clinic, blood donors, residents of an old people's home, patients of a clinic for internal diseases and patients of a general practice. Approximately 20% of the subjects examined had brittle nails. Women suffered from brittleness of nails much more frequently than men (27 vs. 13%) with a ratio of men to women from 1:1.6 to 1:7 depending on age. 44% of the subjects affected (75% of the females, 25% of the males) had tried one or several treatments but only 26% believed in their curative effect. The market for the therapy of brittle nails in the FRG is estimated to be between 2 and 4 million people.

Melanomas of volar and subungual skin in Puerto Ricans. A clinicopathologic study

Nineteen Puerto Rican patients with malignant melanomas in volar and subungual areas were evaluated to define their clinical and histologic characteristics. Ten were male and nine female, with an age span of 36 to 113 years and a median age of 71 years. Sixteen of the lesions were located on the soles or heels of the feet, and three were subungual. Histologically, all nineteen patients exhibited a radial growth phase diagnostic of acral lentiginous melanoma, and twelve of nineteen were Clark's level IV or V. Tumor thickness fluctuated between 0.27 mm and 13.6 mm, with a total of twelve lesions greater than 6 mm. Eleven patients had regional lymph node enlargement at the time of diagnosis; two had regional skin metastasis and one had metastasis to the liver. Survivals ranged from 7 months to 7 years, with an average duration of 2.76 years and an overall mortality of 66% in those patients after a 3-year follow-up. Based on this study, we conclude that the biologic behavior of acral lentiginous melanoma in Puerto Ricans is similar to that reported in other series, with most of the lesions being deeply invasive and correlating with a poor prognosis.

The white nails of old age (neapolitan nails)

Nail changes similar to those reported by Terry and Lindsay were defined in an elderly inpatient population. Two hundred fifty-eight patients were studied, and an overall incidence of 19 per cent was found. There was no significant difference between men and women. The only significant correlations in this study were with osteoporosis and thin skin. Eight men with nail changes were compared with seven men without such changes by calculating the metacarpal index of cortical bone mass. The index was much lower in patients with nail changes (t = 2.64; P less than 0.01). All patients with nail changes had thin skin. No correlations were found with serum albumin, liver function, or kidney function. These nail changes are less frequent in the "less frail" elderly living in the community. Changes of the Terry type are common in children but disappear by early adult life. It is suggested that the nail changes are age-related phenomena and that they may reflect an underlying disturbance of collagen being manifested as changes in the nail bed, skin, and bone.

[The incidence of subungual erythema]

In this study, 506 patients from several hospitals, especially from departments of internal medicine, were examined in order to find out the frequency of subungual erythemas (half and half nails, brown arcs). 44 patients suffered from small erythemas (less than 30%). The nails of 69 patients were inspected after kidney transplantation, only 5 of them revealed subungual erythema, 2 our of 61 healthy persons showed the subungual erythema. There were signs of renal failure in most patients with subungual erythema.

Fungal infections of the nails in Western Australia

Between 1963 and 1972, 986 fungi were isolated from the nails of patients in Western Australia. Three clinical types of infections in both finger and toe nails were studied. All 3 types occurred more commonly in adults over the age of 20. Multiple infections were relatively frequent. Two hundred and fourteen of the nail infections were caused by dermatophyte fungi. Trichophyton rubrum was the predominant aetiologic agent isolated from both finger and toe nails, T. mentagrophytes and other dermatophytes were involved to a lesser degree. Paronychia of the finger nails was common and mainly caused by C. albicans. Aspergillus species were the most frequent fungi grown from superficial white onychomycosis.

The prevalence of splinter haemorrhages

A study was undertaken to determine the prevalence and distribution of subungual splinter haemorrhages in healthy individuals. They were found commonly in both sexes, though significantly more frequently in males. Where present in females, they were confined to a single digit.