Trachyonychia: a retrospective study of 122 patients in a period of 30 years

BACKGROUND

Trachyonychia is a nail disease characterized by longitudinal striations, ridges, fissures and/or pitting. This condition can be both idiopathic and associated with other dermatologic diseases.

OBJECTIVE AND METHODS

The aim of this retrospective study was to analyse the clinical features, onychoscopy, therapy efficacy and outcome of 122 patients with trachyonychia visited at the Hair Disease Outpatient Consultations of the Dermatology Unit of the Department of Experimental, Diagnostic and Specialty Medicine of the University of Bologna, from 1988 to 2018.

RESULTS

Opaque trachyonychia was the most observed type while shiny trachyonychia, less common, was present especially in milder cases. Pitting was the most frequently observed feature (80.3%), followed by koilonychia (45%) and hyperkeratosis (19.6%). Nail matrix longitudinal biopsy was performed for diagnosis confirmation in 29 cases, and spongiotic was the most common pattern. Topical therapy was prescribed in 109 patients while systemic treatments were reserved for severe cases (38 patients); 22 patients did not receive any treatment. A marked improvement in the appearance of the nails or even a total resolution was seen in 63 patients.

CONCLUSIONS

Trachyonychia can occur at any age but is more frequent in children and often associated with alopecia areata. The pathological diagnosis of trachyonychia is not mandatory as the disease has generally a benign outcome. Considering the absence of pain and the high rate of spontaneous resolution, treatment is often prescribed only for cosmetic reasons or reserved for severe cases.

Oral and nail pigmentations: a useful parallelism for the clinician

Oral (OP) and nail (NP) pigmentations may occur simultaneously in physiological or pathological conditions, and may be a sign of underlying syndromic conditions that necessitate further investigation and treatment. Interestingly, the nail unit and oral cavity show a clinical parallelism that may help the clinician to conduct a correct examination and reach a prompt diagnosis. Both OP and NP can manifest clinically with focal or diffuse involvement and are due to external factors (exogenous pigmentation, drug-induced pigmentation) or endogenous factors (racial pigmentation, post-inflammatory pigmentation, nevi, genetic conditions and other disorders). The most concerning differential diagnosis is melanoma. Here we report the pathogenetic basis of OP and NP, together with the description of similar clinical features. To the best of our knowledge this is the first paper to summarize and describe the causes of pigmentation of both the oral cavity and the nail unit.

An Open Study to Evaluate Effectiveness and Tolerability of a Nail Oil Composed of Vitamin E and Essential Oils in Mild to Moderate Distal Subungual Onychomycosis

BACKGROUND

Onychomycosis is the most common nail disease and can affect both fingernails and toenails. When possible, topical treatment is generally preferred both by patients and physicians because it is associated with lower risk of systemic side effects and drug interactions than oral antifungals, avoiding laboratory monitoring.

OBJECTIVE

The aim of our study was to evaluate the efficacy, tolerability, and patient's compliance of a new topical antifungal containing vitamin E and essential oils of lime, oregano, and tea tree.

PATIENTS AND METHODS

We enrolled 20 patients with mild-moderate distal subungual onychomycosis due to dermatophytes or non-dermatophyte molds. The product was applied once daily on the periungual tissues and on the nail plate for 6 months. Follow-up without therapy continued for another 6 months in order to evaluate the product's effect maintenance. Periodic evaluation of treatment efficacy was performed by standardized photography and mycological examination (KOH + culture) of the target nail at baseline (T0), after 3 months (T1) and 6 months (T2) of therapy, and after 6 months of follow-up (T3).

RESULTS

At the end of the 12-month study, the majority of patients achieved a complete cure of onychomycosis (78.5%). All patients were very satisfied by the treatment. No side effects were recorded.

CONCLUSIONS

The results of our study indicate that this new topical antifungal containing vitamin E and essential oils of lime, oregano, and tea tree is an effective and safe option for topical therapy of onychomycosis. This topical antifungal nail oil restructures the nail appearance, improving patient's adherence to therapy and reducing the risk of relapses, maintaining results over time.

A Double Case of Nail-Patella Syndrome in the Same Family: The Importance of Nail Changes as Diagnostic Clues for Renal Involvement

Nail diseases are rarely given significant importance in general consultation and their specific examination is often neglected, while localization to the nails could be an initial sign of a syndrome or a systemic disorder. Although rarely, nail alterations could be a sign of a systemic disorder, in which a prompt observation is crucial for an early diagnosis. We describe the case of an elderly woman with a long history of nail dystrophy, previously labelled as nail fragility. On enquiry, similar nail changes were discovered to have affected the patient's son, who was visited the following week. Diagnosis of the Nail-Patella Syndrome (NPS) was suspected on the basis of nail alterations in both patients and confirmed by complementary radiographic examination. Screening for severe renal complications, which could have negatively affected the prognosis and have led to end-stage renal disease, followed. The prompt diagnosis of NPS and the associated diseases are mandatory for a correct management of these patients.

Monotherapy for Alopecia Areata: A Systematic Review and Network Meta-Analysis

BACKGROUND

There are many treatments available for alopecia areata; however, none are approved by the US Food and Drug Administration. Thus, there is clinician benefit in efficacy comparison.

METHODS

A network meta-analysis was used to create direct and indirect comparisons of alopecia areata studies in addition to an inconsistency analysis, risk of bias, and quality of evidence assessment.

RESULTS

For mild disease, intralesional corticosteroids were ranked the most likely to produce a response at 78.9% according to SUCRA (surface under the cumulative ranking curve) followed by topical corticosteroids (67.9%), prostaglandin analogs (67.1%), diphenylcyclopropenone (DPCP, 63.4%), topical minoxidil (61.2%), and squaric acid dibutylester (SADBE, 35.0%). In contrast, for moderate to severe disease (>50% scalp hair loss), DPCP was the top-ranked treatment (87.9%), followed by laser (77.9%), topical minoxidil (55.5%), topical corticosteroids (50.1%), SADBE (49.7%), and topical tofacitinib (47.6%). There were insufficient eligible trials to include oral tofacitinib in the network.

CONCLUSION

Statistically significant evidence is presented for the use of intralesional and topical corticosteroids for treatment of mild disease and DPCP, laser, SADBE, topical minoxidil and topical corticosteroids for moderate to severe disease. Further controlled trials are required to analyze the relative efficacy of oral tofacitinib.

Alopecia Areata Incognita and Diffuse Alopecia Areata: Clinical, Trichoscopic, Histopathological, and Therapeutic Features of a 5-Year Study

Background

Alopecia areata is a nonscarring hair loss that usually causes round patches of baldness, but alopecia areata incognita (AAI) and diffuse alopecia areata (DAA) can cause a diffuse and acute pattern of hair loss.

Objective

To analyze the clinical, trichoscopic, histological, and therapeutic features of AAI and DAA.

Methods

The study was designed to include data of patients with histological diagnosis of AAI and DAA enrolled in our Hair Disease Outpatient Consultations.

Results

DAA had a greater involvement of the parietal and anterior-temporal regions, while AAI manifested itself mainly in the occipital-parietal regions. The most frequent pattern was empty yellow dots, yellow dots with vellus hairs, and small hair in regrowth, but the presence of pigtail hair was found almost exclusively in those with AAI. In cases of DDA, the finding of dystrophic hair and black dots was more frequent. The most frequent trichoscopic sign in both diseases was the presence of empty yellow dots, which, however, were described in a higher percentage in cases of DAA. The diseases have a benign course and are responsive to topical steroid therapy.

Conclusions

Trichoscopy is very important for the differential diagnosis between the 2 diseases and to select the best site for biopsy. In the presence of diffuse hair thinning, these entities must be considered.

Management and Outcome of Taxane-Induced Nail Side Effects: Experience of 79 Patients from a Single Centre

Background

Nail changes are a common side effect of taxane chemotherapy, although their correct management is poorly standardized.

Objective

To evaluate incidence, clinical aspects, and response to treatment of taxane-induced nail side effects in patients treated with taxanes for malignancies.

Patients and Methods

We performed a retrospective clinical study of 79 patients with taxane-induced nail changes from January 2015 to July 2018.

Results

Paclitaxel was the most responsible drug and both hands and feet were often affected (46.8%). Grade 2 nail toxicity was seen in 63.3% of the patients, including painful subungual hematoma, hemorrhagic onycholysis, and paronychia. Grade 3 nail toxicity was seen only in 2.5% of the patients, including hemorrhagic onycholysis and pyogenic granuloma. Removal of the detached nail plate with application of topical antibiotics and steroids induced regression of symptoms within 2 weeks.

Conclusions

Nail toxicity develops mostly at the end of therapy, and total drug dosage is the only known factor that predisposes to these side effects. Trauma possibly plays a role as the most severe signs are located on the great toenails. Although it is impossible to prevent taxane-induced nail side effects, a careful patient monitoring permits to immediately recognize and manage the symptoms in order to induce their remission and improvement of the patient's quality of life.

Erosive pustular dermatosis of the scalp: challenges and solutions

Erosive pustular dermatosis of the scalp is a rare chronic inflammatory disorder defined. It usually affects elderly people and is characterized by extensive pustular lesions, erosions, and crusts located on the scalp. The pathogenesis of this disease is not completely understood, but a known predisposing factor is skin trauma. Autoimmune disorders including rheumatoid arthritis, autoimmune hepatitis, Hashimoto thyroiditis, and Takayasu aortitis are associated diseases reported. The clinical examination reveals erythema, erosions, crusts, follicular pustules, and in advanced stages, scarring alopecia. A scalp biopsy is recommended but not specific, founding epidermal atrophy, focal erosions, and a mixed inflammatory infiltrate consisting of neutrophils, lymphocytes, and plasma cells. Bacterial cultures, fungal and viral stains are not necessary and are usually negative. . Topical high-potency corticosteroids, retinoids, calcipotriol, dapsone, and topical tacrolimus are reported treatments, while photodynamic therapy has been effective in some patients, but has induced the disease in others. All the findings are suggestive but not specific, so it is an excluding diagnosis. The combination of predisposing factors is very important for a correct diagnosis, such as elderly age, sun-damaged skin, presence of androgenetic alopecia, together with clinical manifestations, non-specific histology and laboratory investigations negative for other disease. In our opinion, this scalp disease is a challenge for the dermatologist. We review all the literature to better define the possible solutions in case of suspected erosive pustular dermatosis of the scalp.

Scalp Sarcoidosis with Systemic Involvement: A Case Report and Literature Review

Scalp sarcoidosis is generally uncommon and it may present itself with varying morphologies; therefore, it is important to differentiate this disease from other forms of cicatricial and non-cicatricial causes of alopecia. Trichoscopy and histopathology are essential to rule out other skin diseases and to confirm diagnosis. Treatment options include topical, oral, and intralesional corticosteroids; immunosuppressive agents; and hydroxychloroquine, in order to arrest the progression of alopecia. Here, the authors present a case of scalp sarcoidosis with systemic involvement, in which dermoscopy gives important clues for its diagnosis. The authors have also reviewed the literature and identified 46 cases of sarcoidosis that induced alopecia.

Onychoscopy with red light for vascular pattern identification: a study of 33 patients

BACKGROUND

Nail dermoscopy (onychoscopy) during physical examination assists in correct diagnosis. Often further magnifications are necessary for an effective differential diagnosis. With the addition of a red light to the dermoscope, important vascular features can be visualized.

OBJECTIVE

To describe common features observed at onychoscopy with a new device that combines the regular white light with the red light illumination, demonstrating that it is useful for diagnosis of nail disorders.

METHODS

We enrolled 33 consecutive patients referred to the Nail Diseases Dermatology Unit of the University of Modena and Reggio Emilia and to the Outpatient Consultation for Nail Disease of the Dermatology Unit of the University of Bologna. Patients were assessed with a standard hand-held dermoscope and at the red light dermoscope. Dermoscopic images were collected.

RESULTS

The new prototype was used during daily clinical practice and allowed a more accurate visualization of some details that classic onychoscopy can miss. In particular, with the help of the red light it was possible to better visualize nail lesions that were characterized by some kind of colour change or vascular alterations.

CONCLUSION

The new device of red light for vascular pattern onychoscopy can be a new investigation method to observe nail alterations, especially due to vascular pattern, even with low magnification, without the necessity to use higher resolutions.

Nail Psoriasis: An Updated Review and Expert Opinion on Available Treatments, Including Biologics

Nail psoriasis affects 50-79% of patients with skin psoriasis and up to 80% of patients with psoriatic arthritis, and can also represent a negative prognostic factor in individuals with plaque psoriasis. Treatments for nail psoriasis are limited, as nails are often difficult to treat with topical therapies alone, and relapse is common. Among different systemic agents, secukinumab, a fully human monoclonal antibody targeting interleukin (IL)-17A, is the only antibody supported by a trial specifically conducted in patients with nail psoriasis (the TRANSFIGURE trial) and has the longest follow-up available to date. In this setting, secukinumab is characterized by the highest efficacy at week 16. This review analysed the different therapeutic options for nail psoriasis, focusing on new treatments that have shown promising results in this field.

Trichoscopy of Scalp Metastases

A 69-year-old woman with invasive ductal breast cancer (BC) presented multiple asymptomatic alopecic areas of the scalp. Trichoscopy revealed peripheral black dots (BDs) and an atypical vascular pattern. Histopathology confirmed the diagnosis of BC metastases. Cutaneous and scalp metastases are a possible sign of advanced and widespread BC, and the diagnosis may be challenging. The trichoscopy of scalp metastases has never been described. BDs and an atypical vascular pattern in our case were a diagnostic clue.

Recommendations for the definition, evaluation, and treatment of nail psoriasis in adult patients with no or mild skin psoriasis: A dermatologist and nail expert group consensus

Nail involvement in psoriasis is common, and the severity of it does not always parallel the intensity of cutaneous disease. We created a consensus group, of which the aim was to provide practical recommendations for the treatment of nail psoriasis in patients without skin psoriasis or with mild skin lesions with no indication for a systemic treatment. This collaborative process was conducted by an international panel of dermatologists with special expertise in nail disorders, using formal consensus methods. During this process, the panel strived to establish an agreement regarding the definition of nail psoriasis, the severity of nail psoriasis, and treatment response. Treatment recommendations are provided regarding nail psoriasis severity and matrix or bed involvement. Few-nail disease was considered as nail psoriasis affecting ≤3 nails. In the case of matrix involvement only, intralesional steroid injections were considered the treatment of choice. Topical steroids alone or in combination with topical vitamin D analogues were suggested for nail psoriasis limited to the nail bed. For the systemic treatment of nail psoriasis acitretin, methotrexate, cyclosporine, small molecules, and biologics may be employed.

Use of Nail Dermoscopy in the Management of Melanonychia: Review

The term melanonychia describes a black-brown-gray pigmentation of the nail plate that, in most cases, appears as a longitudinal band. Melanonychia can be observed at any age, affecting one digit or several digits, in both fingernails and toenails. Its causes can be difficult to differentiate clinically and depend on the number of bands and on their color, edge, and width. For this reason, especially in adults and when the pigmentation is localized in one single digit, biopsy and histopathological examination still represent the gold standard for a definitive diagnosis. Dermoscopy should be used routinely in the evaluation of a pigmented nail, as it provides important information for the management of melanonychia and can help avoid unnecessary nail biopsies. In cases of melanonychia it is important to establish whether the pigment is melanin or not and to determine whether the pigmentation of melanin is due to activation or proliferation and whether it is benign or malignant.

Tinea versicolor of the neck as side effect of topical steroids for alopecia areata

Background: Treatment of alopecia areata (AA) involves use of high potency topical corticosteroids under occlusion that, even very effective, can lead to several adverse effects. Objective: We report 10 cases of patients with AA that, after using high potency topical corticosteroids, have developed tinea versicolor of the neck area. Methods: Ten patients with AA, aged 18-38 years, were prescribed with clobetasone propionate 0.05% cream under occlusion every other day but, after 3-4 months of treatment, they returned to our facility complaining the appearance of multiple white or red-brown round or oval macules in the neck area. Results: Diagnosis of pityriasis versicolor was confirmed by direct microscopy examination of skin scrapings in 10% potassion hydroxide (KOH) solution. All patients received systemic antifungal therapy associated with the daily use of ketoconazole shampoo. Conclusion: Tinea versicolor of the neck should be included among a rare but possible side effect of prolonged application of high potency topical steroids on the scalp. These cases reinforce the importance of careful dermatologic examination and recommend preventive measures in patients with alopecia areata that are using these drugs.

Global perspectives for the management of onychomycosis

Onychomycosis is a fungal nail infection caused by dermatophytes, nondermatophyte molds, and yeasts. This difficult-to-treat chronic infection has a tendency to relapse despite treatment. This paper aims to offer a global perspective on onychomycosis management from expert physicians from around the world. Overall, the majority of experts surveyed used systemic, topical, and combination treatments approved in their countries and monitored patients based on the product insert or government recommendations. Although the basics of treating onychomycosis were similar between countries, slight differences in onychomycosis management between countries were found. These differences were mainly due to different approaches to adjunctive therapy, rating the severity of disease and use of prophylaxis treatment. A global perspective on the treatment of onychomycosis provides a framework of success for the committed clinician with appreciation of how onychomycosis is managed worldwide.

A survey among dermatologists: diagnostics of superficial fungal infections - what is used and what is needed to initiate therapy and assess efficacy?

BACKGROUND

Superficial fungal infections are common. It is important to confirm the clinical diagnosis by mycological laboratory methods before initiating systemic antifungal treatment, especially as antifungal sensitivity and in vitro susceptibility may differ between different genera and species. For many years, the gold standard for diagnosis of superficial fungal infections has been direct fungal detection in the clinical specimen (microscopy) supplemented by culturing. Lately, newer molecular based methods for fungal identification have been developed.

OBJECTIVE

This study was initiated to focus on the current usage of mycological diagnostics for superficial fungal infections by dermatologists. It was designed to investigate whether it was necessary to differentiate between initial diagnostic tests and those used at treatment follow-up in specific superficial fungal infections.

METHODS

An online questionnaire was distributed among members of the EADV mycology Task Force and other dermatologists with a special interest in mycology and nail disease.

RESULTS

The survey was distributed to 62 dermatologists of whom 38 (61%) completed the whole survey, 7 (11%) partially completed and 17 (27%) did not respond. Nearly, all respondents (82-100%) said that ideally they would use the result of direct microscopy (or histology) combined with a genus/species directed treatment of onychomycosis, dermatophytosis, Candida- and Malassezia-related infections. The majority of the dermatologists used a combination of clinical assessment and direct microscopy for treatment assessment and the viability of the fungus was considered more important at this visit than when initiating the treatment. Molecular based methods were not available for all responders.

CONCLUSION

The available diagnostic methods are heterogeneous and their usage differs between different practices as well as between countries. The survey confirmed that dermatologists find it important to make a mycological diagnosis, particularly prior to starting oral antifungal treatment in order to confirm the diagnose and target the therapy according to genus and species.