Nail involvement in systemic sclerosis

Nail involvement in connective tissue diseases: an epidemiological, clinical, and dermoscopic study

BACKGROUND

The assessment of nail changes in connective tissue diseases (CTD) has been rarely explored in previous studies. The use of dermoscopy to study vascular changes in nailfolds is an interesting diagnostic technique. The aim of the study was to describe the epidemiological, clinical, and dermoscopic features of nail lesions in CTD.

METHODS

A prospective study was performed at the Dermatology Department of Habib Thameur Hospital (Tunis, Tunisia) in collaboration with the Internal Medicine Department over a period of 15 months, from July 2020 to September 2021, including patients diagnosed with systemic sclerosis (SS), systemic lupus erythematosus (SLE) and dermatomyositis (DM).

RESULTS

Our study included 48 patients. Nail involvement was found in 44 cases. Dermoscopic nailfold abnormalities were identified in 37 cases. The most common clinical features were ragged cuticle, nailfold erythema, and onycholysis. Additionally, splinter hemorrhage, longitudinal ridging, lunula abnormalities, melanonychia, trachyonychia, leukonychia, increase in transverse curvature, parrot beak nail, half and half nails, and onychorrhexis were described. Nailfold dermoscopy showed a normal pattern in 10 cases, a nonspecific pattern in nine cases (SLE), and a scleroderma pattern in 29 cases (SS and DM). The scleroderma pattern was further categorized into an early pattern (6), an active pattern (14), and a late pattern (9). Normal pattern was observed solely in patients in remission. The late scleroderma pattern was associated with disease duration and systemic involvement. In SLE, disease activity correlated with onycholysis, nailfold erythema, and pathologic pattern in dermoscopy. However, patients with DM displayed a positive correlation between pulmonary involvement and scleroderma pattern.

CONCLUSION

Nail involvement in CTD includes a diverse range of abnormalities. Despite being nonspecific, it can provide crucial clues for establishing a diagnosis. Nailfold dermoscopy serves as a mirror for microangiopathy, enabling the detection of changes at an initial stage, and thus, it becomes a diagnostic and prognostic tool.

Subungual Calcification and Nail Dystrophy: A Case of a Man With Subungual Calcinosis Cutis and an Associated Split Nail Plate

A dystrophic nail is an alteration of the physical appearance and structural properties of the nail from its shape, color, and texture, which can result from multiple etiologies. Calcinosis cutis is a condition that refers to the calcium deposition in the skin and underlying tissue. A 55-year-old man who presented with a split right thumbnail associated with subungual calcinosis cutis affecting the same digit for a duration of nine years is described. He did not recall trauma to the affected area. Microscopic evaluation of the tissue specimen obtained following a biopsy of the affected digit’s nail matrix showed foci of calcium in the dermis. The correlation of his clinical presentation and biopsy findings established a diagnosis of subungual calcinosis cutis. Subungual calcification has been observed in several clinical settings. In addition to subungual calcinosis cutis, it has been noted as a normal finding in elderly individuals. In addition, it has been observed in patients with scleroderma or following trauma to the site. Less commonly, subungual calcification can be associated with idiopathic conditions: calcifying aponeurotic fibroma, digital calcinosis circumscripta, subepidermal calcified nodule, and calcified subungual epidermoid inclusion.

Parrot Beak Nail: Case Report and Review of Parrot Beak Nail Dystrophy

Parrot beak nail dystrophy is an excessive forward curvature of the nail plate that can affect both fingernails and toenails. Few cases have been reported since its original description in 1971; however, the incidence is estimated to be 2.5% in healthy individuals. Although the pathogenesis has not yet been established, parrot beak nail has been associated with chronic crack cocaine use, congenital bone or soft tissue abnormalities, other nail dystrophies, peripheral neuropathy, systemic sclerosis, and trauma to the nail. We describe an 86-year-old man with dementia and neuropathy who presented with an unperceived parrot beak nail of his left fourth toenail and concurrent onycholysis of his left great toenail. He had stopped visits with his podiatrist for nail care, which fostered the growth of these nail dystrophies. Our patient's parrot beak nail was successfully treated with nail clipping and regular nail maintenance to prevent its recurrence. The associated conditions, etiologies, and treatment of parrot beak nails are discussed.

Nail is Systemic Disorders: Main Signs and Clues

Describing and listing all nail symptoms and signs in systemic disorders has already been widely detailed in dedicated textbooks. To be tutorial, this article described most common nails signs and the systemic disorders one may encounter in routine dermatologic consultation. Capsule summaries are presented for each section.

[Ungual lesions in lupus erythematosus: A retrospective study of 14 patients]

INTRODUCTION

There are few studies focusing on ungual lesions in patients with lupus erythematosus (LE). The aim of this study is to describe our experience with ungual lesions in LE patients.

MATERIALS AND METHODS

A multicentric retrospective descriptive study was performed at the dermatology departments of the university hospitals in Strasbourg and at the Tenon hospital in Paris and involved reviewing the medical records and photographs of patients with ungual lesions.

RESULTS

Fourteen patients were included: 12 (86 %) were women with a median age of 38 years (28-78 years). All patients had cutaneous LE presenting as follows: 3 isolated forms (21 %), and associated with systemic LE (LES) for remaining 11 patients (79 %). The most frequent ungual or peri-ungual lesions were longitudinal ridging (12 patients, 86 %), onycholysis and cuticular alterations (8 patients each, 57 %), pterygium (7 patients, 50 %), melanonychia, onychoschizia and subungual hyperkeratosis (5 patients with each, 36 %). Among patients with pterygium and onychoschizia, respectively 6 (86 %) and 5 (100 %) presented the discoid LE subtype, while respectively 6 (86 %) and 4 (80 %) had multisystemic involvement.

DISCUSSION

Ungual lesions do not appear specific and do not in themselves allow diagnosis of LE. They can in fact occur in other diseases such as connective tissue disorders. However, their diagnosis is important because certain of them, such as pterygium, can lead to severe ungual dystrophia, with functional consequences. In our study, pterygium and onychoschizia appeared to be associated with cutaneous discoid lupus erythematosus and multisystemic involvement. The coexistence of peri-ungual lesions related to cutaneous lupus erythematosus and/or multisystemic involvement does not out differentiation of lupus ungual lesions and post-inflammatory lesions.

Cutaneous Manifestations of Scleroderma and Scleroderma-Like Disorders: a Comprehensive Review

Scleroderma refers to an autoimmune connective tissue fibrosing disease, including three different subsets: localized scleroderma, limited cutaneous systemic sclerosis, and diffuse cutaneous systemic sclerosis with divergent patterns of organ involvement, autoantibody profiles, management, and prognostic implications. Although systemic sclerosis is considered the disease prototype that causes cutaneous sclerosis, there are many other conditions that can mimic and be confused with SSc. They can be classified into immune-mediated/inflammatory, immune-mediated/inflammatory with abnormal deposit (mucinoses), genetic, drug-induced and toxic, metabolic, panniculitis/vascular, and (para)neoplastic disorders according to clinico-pathological and pathogenetic correlations. This article reviews the clinical presentation with emphasis on cutaneous disease, etiopathogenesis, diagnosis, and treatment options available for the different forms of scleroderma firstly and for scleroderma-like disorders, including scleromyxedema, scleredema, nephrogenic systemic fibrosis, eosinophilic fasciitis, chronic graft-versus-host disease, porphyria cutanea tarda, diabetic stiff-hand syndrome (diabetic cheiroartropathy), and other minor forms. This latter group of conditions, termed also scleroderma mimics, sclerodermiform diseases, or pseudosclerodermas, shares the common thread of skin thickening but presents with distinct cutaneous manifestations, skin histology, and systemic implications or disease associations, differentiating each entity from the others and from scleroderma. The lack of Raynaud's phenomenon, capillaroscopic abnormalities, or scleroderma-specific autoantibodies is also important diagnostic clues. As cutaneous involvement is the earliest, most frequent and characteristic manifestation of scleroderma and sclerodermoid disorders, dermatologists are often the first-line doctors who must be able to promptly recognize skin symptoms to provide the affected patient a correct diagnosis and appropriate management.

Systemic sclerosis: Current concepts of skin and systemic manifestations

Systemic sclerosis is an uncommon autoimmune connective tissue disease with multiorgan system involvement and significant associated morbidity and mortality. Cutaneous signs and clinical manifestations are of particular importance, as they may be recognized before systemic manifestations, allowing earlier risk stratification into the limited and diffuse cutaneous subtypes, as well as earlier initiation of treatment. Important cutaneous manifestations include Raynaud's phenomenon, digital ulcers, cutaneous sclerosis, calcinosis cutis, telangiectasias, pruritus, and dyspigmentation. Despite investigation of a wide variety of treatments, no FDA-approved pharmacologic therapies exist for systemic sclerosis, and data from high-quality studies are limited. In the following review, we will discuss skin-directed therapies. Although there is evidence to support specific treatments for Raynaud's phenomenon, digital ulcers, and cutaneous sclerosis, there are limited rigorous studies evaluating the treatment of other cutaneous signs and clinical manifestations. Additional randomized-controlled trials and large observational studies are necessary to develop future evidence-based treatment options.

Parrot Beak Nails Revisited: Case Series and Comprehensive Review

The term "parrot beak nail" describes a morphologic change of the nail plate characterized by excessive forward curvature. It may be associated with systemic disease or, most commonly, occurs as an idiopathic finding complicated by delayed nail plate trimming. The characteristics of parrot beak nails in ten men are described, and the features of this acquired nail deformity are reviewed. Of the ten patients, six presented with concurrent neuropathies that resulted in frequent foot injuries or falls. While the true incidence of parrot beak nails is unknown, this nail deformity occurred in 2.1 % of patients seen by a single physician during a 3-month period. In conclusion, parrot beak nails secondary to poor nail care may lead to functional impairment, tissue injury, and subsequent infections. Therefore, it is important for clinicians to look for these nail lesions on cutaneous examination and recommend frequent nail trimmings to individuals with parrot beak nails.