Calcipotriol ointment in nail psoriasis: a controlled double-blind comparison with betamethasone dipropionate and salicylic acid

This double-blind randomized study was designed to compare the efficacy and safety of calcipotriol ointment (50 microg/g) with betamethasone dipropionate (64 mg/g) and salicylic acid (0.03 g/g) ointment in the treatment of nail bed psoriasis. Fifty-eight patients applied the given drug to the affected nails twice a day for 3-5 months, depending on clinical response. Efficacy was assessed monthly on the basis of nail thickness, measured in millimetres. Photographs of the treated nails were taken at baseline, and after 3 and 5 months. Tolerability was assessed at 3 and 5 months. In patients with fingernail psoriasis, after 3 months of treatment subungual hyperkeratosis was reduced from 2.3 +/- 0.1 mm (mean +/- SEM) to 1.5 +/- 0.1 mm (-26.5%) in the calcipotriol group and from 2.3 +/- 0.1 mm to 1.6 +/- 0.1 mm (-30.4%) in the betamethasone dipropionate and salicylic acid group [not significant (NS) between treatments, analysis of variance (ANOVA)]. After 5 months, responders showed a 49.2% reduction in hyperkeratosis in the calcipotriol group (from 2.8 +/- 0.1 mm to 1.4 +/- 0.2 mm) and 51.7% (from 2.1 +/- 0.1 mm to 1.0 +/- 0.1 mm) in the betamethasone dipropionate and salicylic acid group (P < 0.001 from baseline, NS between treatments, ANOVA). In patients with toenail psoriasis, after 3 months of treatment there was an overall reduction in hyperkeratosis from 2.6 +/- 0.1 mm to 2.1 +/- 0.1 mm (-20.1%) in the calcipotriol group and from 3.0 +/- 0.1 mm to 2.3 +/- 0.1 mm (-22. 9%) in the betamethasone dipropionate and salicylic acid group (P < 0.001 from baseline, NS between treatments, ANOVA). By the end of the fifth month there was a 40.7% reduction in hyperkeratosis in the calcipotriol group (from 2.1 +/- 0.1 mm to 1.2 +/- 0.1 mm) and 51.9% in the betamethasone dipropionate and salicylic acid group (from 2.7 +/- 0.1 mm to 1.3 +/- 0.1 mm; P < 0.0001 from baseline, NS between treatments, ANOVA). The results of the study show that calcipotriol is as effective as a combination of a topical steroid with salicylic acid in the treatment of nail psoriasis and represents a safe alternative in the topical treatment of nail psoriasis.

Multiple nodular lesions of the chin and oral mucosa in a patient with Sjögren's syndrome

Sjögren's syndrome is an autoimmune disease characterised by generalised lymphoproliferation. Patients have an increased risk of developing lymphomas which are usually derived from mucosa-associated lymphoid tissue (MALT). We report a low grade, non-Hodgkin's lymphoma of the skin and oral mucosa in a patient with Sjögren's syndrome.

Candida onychomycosis in HIV infection

Primary nail invasion by Candida is uncommon and almost exclusively seen in patients with an impaired immune function. The appearance of Candida onychomycosis in an adult who is not under immunosuppressive treatment always requires a laboratory evaluation of the immunologic function including HIV assays. We report 2 cases of distal subungual onychomycosis due to Candida sp. in HIV. In one of our patients, the diagnosis of Candida onychomycosis preceded the diagnosis of advanced HIV infection. In both of our patients treatment with systemic antifungals produced complete cure of Candida onychomycosis and the 1 year follow-up did not reveal any relapse of the onychomycosis.

Are local and systemic conditions important for the development of onychomycosis?

Available epidemiological data indicate that the prevalence of onychomycosis due to dermatophytes increases with ageing. The aim of this study was to investigate the epidemiology of dermatophyte nail infections in 2 populations selected only on an age basis and to verify whether the presence of onychomycosis was associated with increased exposure to possible predisposing factors. From January to June 1995, the nails of 1,800 military recruits and 253 elderly individuals living in a nursing home were examined. Mycological studies were performed in all cases of suspected onychomycosis. The presence of systemic or local diseases that may favor fungal nail infection as well as exposure to environmental factors were assessed in the 2 populations. Onychomycosis was diagnosed in 8 recruits (0. 44%) and 38 of the elderly people (15%). The presence of onychomycosis was not related to the degree of exposure to environmental factors or to systemic or local diseases.

Contact and irritant stomatitis

Contact stomatitis is rather uncommon because of the relative resistance of the oral mucosa to irritant agents and allergens. The clinical manifestations of contact stomatitis are extremely variable and include erythema, erosions, ulcerations, leukoplakia-like lesions, and lichenoid reactions. Clinical signs are frequently less pronounced than subjective symptoms, and patients commonly experience severe functional problems despite only mild mucosal alterations. Allergic stomatitis is rare and almost always attributable to metallic mercury and gold salts. A careful history and an accurate examination of the oral cavity, teeth, and dental restorations are essential for a correct diagnosis. Patch testing is indicated in all lesions that are not clearly related to trauma or physical injuries. Patch testing is not useful in the burning mouth syndrome. Evaluation of clinical relevance of patch test results is always very difficult and requires an interdisciplinary approach to the patient. Successful treatment requires the identification and elimination of the causative factor, when possible. It is important to bear in mind that replacement of dental restorations and prostheses may be very expensive and stressful for the patient and thus should not be recommended when their causative role is doubtful.

Uncommon clinical patterns of Fusarium nail infection: report of three cases

Three cases of proximal subungual onychomycosis due to Fusarium oxysporum, including a patient with a fingernail infection, are described. All patients were immunocompetent and presented with acute paronychia associated with proximal or total leukonychia of the affected nails. Nail avulsion followed by topical treatment produced clinical and mycological cure. The literature on Fusarium onychomycosis is discussed. The combination of proximal subungual onychomycosis with subacute or acute paronychia involving fingernails or toenails is highly suggestive of Fusarium sp.

Itraconazole in the treatment of two young brothers with chronic mucocutaneous candidiasis

We report on two children affected by chronic mucocutaneous candidiasis involving the mouth and all the nails who were successfully treated with itraconazole at 200 mg/day for 2 months. This therapy produced a rapid cure of both candidal nail and mouth infections. The drug was very well tolerated, and routine laboratory monitoring during treatment did not reveal any abnormalities.

Onychomycosis due to Scopulariopsis brevicaulis: clinical features and response to systemic antifungals

Six cases of Scopulariopsis onychomycosis, including four patients with onychomycosis exclusively caused by Scopulariopsis brevicaulis and two patients with a mixed nail infection (S. brevicaulis + Tricophyton rubrum and S. brevicaulis + T. interdigitale), are reported. Four patients presented with a typical distal subungual onychomycosis characterized by subungual hyperkeratosis and onycholysis of the distal nail plate. In two patients, Scopulariopsis infection produced a total dystrophic onychomycosis associated with painful periungual inflammation. Three patients were treated with four pulses of itraconazole, 400 mg daily for 1 week a month, and three patients with terbinafine, 250 mg daily for 4 months. The mycological examination 8 months after discontinuation of treatment showed that one patient was mycologically cured whereas the remaining five patients still carried S. brevicaulis in their nails. The clinical examination at the end of the follow-up period showed a complete cure of the nail abnormalities in only one patient.

Nail matrix nevi: a clinical and histopathologic study of twenty-two patients

BACKGROUND

Because most dermatologists do not regularly perform biopsies of longitudinal melanonychia, even when the pigmentation presents as a single band, the true prevalence of nail matrix nevi is unknown.

OBJECTIVE

Our purpose was to determine the prevalence of nail matrix nevi in white patients with longitudinal melanonychia involving a single digit and to determine whether longitudinal melanonychia caused by a nail matrix nevus can be clinically distinguished from longitudinal melanonychia from other causes.

METHODS

From January 1989 to December 1994 we performed a nail biopsy on 100 of 128 consecutive white patients who had a single band of "idiopathic" longitudinal melanonychia.

RESULTS

A nail matrix nevus was detected in 22 patients. A junctional nevus was found in 19 specimens and a compound nevus in three specimens.

CONCLUSION

Nail matrix nevi in Caucasian patients are uncommon but not exceptional. The number of nevi presenting with longitudinal melanonychia exceeded that of melanoma. The diagnosis of nail matrix nevi is impossible clinically and always requires histopathologic study. The pathologic features of nail matrix nevi are similar to those of skin nevi except for their architectural pattern, which reflects the peculiar anatomy of the nail unit.

Treatment of dermatophyte nail infections: an open randomized study comparing intermittent terbinafine therapy with continuous terbinafine treatment and intermittent itraconazole therapy

BACKGROUND

terbinafine persists in the nail at effective concentrations for several weeks after discontinuation of treatment.

OBJECTIVE

Our purpose was to verify whether intermittent terbinafine therapy is effective in dermatophytic onychomycosis and to compare the results of intermittent terbinafine with those of intermittent itraconazole and continuous terbinafine treatment.

METHODS

An open, randomized study of 63 patients was performed with three treatment regimens: terbinafine, 250 mg daily (21 patients); terbinafine, 500 mg daily for 1 week every month (21 patients); or itraconazole, 400 mg daily for 1 week every month (21 patients). Treatment was continued for 4 months in toenail infections (60 patients) and 2 months in fingernail infections (3 patients).

RESULTS

At the end of the follow-up period (6 months after discontinuation of treatment) 16 of the 17 patients (94.1%) with toenail onychomycosis were mycologically cured in the terbinafine 250 mg group, 16 of 20 (80%) in the terbinafine 500 mg group, and 15 of 20 (75%) in the itraconazole group.

CONCLUSION

The percentage of patients who were mycologically cured was higher in the continuous terbinafine group than in the intermittent terbinafine and itraconazole groups, but statistical analysis did not reveal any significant difference between these cure rates.

Sea urchin granuloma of the nail apparatus: report of 2 cases

The authors report 2 cases of sea urchin granuloma of the nail apparatus resulting in permanent nail deformity. Both patients developed periungual and subungual nodular lesions 1-2 months after sea urchin spine injuries in the Mediterranean sea. The affected nails showed periungual nodules associated with splitting of the nail plate distal to the nodules. Surgical excision of the nail lesions required the removal of a large amount of nail matrix that resulted in permanent nail plate dystrophy. Histopathology revealed typical foreign-body granulomas in the nail dermis.

Proximal subungual onychomycosis due to Microsporum canis

A case of proximal subungual onychomycosis due to Microsporum canis in a 36-year-old woman is presented. The onychomycosis involved the left thumb and the little fingernails, with thinning of the nail plate and crumbling of the nail plate surface. A milky-white discoloration of the proximal portion of the left thumbnail was also evident. A 2-mm longitudinal nail biopsy showed a large number of fungal elements in the whole length of the nail plate. Fungal hyphae were more numerous in the ventral nail plate and produced detachment of the superficial nail plate. The nail bed was not invaded by fungal elements and was devoid of inflammatory changes. Proximal subungual onychomycosis is uncommon in immunocompetent individuals but has frequently been described in patients with AIDS. In our patient, in whom the proximal subungual onychomycosis was due to M. canis, there were no clinical or biochemical signs of immunodeficiency. Oral treatment with terbinafine, 250 mg/daily for 2 months, produced clinical and mycological cure.

Diffuse partial woolly hair

We report here a 14-year-old girl with diffuse partial woolly hair. The patient presented mild hair loss associated with the presence of fine, short and kinky hairs closely interspersed with the normal hair throughout the scalp. The pathology of the scalp revealed the presence of intermediate-sized hair follicles regularly intermingled with normal follicles in each follicular unit. The possibility that diffuse partial woolly hair may result from a progressive miniaturization of the hair follicles may explain the presence of evident hair thinning in several adult patients affected by this rare abnormality.

Idiopathic atrophy of the nails: clinical and pathological study of 2 cases

BACKGROUND

Whether idiopathic atrophy of the nails (IAN) should be considered a separate entity or a clinical variant of nail lichen planus is still controversial.

OBJECTIVE

We report here the pathological study of 2 patients with IAN.

METHODS

Our patients had similar clinical features consisting of severe nail atrophy with and without pterygium.

RESULTS

The nail matrix architecture was markedly deformed with complete disappearance of the keratogenous zone that was replaced by a 3- to 10-cell-thick granular layer.

CONCLUSION

The hypothesis that IAN is an acute and self-limited variety of lichen planus is still the most presumable. Even though this hypothesis can not be definitely proven, it is nevertheless not excluded by the clinical and pathological findings of our cases.

Idiopathic trachyonychia (twenty-nail dystrophy): a pathological study of 23 patients

We report the clinical features and pathological findings in 23 patients with idiopathic trachyonychia (twenty-nail dystrophy). Clinically, the nail changes in the majority of patients consisted of the typical 'sandpapered' appearance, with a rough, lustreless nail plate. In some, however, the nail plate abnormality was less severe, with numerous small, superficial pits, which imparted a shiny appearance to the surface of the nail. Histology of nail biopsy specimens showed spongiotic changes in 19 patients, psoriasiform features in three, and features of lichen planus in one patient. The mean follow-up of these patients was 2 years, during which time none developed alopecia areata or mucocutaneous lesions. Idiopathic trachyonychia is therefore a consequence of several inflammatory disorders, which produce a disturbance of nail matrix kinetics. The course of the inflammation and the extent of the inflammatory process within the nail matrix produce two different patterns of nail plate surface abnormalities.

Characterization of nail matrix melanocytes with anti-PEP1, anti-PEP8, TMH-1, and HMB-45 antibodies

BACKGROUND

The normal nail matrix contains quiescent melanocytes with a peculiar arrangement and behavior.

OBJECTIVE

Our purpose was to identify nail matrix melanocytes with antibodies that recognize melanocytic cells in tissue sections.

METHODS

We used the polyclonal antibodies anti-PEP1 and anti-PEP8 and the monoclonal antibody TMH-1, which recognize melanocytic enzymes, and the monoclonal antibody HMB-45, which reacts with melanoma cells and fetal melanocytes, but not with normal adult melanocytes. Nail matrix specimens were obtained from longitudinal specimens of eight white patients with ingrown toenails. Specimens from normal adult forearm skin were used as controls.

RESULTS

All nail specimens gave similar results. Dendritic melanocytes were more numerous in the distal than in the proximal nail matrix. They were not restricted to the basal layer, but were also found in the suprabasal layers of the nail matrix epithelium. Melanocytes were seen both a single dendritic cells among the nail matrix keratinocytes and as small clusters that appeared irregularly distributed along the length of the nail matrix. Each cluster usually consisted of three to four cells.

CONCLUSION

Even if normally quiescent, nail matrix melanocytes possess the key enzymes responsible for the formation of melanin. The suprabasal location of nail matrix melanocytes may be a consequence of the distribution of adhesion molecules in the nail epithelium. In fact, in the nail matrix alpha 2, alpha 3, and beta 1 integrins are not only expressed on the basal, but also on the fourth to fifth suprabasal layers, with suprabasal expression gradually decreasing from distal to proximal matrix. The behavior of nail matrix keratinocytes may cause the peculiar arrangement and behavior of nail matrix melanocytes.

Drug-induced hair loss and hair growth. Incidence, management and avoidance

A large number of drugs may interfere with the hair cycle and produce hair loss. Drugs may affect anagen follicles through 2 main different modalities: (i) by inducing an abrupt cessation of mitotic activity in rapidly dividing hair matrix cells (anagen effluvium) or (ii) by precipitating the follicles into premature rest (telogen effluvium). In anagen effluvium, hair loss usually occurs within days to weeks of drug administration, whereas in telogen effluvium, hair loss becomes evident 2 to 4 months after starting treatment. Anagen effluvium is a prominent adverse effect of antineoplastic agents, which cause acute damage of rapidly dividing hair matrix cells. Telogen effluvium may be a consequence of a large number of drugs including anticoagulants, retinol (vitamin A) and its derivatives, interferons and antihyperlipidaemic drugs. Drug-induced hair loss is usually reversible after interruption of treatment. The prevalence and severity of alopecia depend on the drug as well as on individual predisposition. Some drugs produce hair loss in most patients receiving appropriate dosages while other drugs are only occasionally responsible for hair abnormalities. Both hirsutism and hypertrichosis may be associated with drug administration. Drugs most commonly responsible for the development of hirsutism include testosterone, danazol, corticotrophin (ACTH), metyrapone, anabolic steroids and glucocorticoids. Hypertrichosis is a common adverse effect of cyclosporin, minoxidil and diazoxide.

Hallopeau's acrodermatitis continua of the nail apparatus: a clinical and pathological study of 20 patients

The clinical diagnosis of Hallopeau's acrodermatitis (HA) restricted to nail and digital pulp may be difficult, and even dermatologists often fail to recognize this condition. The aim of this study was to review the clinical and pathological features of 20 patients, observed over a period of 5 years (1988-1993), who were affected by HA limited to the nails. Our study shows that HA of the nail unit more commonly affects middle-aged females. In all our patients HA of the nail was restricted to one digit and not associated with other manifestations of pustular psoriasis. HA of the nail unit is characterized by a chronic course. None of our patients had a complete clearing of the dermatitis during the follow-up period. In 4 patients the acute phases of HA were treated with the non-steroidal anti-inflammatory agent nimesulide 200 mg/day, with great improvement of inflammatory signs and subjective pain within a few days. In these patients, prolongation of treatment with nimesulide during remission phases prevented relapses of the dermatitis.

Nail lichen planus: clinical and pathologic study of twenty-four patients

BACKGROUND

We studied a large series of patients with lichen planus (LP) limited to the nails.

OBJECTIVE

Our purpose was to review the clinical and histopathologic features of 24 patients with LP limited to the nails and to discuss treatment and long-term prognosis.

METHODS

The records of 24 patients with biopsy-confirmed nail LP were analyzed. Clinical and follow-up data were obtained.

RESULTS

Nail LP usually appears during the fifth or sixth decade of life. Neither gender-associated susceptibility nor seasonal influences were detected. In most cases, nail LP is self-limiting or promptly regresses with treatment. Recurrences of nail lesions as well as development of LP in other regions of the body are possible. The development of severe and early destruction of the nail matrix characterizes a small subset of patients with nail LP.

CONCLUSION

Approximately 25% of patients with nail LP have LP in other sites before or after the onset of nail lesions. Long-term observation indicates that permanent damage to the nail is rare even in patients with diffuse involvement of the matrix.