Squamous cell carcinoma of the nail unit

Squamous cell carcinoma (SCC) of the nail apparatus is a rare malignant tumor that usually originates underneath the nail plate and grows slowly with possible bone invasion. The etiology remains unknown, although a strong association with different conditions, such as high-risk human papillomavirus (HPVs), trauma, or radiation exposure has been demonstrated. Nail SCC is called "the great mimicker nail tumor" because different clinical presentations may coexist, resembling benign or malignant nail lesions. For this reason, there is often a significant delay between the onset of nail SCC and the diagnosis. Clinical manifestation includes onycholysis and erythema, while in the advanced stages nail ulceration can be observed. The association with pain, swelling, and inflammation usually indicates an invasive SCC with involvement of the underlying bone. Metastasis is rare but possible with involvement of lymph nodes. A multidisciplinary approach to assessment, management, and follow-up is advised. Using careful examination and modern diagnostic methods, including onychoscopy, biopsy, and histopathology, will help identify SCC and prevent the invasive progression. X-ray is important to investigate the bone invasion to determine the best surgical approach that will have satisfying cosmetic and functional outcomes. Nevertheless, local excision with sufficient surgical margins, best if using Mohs surgery, is usually sufficient and superior to amputation of the distal phalanx. This review aims to highlight the correct approach in suspected SCC of the nail unit.

Ciclopirox Hydroxypropyl Chitosan: Efficacy in Mild-to-Moderate Onychomycosis

The severity and percentage of nail involvement are usually considered the main prognostic factors for the treatment of onychomycosis. This study investigated the efficacy of P-3051 (ciclopirox [CPX] 8% nail lacquer in hydroxypropyl chitosan technology) in a population subset of the pivotal study, selected according to the criteria used in recent onychomycosis pivotal studies. The original study was a multicenter, randomized, three-arm, placebo-controlled, parallel groups, evaluator-blinded study comparing P-3051 with reference CPX (standard, insoluble 8% CPX nail lacquer) and placebo (P-3051 vehicle) in a 2: 2: 1 ratio, applied once daily for 48 weeks to 467 patients with onychomycosis, followed by a 12-week follow up. The primary endpoint was complete cure (negative mycology and 100% clear nail) at the end of treatment. Among the secondary endpoints, response rate (negative mycology and ≥90% clear nail) and negative culture were chosen as most representative for a clinical setting. A population subset (modified intention-to-treat population, 302 patients) was selected, excluding those with more severe disease (> 50% nail involvement), in line with recent onychomycosis pivotal trials. P-3051 was superior to placebo in all parameters but culture at week 60 and was superior to reference CPX in cure and response rates at week 60. Compared to the overall patient population, efficacy rates in the P-3051 group were higher in the subset excluding patients with nail involvement > 50%. Results increased by 33% (from 5.7 to 7.6%) at week 48 and by 19.0% (from 12.7 to 15.1%) at week 60 for cure rate, by 33% (from 24.0 to 31.9%) and 20% (from 28.7 to 34.5%) for response rate, and by 3% (from 89.1 to 91.6%) and 4.0% (from 79.0 to 82.4%) for culture conversion to negative. This post hoc analysis confirms that the severity of onychomycosis is a prognostic factor for responsiveness to antifungal treatments and that this can significantly affect reported efficacy data. The different inclusion criteria should be taken into account when reviewing the efficacy of antifungal agents from different studies.

Mohs micrographic surgery for nail unit tumours: an update and a critical review of the literature

Mohs micrographic surgery (MMS) is a good treatment option for epithelial neoplasms, especially when localized in areas where tissue conservation is crucial, such as the nail unit (NU). MMS is a method of radical excision offering high cure rates due to the margin control and functional preservation. Our aim is to provide a review on the use of MMS for the treatment of the most common nail tumours. We revised the current literature on the use of MMS to treat malignant neoplasms (Bowen's disease, squamous cell carcinoma, melanoma, basal cell carcinoma, keratoacanthoma, carcinoma cuniculatum) and benign neoplasms (onychomatricoma and glomus tumour). MMS represents a successful surgical option for nail tumours, firstly in terms of tissue conservation: the NU anatomy is complex and the preservation of the component structures is imperative for its functionality. Secondly, due to the surgical radicality, which is essential not only for the clearing of malignant tumours, but also for benign cases, in order to reduce recurrences. Although a conservative treatment of NU melanoma with MMS has been proposed, in our experience, the conservative approach with functional surgery is a good option for the treatment of non-invasive melanoma (in situ and Ia).

When the Nail Appearance Plays Tricks: A Case of Longitudinal Melanonychia

A paediatric nail consultation is often required to reduce parents’ concerns regarding their child’s abnormal nail appearance. Nail pigmentation in children is a dermatological challenge because guidelines are not standardised, causing many doubts for dermatologists. In general, the majority of cases of melanonychia are benign in children and nail melanoma cases are very rare. However, alarming clinical and dermoscopic features can be observed, requiring nail surgery to confirm a diagnosis. Here, we present a case of longitudinal melanonychia in a teenager with atypical signs and a good prognosis.

Nail Disorders in Children

Nail diseases in children do not account for a significant proportion of pediatric consultations, and most of the time the nails are not observed by the clinician, overlooking their importance. Specific examination of the nails is neglected, while localization to the nails could be an initial sign of a syndrome or a systemic disorder. Nail diseases in the pediatric population differ from those in adults in terms of diagnostic approach and management; some of them even are manifested mainly or exclusively in children. Pediatric patients with underlying systemic disorders are more likely to manifest acquired disorders of the nails. Although rare, nail diseases in children are a source of anxiety for the parents. Examination of the nails is an essential part of pediatric physical examination. A correct clinical history and careful examination help the clinician to distinguish the different conditions and to decide on the correct management of nail diseases in young patients. A classification of nail dystrophies according to age is somewhat arbitrary and a unique classification does not exist. Nail diseases in the pediatric population can be divided according to age groups where a predilection appears in most of the cases. Moreover, certain abnormalities may be lifelong once acquired, but their presentation may be modified by age, worsening or improving during life. This review describes many of the nail conditions that are seen in the pediatric population aging from newborn to toddler, starting with physiological aspects to better recognize the pathological conditions.

Topical 1% propranolol ointment with occlusion in treatment of pyogenic granulomas: An open-label study in 22 children

BACKGROUND

Pyogenic granuloma (PG) is a common, acquired, benign vascular neoplasm of the skin and mucous membranes. It occurs most often in children and adolescents. First-line treatment options for PG are based on destructive approaches. Pain, permanent scarring, and pigmentation are potential complications of these therapies.

METHODS

This single-arm, open-label, prospective study evaluated the efficacy of topical propranolol for treatment of PGs in children. All patients clinically diagnosed with cutaneous PG consecutively at the Dermatology Pediatric Outpatient Service of the University of Bologna from January 2010 to December 2010 received a compounded formulation of propranolol ointment 1%.

RESULTS

We found propranolol ointment to be effective in consecutive patients; 59.0% completely regressed in a mean of 66 days, 18.2% remained stable, and 22.7% did not respond. No side effects (eg, skin irritation, allergy, bleeding) were observed.

CONCLUSION

Topical propranolol ointment 1% with occlusion appears to be an effective treatment for PGs in children. Early treatment was associated with a more favorable outcome.

Evidence-based (S3) guideline for the treatment of androgenetic alopecia in women and in men - short version

Androgenetic alopecia is the most common hair loss disorder, affecting both men and women. Initial signs of androgenetic alopecia usually develop during teenage years leading to progressive hair loss with a pattern distribution. Moreover, its frequency increases with age and affects up to 80% Caucasian men and 42% of women. Patients afflicted with androgenetic alopecia may undergo significant impairment of quality of life. The European Dermatology Forum (EDF) initiated a project to develop evidence-based guidelines for the treatment of androgenetic alopecia. Based on a systematic literature research the efficacy of the currently available therapeutic options was assessed and therapeutic recommendations were passed in a consensus conference. The purpose of the guideline is to provide dermatologists with an evidence-based tool for choosing an efficacious and safe therapy for patients with androgenetic alopecia.

Early Visible Improvements during K101-03 Treatment: An Open-Label Multicenter Clinical Investigation in Patients with Onychomycosis and/or Nail Psoriasis

INTRODUCTION

Onychomycosis and nail psoriasis can be embarrassing to patients, so improving the appearance of affected nails should be one of the key short-term goals of treatment.

METHODS

An 8-week open-label multicenter study was conducted to assess whether K101-03, a marketed topical treatment containing propylene glycol, glycerol, urea, and lactic acid, could produce rapid cosmetic improvements in affected nails. Adult patients with a big toenail or thumbnail (the "target" nail) affected by onychomycosis (n = 72) or psoriasis (n = 34) or both (n = 1) applied K101-03 to their affected nails once a day for 8 weeks. During and after treatment, patients rated the overall appearance of their target nail on a 4-point scale. They also assessed whether thickening, discoloration, brittleness, and softness of the target nail had improved since baseline. Adverse events (AEs) that occurred between the first application of K101-03 and the end of treatment were recorded and categorized according to severity and relationship to K101-03.

RESULTS

After 8 weeks of K101-03 treatment, 92.2% of patients (95% confidence interval [CI] 87.06-97.40) reported at least some improvement in the target nail. After 1 week of treatment, 78.3% of patients with onychomycosis (95% CI 68.53-87.99) reported at least some improvement in the target nail, and 55.1% of them reported that discoloration of their target nail had improved. Three patients reported a total of 5 AEs, none of which were judged to be related to K101-03.

CONCLUSIONS

In summary, K101-03 was well tolerated in patients with onychomycosis or nail psoriasis and rapidly improved their nails.

Poliosis and Neurofibromatosis Type 1: Two Familiar Cases and Review of the Literature

Two brothers were referred to our clinic for reevaluation of neurofibromatosis type 1 (NF1). Both brothers presented a peculiarity that is not so common in NF1: poliosis overlying plexiform neurofibromas on the scalp. Poliosis overlying plexiform neurofibromas is rarely reported in the literature. The peculiarity of our cases is the familiarity and the presence of poliosis in the same location.

Dermoscopy of Subungual Exostosis: A Retrospective Study of 10 Patients

INTRODUCTION

Subungual exostosis (SE), the most common nail tumor of young adults, is a benign bony proliferation of the distal phalanx occurring beneath the nail. Misdiagnosis or late diagnosis frequently occurs and no dermoscopy features of this tumor were previously outlined.

MATERIAL AND METHODS

To describe the dermoscopic appearance of SE, 10 patients with radiologically and histologically confirmed SE were retrospectively retrieved from our tertiary referral centers. Data regarding age, gender, time to diagnosis, clinical presentation, dermoscopic features, involved nail and history of trauma were recorded for each patient.

RESULTS

In our patients, clinical findings were similar to previous reports. Among the dermoscopic features, vascular ectasia was the most common finding (70%), followed by hyperkeratosis (60%), onycholysis (40%), and ulceration (30%).

CONCLUSION

Dermoscopy could be a useful technique aimed at creating diagnostic suspicion of this benign nail condition, although X-ray examination and histopathology are mandatory for the diagnosis.

Dermoscopy in the Evaluation of Nail Disorders

Nail dermoscopy was initially used only in the assessment of nail pigmentation, but now it is widely utilized for the evaluation of many nail disorders. In daily practice, dermoscopy may confirm clinical diagnoses and guides in the management of nail diseases and treatments, permitting a better visualization of symptoms. Dry dermoscopy is required for evaluation of the nail plate surface, while gel as an interface is necessary for assessment of nail pigmentation and onycholysis, as well as for the evaluation of the distal nail margin. In this review, we describe the dermoscopic features of the most important nail disorders, looking at the different areas of the nail. Dermatoscopic changes that usually accompany specific nail diseases are also reviewed.

Clinical and dermoscopic clues to differentiate pigmented nail bands: an International Dermoscopy Society study

BACKGROUND

Longitudinal melanonychia might be difficult to differentiate and the use of dermoscopy can be useful for the preoperative evaluation and management decision.

OBJECTIVES

The aim of our study was to investigate clinical and dermoscopic criteria of acquired longitudinal melanonychia in adults to identify the best predictors of melanoma using a multivariate analysis and to explore eventual new dermoscopic criteria for nail melanoma diagnosis.

METHODS

In this retrospective observational study, 82 histopathologically diagnosed, acquired nail pigmented bands were collected and examined. All variables were included in the analysis and examined as possible predictors of nail melanoma. Both univariate and multivariable analyses have been performed.

RESULTS

Among 82 cases, 25 were diagnosed as nail melanoma and 57 as benign lesions (including 32 melanocytic nevi and 25 benign melanocytic hyperplasia). Melanoma cases were significantly associated with a width of the pigmented band higher than 2/3 of the nail plate, grey and black colours, irregularly pigmented lines, Hutchinson and micro-Hutchinson signs, and nail dystrophy. Granular pigmentation, a newly defined dermoscopic criterion, was found in 40% of melanomas and only in 3.51% of benign lesions.

CONCLUSIONS

Dermoscopic examination of longitudinal melanonychia provides useful information that could help clinicians to improve melanoma recognition.

Nail involvement as a negative prognostic factor in biological therapy for psoriasis: a retrospective study

BACKGROUND

Psoriasis (Pso) has a strong impact on quality of life and a positive association has been reported between nail psoriasis (NP) and more severe disease, together with a longer duration of skin lesions. The treatment of NP represents a challenge and biological therapy can be recommended for severe disease.

OBJECTIVE

The first end point of this retrospective study was to evaluate the time to achieve Psoriasis Area Severity Index (PASI) 75 in patients with and without NP treated with biological therapy. The second end point was to evaluate the efficacy of biological therapy to improve NP.

METHODS

A total of 127 patients (88 men and 39 women) with moderate to severe Pso referring to our Service between 2007 and 2014 were included. Inclusion criteria were age ≥18 years and a 24 week treatment. The outcome variable was achievement of PASI 75 at 24 weeks with and without NP. All patients were treated with topical therapy and one of four different biological treatments: adalimumab (44.09%), etanercept (18.11%), infliximab (13.39%) and ustekinumab (24.41%). Physical examinations were performed every 4 weeks, and at each visit, the clinician assessed the PASI and Nail Psoriasis Severity Index (NAPSI).

RESULTS

At multivariate Cox regression analysis, a smaller proportion of patients with NP achieved PASI 75 at 24 weeks than patients without NP when adjusted for the epidemiological, clinical features and biological treatment received. With all biological drugs, the NAPSI score began to improve already after 8 weeks (from 18.53 at week 0-2.83 at week 24).

CONCLUSION

Patients with NP reach PASI 75 more slowly than patients without NP. Clinicians should therefore consider that treatment with a biological agent may require a longer period before reaching a satisfying therapeutical goal. Nevertheless, adalimumab, infliximab, ustekinumab and etanercept demonstrated their equal effectiveness in reducing the NAPSI score.

Visualization of Hair Bulbs through the Scalp: A Trichoscopic Feature of Erosive Pustular Dermatitis of the Scalp

Erosive pustular dermatitis of the scalp (EPDS) typically affects elderly people with scarring alopecia. Videodermoscopy (VD) of the scalp has never been assessed in the diagnosis of EPDS. To evaluate the trichoscopy features of EPDS, we carried out a retrospective analysis of VD images obtained in the scalp of ten patients who affected by EPDS and were compared with those obtained from a series of thirty patients who affected by other type of scarring alopecia. The most specific VD feature was thus represented by evident hair bulb in the scarring scalp, observed in all patients.