Allium sativum Extract Chemical Composition, Antioxidant Activity and Antifungal Effect against Meyerozyma guilliermondii and Rhodotorula mucilaginosa Causing Onychomycosis

Onychomycosis is a major health problem due to its chronicity and resistance to therapy. Because some cases associate paronychia, any therapy must target the fungus and the inflammation. Medicinal plants represent an alternative for onychomycosis control. In the present work the antifungal and antioxidant activities of Alium sativum extract against Meyerozyma guilliermondii (Wick.) Kurtzman & M. Suzuki and Rhodotorula mucilaginosa (A. Jörg.) F.C. Harrison, isolated for the first time from a toenail onychomycosis case, were investigated. The fungal species were confirmed by DNA molecular analysis. A. sativum minimum inhibitory concentration (MIC) and ultrastructural effects were examined. At the MIC concentration (120 mg/mL) the micrographs indicated severe structural alterations with cell death. The antioxidant properties of the A. sativum extract were evaluated is a rat turpentine oil induced inflammation, and compared to an anti-inflammatory drug, diclofenac, and the main compound from the extract, allicin. A. sativum reduced serum total oxidative status, malondialdehyde and nitric oxide production, and increased total thiols. The effects were comparable to those of allicin and diclofenac. In conclusion, the garlic extract had antifungal effects against M. guilliermondii and R. mucilaginosa, and antioxidant effect in turpentine-induced inflammation. Together, the antifungal and antioxidant activities support that A. sativum is a potential alternative treatment in onychomycosis.

Nail clipping in onychomycosis and comparison with normal nails and ungual psoriasis

BACKGROUND

Of all nail disorders seen in dermatology offices, half of them are due to onychomycosis. The main differential diagnosis is nail psoriasis. The objective of this study was to compare the microscopic findings, other than the presence of fungi, in the clipping of onychomycosis versus normal nails and nail psoriasis.

METHODS

Cross-sectional study of onychomycosis cases, analyzed by clipping and compared with data on normal nails and those with nail psoriasis.

RESULTS

Sixty-two onychomycosis samples were compared with 30 normal nails and 50 nails with psoriasis. In onychomycosis, measurement of subungual region, serous lakes, neutrophils and number of layers of parakeratosis are more intense than in psoriasis. Onychocariosis is less common in psoriasis, while bacteria are more frequent. The nail transition zone is more commonly blurred and irregular in onychomycosis.

CONCLUSION

Clipping helps in the differential diagnosis of onychomycosis and nail psoriasis and may be useful even when fungi are not found.

DNA-based detection for onychomycosis correlates better to histopathology than does fungal culture

Onychomycosis is a prevalent disease of the nail. Traditional methods for diagnosis include direct microscopy with potassium hydroxide (KOH microscopy) and fungal culture. Other techniques using histochemical staining have higher sensitivity, but cannot identify genus or species of the infecting agent. PCR assays are sensitive, specific, and capable of genus and species level identification. We describe a real-time PCR assay for 15 different fungi that are associated with onychomycosis. Of 425 clinical samples suspected of onychomycosis analyzed by fungal culture and PCR, 219 samples were positive for both (52% agreement). Of the 206 discordant samples, 95% were resolved in favor of PCR by DNA sequencing. On a larger data set of 2,452 samples, positivity rates for histopathology, PCR, and culture were 85%, 73%, and 54% respectively. Further, 48% of PCR positive and 51% of histopathology positive samples were negative by culture. PCR outperformed culture compared to histopathology for sensitivity (80% versus 49%), specificity (92% versus 79%), positive predictive value (94% versus 77%), and negative predictive value (76% versus 52%). These results indicate the culture method lacks the sensitivity to be a reliable assay for onychomycosis, that PCR and histopathology are highly concordant, and that PCR provides the highest degree of diagnostic accuracy available.

Acquired digital fibrokeratoma presenting as a painless nodule on the right fifth fingernail

A 53-year-old woman presented with an asymptomatic nodule on the distal subungual right fifth fingernail that had slowly enlarged over the last year. An excisional biopsy showed an acanthotic epidermis surmounted by hyperkeratotic scale as well as a fibrotic dermis with collagen bundles assuming a vertical orientation to the long axis of the epidermis, characteristic of an acquired digital fibrokeratoma (ADF). There was no sign of recurrence 4 months following excision. There are no known associations or risk factors for development of ADF, though prior trauma might play a role. This case describes the clinical and histopathological features of ADF and the differential diagnosis and treatment options. It is important to consider ADF when examining subungual nodules, and to be able to identify and differentiate between other benign and malignant nail tumors.

The nail flag sign in heart transplant recipients: case reports and review of the patients with the flag sign of the nail

The nail plate flag sign is a distinctive nail plate change that appears as white, red, white, and red sequential transverse bands beginning at the proximal nail fold. This distinctive nail change was initially described in patients with diabetes mellitus and leprosy; indeed, it was considered to be characteristic, but not diagnostic of leprosy. Subsequently, the flag sign was observed in patients with vitiligo. The flag sign has recently been noted in two men following heart transplantation. In summary, the flag sign is a unique nail change that has occurred in patients with autoimmune disorders, infection, and post transplantation surgery associated with immunosuppressive therapy to prevent organ rejection.

Investigation of diabetic patient's fingernail quality to monitor type 2 diabetes induced tissue damage

Long-term Type 2 Diabetes (T2D) affects the normal functioning of heart, kidneys, nerves, arteries, bones, and joints. The T2D gradually alters the intrinsic material properties, and structural integrity of the tissues and prolonged hyperglycemia causes chronic damages to these tissues quality. Clinically no such technique is available which can assess the altered tissues quality associated with T2D. In the present study, the microstructural characterization (surface morphology, surface roughness and density and calcium content), material characterization (modulus, hardness), and macromolecular characterization (disulfide bond content, protein content and its secondary structure) are investigated among healthy, diabetic controlled (DC) and uncontrolled diabetic (UC) group of fingernail plate. It is found that T2D has an adverse effect on the human fingernail plate quality. The parameters of nail plate quality are changing in a pattern among all the three groups. The properties mentioned above are degrading in DC group, but the degradation is even worst in the case of severity of T2D (UC group) as compared to the healthy group (Healthy Collapse

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MESH Headings

• Adult
• Aged
• Bone and Bones/metabolism
• Chronic Disease
• Diabetes Mellitus, Type 2/metabolism
• Female
• Humans
• Male
• Middle Aged
• Nails/metabolism
• Nails/pathology

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Grants

• IIT Ropar

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Nail Involvement as a Predictor of Disease Severity in Paediatric Psoriasis: Follow-up Data from the Dutch ChildCAPTURE Registry

Little is known about the relationship between nail psoriasis and psoriasis severity in children, and there has been no longitudinal assessment of psoriasis severity related to nail psoriasis. The aim of this study was to assess whether nail psoriasis could serve as a predictor for a more severe disease course. De-identified data were obtained from the ChildCAPTURE registry, a daily clinical practice cohort of children with psoriasis, from September 2008 to November 2015. Cross-sectional analyses were performed at baseline. Longitudinal data until 2-year follow-up were analysed by linear mixed models. Nail psoriasis was present in 19.0% of all 343 patients at baseline and cross-sectionally associated with higher Psoriasis Area and Severity Index (PASI) (p = 0.033). Longitudinal analysis demonstrated higher PASI (p <0.001) during 2-year follow-up in patients with nail involvement at baseline. These findings suggest that nail psoriasis is a potential clinical predictor for more severe disease course over time in paediatric psoriasis.

Nail size and appearance following nail fusion plasty of thumb duplication✰

PURPOSE

To evaluate nail appearance after nail fusion plasty to treat thumb duplication.

METHODS

A modified form of nail fusion plasty was performed on 17 reconstructed thumbs of 16 children with thumb duplications, commencing in January 2010. We assessed nail width and nail, lunular, and nail fold deformities using the Wang-Gao scoring system. All 17 thumbs were evaluated over an average of 32 months (range, 12-48 months) of follow-up.

RESULTS

One patient with bilateral thumb deformities was excluded. The width ratios of 15 reconstructed nails (compared with those of the contralateral thumbs) were 82-118% (average, 97%). Nine thumbs exhibited nail ridges or gaps; the average ridge/gap score was 1.23 (maximum, 2). Six thumbs exhibited lunular deformities; the average score was 1.58 (maximum, 2). Another six thumbs evidenced nail fold deformities; the average score was 1.64 (maximum, 2). Only one thumb exhibited nail dehiscence. Two thumbs had no nail deformity. The final assessments were excellent in 14 cases, good in 2 cases, and fair in 1 case.

CONCLUSIONS

We could not significantly reduce the deformity rate of the nail plate, nail fold, or lunula using our new technique, but the deformities were much less marked than previously. Nail fusion plasty usefully enlarges the nail and pulp in patients with hypoplastically duplicated thumbs.

[A woman with a growing mass close to the fingernail]

A 23-year-old woman had a painful, growing mass close to the nail of her left index finger. The differential diagnosis consisted of acquired digital fibrokeratoma, digital fibromyxoma, periungual fibroma or verruca vulgaris. Surgical excision of the mass was performed, and histopathological analysis revealed a subungual exostosis.

Subungual nail bed melanoma masquerading as tinea ungium

Subungual amelanotic melanoma can masquerade as onychomycosis. Recently a man whose amelanotic nail bed melanoma presented as persistent onychodystrophy was reported in the Dermatology Online Journal. The patient had a persistent nail dystrophy; culture and biopsy of the nail demonstrated Candida and dermatophyte infection, respectively. However, he subsequently presented with a nodule that was biopsied and demonstrated melanoma. Similar to that patient, we recently described a 67-year-old woman with a four-year history of persistent nail dystrophy of the left fourth fingernail who had a periodic acid-Schiff staining of the nail plate demonstrating fungal hyphae. Her nail plate subsequently detached, demonstrating a friable nodule; a biopsy of the nodule demonstrated melanoma. In conclusion, in individuals with new morphologic changes to a dystrophic nail or with persistent nail dystrophy despite appropriate therapy, it is important for clinicians to consider performing additional evaluation and possible biopsy to exclude malignancy.

Ultrasonography of the nail unit reveals quantitative and qualitative alterations in patients with psoriasis and psoriatic arthritis

AIMS

The nail unit is a matter of interest both for dermatologist and rheumatologist. The nail is considered one of the possible targets of assessment, especially when ultrasonography is performed. The aim of the study is to highlight peculiar features and alterations of the nail unit in patients affected by psoriasis and psoriatic arthritis versus healthy controls using ultrasonography.

MATERIALS AND METHODS

The study sample included 82 patients affected by psoriasis and/or psoriatic arthritis and 50 healthy controls. The patients were consecutively enrolled during their routine visit in the outpatient clinic and they performed clinical and ultrasonographic evaluation of the nail. The evaluationof disease activity was done using Disease Activity in Psoriatic Arthritis (DAPSA), Psoriasis Activity Severity Index (PASI), and Nail Psoriasi Severity Index (NAPSI).

RESULTS

Multivariate analysis of variance was performed between groups. Post hoc analysis underlined the differences between healthy and affected regarding nail plate thickness (0.063±0.011 cm for patients with psoriasis, 0.065±0.014 cm for patients with psoriatic arthritis and 0.051±0.006 cm for healthy controls, p<0.05). Elementary lesions of nail plate and nail bed were compared using Pearson's chi square test between patients in psoriasis and psoriatic arthritis groups, with no differences except for a trend for onycholisis and crumbling (p=0.07 and 0.06, respectively) in the psoriatic arthritis group. ROC curves were calculated (AUC = 0.68) obtaining also quantitative cut offs for nail plate andnail bed thickness in the affected vs healthy patients.

CONCLUSIONS

Our study shows that ultrasonography may be a potential advantage in clinical practice. Our results strengthen the information already available in the literature and add quantitative parameters for ultrasonography of the nail.

Epidermolysis Bullosa (EB) Acquisita in an Adult Patient with Previously Unrecognized Mild Dystrophic EB and Biallelic COL7A1 Mutations

Circulating anti-type VII collagen autoantibodies are frequently detected in patients with recessive dystrophic epidermolysis bullosa (RDEB). However, evidence supporting their pathogenic role in inducing epidermolysis bullosa acquisita (EBA) has been provided for only one individual with dominant dystrophic epidermolysis bullosa (DDEB). We describe here a patient who presented with dystrophic toenails since early childhood and developed trauma-induced skin blisters and oral erosions at age 26 years. Direct immunofluorescence showed IgG deposits with a u-serrated pattern along the cutaneous basement membrane zone, while no change in the expression of collagen VII could be detected by antigen mapping. High-titre anti-collagen VII antibodies were detected by enzyme-linked immunoassay (ELISA). In parallel, sequencing of epidermolysis bullosa (EB) genes identified compound heterozygous COL7A1 missense c.410G>A (p.Arg137Gln) and splicing c.3674C>T (p.Ala1225_Gln1241del) mutations, previously unrecognized in dystrophic epidermolysis bullosa (DEB). Thus, our patient had RDEB "nails-only" and developed mechanobullous EBA in adulthood. These data support a pathogenic role of circulating autoantibodies to collagen VII in inducing EBA in selected patients with DEB. Unforeseen worsening of skin symptoms in DEB should prompt laboratory investigations for EBA.

Gel manicures and ultraviolet A light: A call for patient education

Gel manicures have become a popular beauty trend in recent years. The specially formulated nail polish must undergo curing under light-based units. The majority of these curing lamps emit high-intensity ultraviolet A, which can cause skin damage and increase the risk for skin cancers. Incorporating relevant information in patient education endeavors can help them practice avoidance, apply broad-spectrum sunscreen prior, or use nitrile exam gloves in order to prevent photoaging and skin cancer resulting from these procedures.

An amelanotic nail bed melanoma presenting as persistent onychodystrophy

Nail apparatus melanomas are rare and may present with a wide variety of clinical presentations. In particular, the amelanotic subtype can pose a diagnostic challenge, often leading to a poor prognosis related to a delayed diagnosis. We report a 69-year-old man with an unusual subungual amelanotic melanoma presenting as a persistent single nail dystrophy that was repeatedly treated as onychomycosis. Owing to the delayed diagnosis of the melanoma and to minimize recurrence risk, the patient underwent a partial amputation of his left thumb.