Nail Involvement in Alopecia Areata: A Questionnaire-based Survey on Clinical Signs, Impact on Quality of Life and Review of the Literature

Alopecia areata (AA) is an immune-mediated disease causing temporary or permanent hair loss. Up to 46% of patients with AA also have nail involvement. The aim of this study was to determine the presence, types, and clinical implications of nail changes in patients with AA. This questionnaire-based survey evaluated 256 patients with AA. General demographic variables, specific nail changes, nail-related quality of life (QoL), and treatment history and need were evaluated. Prevalence of nail involvement in AA was 64.1%. The specific nail signs reported most frequently were pitting (29.7%, p = 0.008) and trachyonychia (18.0%). Red spots on the lunula were less frequent (5.1%), but very specific for severe AA. Nail-related QoL was only minimally affected by nail changes. In conclusion, nail involvement is common in patients with AA and presents mostly with pitting and trachyonychia. The presence of these nail changes reflects the severity of the disease, with red spots on the lunula as a predictor for severe alopecia.

Distal Lateral Subungual Onychomycosis Owing to Tritirachium oryzae: A Bystander or Invader?

The genus Tritirachium is a mitosporic fungus which inhabits in soil and decaying plant material and also a notable insect pathogen. Human infections with Tritirachium species though rare were previously reported to cause corneal ulcers, otomycosis, onychomycosis, and dermatomycosis of the scalp and hence may be considered as a potential pathogen. Here we report a case of distal lateral subungual onychomycosis involving right great toenail in a 22-year-old female, wherein direct potassium hydroxide preparations, fungal cultures, and molecular sequencing of the isolate established Tritirachium oryzae as the etiological agent. Antifungal susceptibility performed by the microbroth technique of CLSI revealed increased MICs to amphotericin B and low MICs to azoles and echinocandins. The case was managed with surgical nail avulsion followed by topical application of 2% ketoconazole cream resulting regrowth of normal nail. To the best of our knowledge, this is the first report of non-dermatophytic mold T. oryzae causing onychomycosis in India.

Missed opportunity to diagnose subungual melanoma: potential pitfalls!

Subungual melanoma, an uncommon form of acral melanoma that arises within the nail matrix, accounts for 1%-3% of all cutaneous melanoma in Caucasians. As subungual melanoma presents in a more disguised manner than cutaneous lesions, increased vigilance is required. It most commonly presents as a discolouration of the nail, nail splitting or nail-bed bleeding. Black pigmentation of the adjacent nail fold, termed Hutchinson's sign, may be a diagnostic clue. Treatment of subungual melanoma remains surgical with wide local excision and amputation primary modalities. We present the case of a 61-year-old man with an 18-month history of a left thumb nail-bed abnormality and a 6-week history of left axillary lymphadenopathy. One year earlier, he presented to the emergency department with a purulent discharge from his left thumb but declined nail-bed ablation. He was referred to the 'Hand and Plastic Injuries Clinic' by his general practitioner and diagnosed with a chronic traumatic-induced nail-bed injury. As his symptoms did not improve, he was referred to the 2-week wait Skin Cancer Clinic. The left thumb nail-bed was excised as a nail unit down to bone, and the diagnosis of melanoma was rendered. Left axillary lymphadenopathy was confirmed as metastatic melanoma. He underwent amputation of his left thumb at the interproximal phalangeal joint, and a left axillary node dissection was performed. No residual melanoma was identified in his thumb. Microscopically, his left axillary dissection confirmed 9 out of 36 positive nodes for metastatic melanoma with extracapsular spread. He was staged at IIIC disease. This case report demonstrates missed opportunities to diagnose subungual melanoma and acts as a cautionary tale in considering this pathology in the differential diagnosis of nail-bed lesions with prompt referral for further investigation.

Lesson of the month 2: Dry skin, yellow nails and breathlessness

Interstitial lung disease (ILD) is a common clinical problem, representing a group of diseases consisting of inflammation and progressive fibrosis of the lung. In some cases, an underlying cause is not identified; however, a significant proportion of ILD is associated with connective tissue disease (CTD). A detailed history and examination is the most important part of the assessment of patients with suspected ILD and will direct further investigation. This case illustrates the importance of identifying the symptoms and signs of CTD when assessing a patient with ILD. In addition, we describe an unusual presenting manifestation of yellow nails, which is not a recognised feature of CTD-ILD, but improved following immunomodulatory treatment for the overall condition.

Surgical Treatment of Subungual Squamous Cell Carcinoma by Wide Excision of the Nail Unit and Skin Graft Reconstruction: An Evaluation of Treatment Efficiency and Outcomes

Importance

The best surgical treatment modalities for subungual squamous cell carcinoma (SUSCC) without bone invasion need to be determined. The limited available data on Mohs micrographic surgery do not demonstrate its use as a standard procedure. A previous study in a limited series of patients has shown that wide surgical excision of the nail unit was associated with a low rate of recurrence.

Objectives

To confirm the efficiency of wide surgical excision of the nail unit with full-thickness skin graft reconstruction on a series of patients with SUSCC with an extended follow-up and to evaluate short- and long-term postoperative morbidity and patient satisfaction.

Design, Setting, and Participants

A consecutive series of 55 patients with biopsy-proven SUSCC without bone invasion treated by wide surgical excision of the nail unit followed by full-thickness skin graft reconstruction from January 1, 2000, to August 31, 2012 were included. After a minimum follow-up of 5 years, the recurrences were collected from the referring physicians. Statistical analysis was conducted from January 1 to June 30, 2016.

Main Outcomes and Measures

Demographic data, pathologic characteristics of tumors, postoperative follow-up, and recurrences were collected from medical records. Patients' satisfaction with surgery, quality of life, and delayed postoperative morbidity (functional outcome and sensory disorders) were assessed from a questionnaire mailed to patients and physicians.

Results

Among the 55 patients (23 women and 32 men; mean age, 64 years), the mean follow-up was 6.6 years (range, 5.0-11.2 years), with a minimum follow-up of 5 years. Fifty-two questionnaires (95%) were returned. Two recurrences were observed. Minor early postoperative complications, such as graft infection and delayed wound healing, were seen in 6 patients; 8 patients experienced severe pain. Late postoperative complications included hypersensitivity to mechanical shocks (39 of 51 patients [76%]), mildly increased sensitivity to cold (38 of 51 patients [75%]), loss of fine touch sensation (17 of 35 patients [49%]), and epidermal inclusion cysts (9 of 51 patients [18%]). Most patients were very satisfied with cosmetic and global outcomes of the surgery.

Conclusions and Relevance

Total excision of the nail unit followed by a full-thickness skin graft is a safe and efficient treatment for SUSCC without bone involvement, with satisfying cosmetic and functional outcomes.

[Nail changes : diagnostic considerations in everyday medical general practice]

Consultations for nail changes are frequent in everyday practice with direct diagnostic considerations into different directions, traumatism, infection, inflammation being the most common ones, and neoplasia being less frequent. The most common symptom is ungual dystrophia ; that is an alteration or perturbation of ungual growth. It presents differently depending on nature or length of the underlying pathologia. The purpose of this article is to highlight some ungual disorders to help the general practitioner to identify and refer them to the specialist if necessary.

Alterations of Hair and Nail Content of Selected Trace Elements in Nonoccupationally Exposed Patients with Chronic Depression from Different Geographical Regions

The aim of this study was to determine if altered levels of selected trace elements manifest themselves during chronic depression. To identify elements strongly associated with chronic depression, relationships between the elemental contents of hair and nails and the interelement correlations were checked. Inductively coupled plasma mass spectrometry and ion chromatography were used to evaluate the contents of Zn, Cu, Co, Pb, Mn, and Fe in hair and nail samples from a total of 415 subjects (295 patients and 120 healthy volunteers). The study included logistic regression models to predict the probability of chronic depression. To investigate possible intercorrelations among the studied elements, the scaled principal component analysis was used. The research has revealed differences in TE levels in the group of depressed men and women in comparison to the healthy subjects. Statistically significant differences in both hair and nails contents of several elements were observed. Our study also provides strong evidence that the intermediary metabolism of certain elements is age- and gender-dependent. Zn, Mn, Pb, and Fe contents in hair/nails seem to be strongly associated with chronic depression. We found no statistically significant residence-related differences in the contents of studied elements in nonoccupationally exposed patients and healthy subjects.

Pediatric nail diseases: clinical pearls

This article highlights pearls shared during a unique and enlightening lecture by Antonella Tosti, MD, a professor at the University of Miami Health System, Florida, on the presentation and management of common pediatric nail diseases. These clinical pearls are shared to help deliver utmost care to our pediatric patients presenting with nail pathology and may help shed light on the management of pediatric nail diseases.

[A man with Bowen disease of the nail]

We describe a 40-year-old male patient with a 2-year history of a sensitive fingernail of the right hand. The nail had partly a rough surface, longitudinal cleavage and was brittle and vulnerable at the tip. Biopsy of the nail showed a Bowen disease (squamous cell carcinoma in situ) of the nail.

HAS A GLOMUS TUMOR ALWAYS A QUICK DIAGNOSIS?

INTRODUCTION

Glomus tumor is a rare and benign vascular tumor. Although symptoms specific for this tumor are quite clear, there is still a delay between the onset of symptoms, diagnosis and subsequent surgical therapy. The authors monitor the time from the onset of symptoms to the diagnosis and management of the problems.

MATERIAL AND METHODS

Between 2004-2012, a total of 5 patients were diagnosed with subungual glomus tumor in the area of the distal phalanges of the hand. It involved 3 women and 2 men with the mean age of 32.2 years (26-47 years). During the first examination, we monitored the duration of symptoms, number and specialty of the doctors who examined the patient, and what examinations were performed. When the cold test was positive, MRI was performed and the patients were indicated for surgical revision. Tissue samples in all patients were histologically examined. Patients were followed for 2 years.

RESULTS

It was found that the patients had clinical symptoms for an average of 2.4 years. In our group, the patients were examined by an average of 5.4 physicians (3-9 physicians). On examination before surgery, three patients reported changes in the nail bed and two patients reported no change. When following the patients 2 years after the surgery, relapse occurred in one patient and it was treated with reoperation. During regular follow-up 2 years after the surgery, 4 patients were without nail deformity. In one patient, there was resulting nail deformity. Relapse occurred in only one case.

DISCUSSION

Because the glomus tumor is a rare lesion, occurring most frequently in the nail bed, early diagnosis is still a problem. Even in literature, we encounter a similar time frame from the onset of symptoms until the final diagnosis of 1.9 to 8 years.

CONCLUSION

Although clinical signs and problems concerning the glomus tumor are very obvious, there still remains a long time for diagnosis. It would certainly be most beneficial for patients with persistent symptoms not to be referred to different specialists, but directly to a department that specializes in hand surgery.

[A woman with onychomatricoma of a toe nail]

The authors present a 43-year-old woman with a yellow, swollen toe nail of the right foot. This nail was lesioned 20 years before. The proximal nail fold of the right hallux was erythematous and indurated. The medial half of the nail was thickened and yellowish, sharply demarcated from the unaffected half. This aspect is typical for onychomatricoma.

Nailfold capillary abnormalities are associated with type 2 diabetes progression and correlated with peripheral neuropathy

Diabetes mellitus (DM) is associated with a state of chronic hyperglycemia with a highly increased risk of vascular complications. The current study aimed to investigate microcirculation abnormalities in patients with type 2 DM and those with pre-DM using nailfold videocapillaroscopy (NVC) and evaluate the possible correlation with microvascular complications.A total of 115 patients with type 2 DM, 41 patients with pre-DM, and 37 healthy subjects without diabetes were enrolled. All subjects underwent NVC to evaluate capillary density, length, morphology, distribution, presence of enlarged loops or hemorrhages, and blood flow. NVC score was used to quantitate the aforementioned characteristics.Patients with type 2 DM showed significantly increased alterations including reduced capillary length (29.6%), irregular distribution (35.7%), and abnormal morphology (59.1%), while the corresponding NVC scores were comparable to those of control subjects. In addition, subjects with pre-DM had a significantly higher NVC score and greater alterations in distribution (26.8%) and morphology (48.8%) than control subjects. NVC score was positively correlated with diabetic peripheral neuropathy (DPN) and the number of microvascular complications.NVC identified a high frequency of microcirculation abnormalities in subjects with pre-DM or type 2 DM compared to those in the control group. NVC score was also capable of detecting microvascular complications in patients with type 2 DM and was correlated with DPN and the number of microvascular complications.

Pigmented lesions of the nail bed - Clinical assessment and biopsy

BACKGROUND

Subungual melanoma is an uncommon type of melanoma that can be difficult to diagnose. Patients often present with advanced primary lesions and have an associated increased risk of nodal disease. Delays in diagnosis are believed to contribute to poor patient outcomes.

OBJECTIVE

The objective of this article is to offer an approach to assessing and managing patients who present with subungual pigmented lesions. We describe the anatomy of the nail bed to offer a rationale for our technique of nail bed biopsy, and warn of the potential to cause permanent nail dystrophy through other approaches.

DISCUSSION

Many clinicians have limited experience in assessing lesions of the nail apparatus.Subungual pigmentation has extremely broad differential diagnoses, which include a variety of benign pathologies. A systematic approach to assessment, and early referral of patients with suspicious lesions to a specialist unit, has the potential to improve patient outcomes.

Magnetic Resonance Imaging in the Diagnosis of Glomus Tumours of the Hand

This paper studies the sensitivity, specificity and predictive values of MRI in the diagnosis of glomus tumours of the hand and investigates the final diagnosis and outcome in cases with false positive or negative imaging tests. A total of 42 cases with the clinical diagnosis of a glomus tumour were included in the study. All patients underwent MRI and the results of MRI were correlated with the final histological diagnosis of the excised lesion. MRI had a sensitivity of 90%, a specificity of 50%, a positive predictive value of 97% and a negative predictive value of 20%. The four cases in which the MRI was negative all proved histologically to be glomus tumours. All four tumours were small (2–3 mm in diameter) and the lack of delineation of the lesions by MRI was attributed to their small size. Despite negative MRIs, surgical exploration identified the glomus tumours. Based on the results of the current study and the cost of MRI, the senior author has stopped ordering pre-operative MRIs in patients clinically diagnosed with a glomus tumour.