Paronychia associated with antiretroviral therapy

Surgery for benign nail tumor

The vast majority of tumors in the nail apparatus have a different clinical presentation and course from their equivalents on the skin. Some, such as onychomatricoma and onychopapilloma, are unique to the nail and others, such as superficial acral fibromyxoma, have a tropism for the nail apparatus. As a rule, benign lesions respect the general architecture of the nail apparatus, whereas malignant tumors are destructive. Treatment is always surgical and good knowledge of the anatomy and the procedures is mandatory in order not to induce postoperative nail dystrophy.

Fingertip Infections

The fingertip is the interface between humans and the world, including the various thorns, dirty needles, and other hazards to be found there. It is unsurprising that this is the site where hand infections most frequently occur. Although commonly encountered by hand surgeons and other physicians, fingertip infections have several mimics, and diagnosis and management is not always straightforward. Early diagnosis and treatment are key to success. As with all infections, they are more common and are more aggressive in immunosuppressed patients. This article reviews fingertip anatomy, common and uncommon fingertip infections and their mimics, and recommendations for management.

Oral Pyogenic Granuloma: A Narrative Review

Pyogenic granuloma (PG) is a benign vascular lesion found predominantly in the oral cavity. Characterized by rapid growth and propensity to bleed, PG presents diagnostic challenges due to its similarity and alarming proliferation. This narrative review synthesizes current knowledge on the epidemiology, etiopathogenesis, clinical manifestations, and management of oral PG, with emphasis on recent advances in diagnostic and therapeutic approaches. The epidemiology of the injury is meticulously analyzed, revealing a higher incidence in women and a wide range of ages of onset. It delves into the etiopathogenesis, highlighting the uncertainty surrounding the exact causal factors, although historical attributions suggest an infectious origin. It exhaustively analyzes the clinical and histopathological aspects of oral PG, offering information on its various presentations and the importance of an accurate diagnosis to guide effective treatment. It details treatment strategies, emphasizing the personalized approach based on individual patient characteristics. This comprehensive review consolidates current knowledge on oral PG, highlighting the need for further research to clarify its pathogenesis and optimize treatment protocols.

Optimal diagnosis and management of common nail disorders

Nail conditions are not only aesthetic concerns, and nail changes may be a clue to an underlying systemic diseases or infection. Without timely treatment, nail diseases can continue to worsen and significantly impair performance of daily activities and reduce quality of life. Examination of the nails is essential at every medical visit, and may uncover important findings. Brittle nail syndrome, onychomycosis, paronychia, nail psoriasis, longitudinal melanonychia, Beau's lines, onychomadesis and retronychia are common nail disorders seen in clinical practice. These conditions stem from infectious, inflammatory, neoplastic and traumatic aetiologies. Though each nail condition presents with its own distinct characteristics, the clinical findings may overlap between different conditions, resulting in misdiagnosis and treatment delays. Patients can present with nail plate changes (e.g. hyperkeratosis, onycholysis, pitting), discolouration, pain and inflammation. The diagnostic work-up of nail disease should include a detailed history and clinical examination of all 20 nail units. Dermoscopy, diagnostic imaging and histopathologic and mycological analyses may be necessary for diagnosis. Nail findings concerning for malignancy should be promptly referred to a dermatologist for evaluation and biopsy. Nail disease management requires a targeted treatment approach. Treatments include topical and/or systemic medications, discontinuation of offending drugs or surgical intervention, depending on the condition. Patient education on proper nail care and techniques to minimize further damage to the affected nails is also important. This article serves to enhance familiarity of the most common nail disorders seen in clinical practice. It will highlight the key clinical manifestations, systematic approaches to diagnosis and treatment options for each nail condition to improve diagnosis and management of nail diseases, as well as patient outcomes.Key messagesNail disease is not only a cosmetic issue, as nail changes can indicate the presence of a serious underlying systemic disease, infection or malignancy.Nail pain and changes associated with NP are physically and emotionally distressing and may contribute to functional impairment and diminished quality of life.LM is a hallmark sign of subungual melanoma and this finding warrants further investigation to rule out malignancy.

Fingertip Infections

The fingertip is the most common site of infections in the hand, which frequently are encountered by surgeons, dermatologists, and emergency and primary providers. Their mismanagement may have serious consequences. This review discusses the unique anatomy of the volar fingertip pulp and perionychium and reviews pathophysiology and treatment of acute and chronic paronychia, including the decision for surgical versus medical management, choice of antibiotics, incisional techniques, and postincisional care. Felons and the evidence regarding their management are reviewed. Several infectious, rheumatologic, and oncologic conditions that may mimic common fingertip infections and about which the managing provider must be aware are presented.

Toenail paronychia

Paronychia is an inflammation of the tissues alongside the nail. It may be acute or chronic and can be seen in isolation or in association with an ingrowing toenail. Acute paronychial infections develop when a disruption occurs between the seal of the nail fold and the nail plate, providing a portal of entry for invading organisms. The treatment of paronychia associated with an ingrowing toenail is aimed at treating the causal toenail. In paronychia not associated with an ingrowing toenail, antibiotics may cure an early infection but surgical drainage of an abscess is often required. In this case, an intra-sulcal approach is preferable to a nail fold incision. Chronic paronychia is less common in the feet than in the hands. It is a form of contact dermatitis and is frequently non-infective, however the chronically irritated tissue may become secondarily colonised by fungi. A dermatology consultation should be obtained for suspected chronic paronychia. Patients with chronic paronychia that is unresponsive to standard treatment should be investigated for unusual causes, such as malignancy. An algorithm for the treatment of paronychia is presented in this review.

Management of chronic paronychia

Chronic paronychia is an inflammatory disorder of the nail folds of a toe or finger presenting as redness, tenderness, and swelling. It is recalcitrant dermatoses seen commonly in housewives and housemaids. It is a multifactorial inflammatory reaction of the proximal nail fold to irritants and allergens. Repeated bouts of inflammation lead to fibrosis of proximal nail fold with poor generation of cuticle, which in turn exposes the nail further to irritants and allergens. Thus, general preventive measures form cornerstone of the therapy. Though previously anti-fungals were the mainstay of therapy, topical steroid creams have been found to be more effective in the treatment of chronic paronychia. In recalcitrant cases, surgical treatment may be resorted to, which includes en bloc excision of the proximal nail fold or an eponychial marsupialization, with or without nail plate removal. Newer therapies and surgical modalities are being employed in the management of chronic paronychia. In this overview, we review recent epidemiological studies, present current thinking on the pathophysiology leading to chronic paronychia, discuss the challenges chronic paronychia presents, and recommend a commonsense approach to management.

Nail abnormalities associated with systemic pathologies

Nail abnormalities can arise in conjunction with or as a result of systematic pathologies. These pathologies include single-organ diseases, multisystemic diseases, and drug-induced insults. Clinical signs associated with these conditions include dyschromias, vascular alterations, periungual tissue changes, textural dystrophies, contour alterations, and growth-rate alterations. The associated systemic pathologies may affect any part of the nail apparatus, including the nail matrix, the nail plate, the nail bed, the underlying vasculature, and the periungual tissues. The anatomical location and extent of damage determine the clinically manifested anomaly.

Acute and chronic paronychia of the hand

Acute and chronic infections and inflammation adjacent to the fingernail, or paronychia, are common. Paronychia typically develops following a breakdown in the barrier between the nail plate and the adjacent nail fold and is often caused by bacterial or fungal pathogens; however, noninfectious etiologies, such as chemical irritants, excessive moisture, systemic conditions, and medications, can cause nail changes. Abscesses associated with acute infections may spontaneously decompress or may require drainage and local wound care along with a short course of appropriate antibiotics. Chronic infections have a multifactorial etiology and can lead to nail changes, including thickening, ridging, and discoloration. Large, prospective studies are needed to identify the best treatment regimen for acute and chronic paronychia.

Paronychia induced by the epidermal growth factor receptor inhibitor cetuximab

While the development of epidermal growth factor receptor inhibitors has been hailed as a remarkable triumph in the field of oncology, it has inherited with it a host of cutaneous side-effects that have been increasingly observed in a substantial number of patients in the recent years. One cutaneous manifestation that may inflict significant pain and affect activities of daily living among some of the patients receiving epidermal growth factor receptor inhibitors is paronychia. A case of paronychia associated with the use of cetuximab in the management of KRAS wild-type midrectal adenocarcinoma along with its management has been described.

Periungual and subungual pyogenic granuloma

BACKGROUND

Nail pyogenic granuloma (PG) is common, often seen as an urgent case, given the recent onset as a bleeding nodule. Nail PGs are due to different causes that act through different pathogenetic mechanisms and may be treated in several ways. Both causes and treatments of nail PG have never been classified.

OBJECTIVES

To classify nail PG according to the pathogenesis, describe the clinical and pathological features and provide guidelines for a correct diagnosis and treatment.

METHODS

A retrospective, observational study was performed reviewing epidemiological and clinical features of 58 cases of PG seen at our Departments in the last 5 years. A review of the literature was also carried out, using PubMed database and dermatological textbooks.

RESULTS

Nail PG is usually due to the following causes: drugs, local trauma and peripheral nerve injury. Histopathology shows similar features in every type of PG, irrespective of cause and location.

CONCLUSIONS

The localization of nail PG, the number of digits involved and clinical history help to identify the cause. When PG is single, especially if it involves the nail bed, histological examination is necessary to rule out malignant melanoma. Treatment must be chosen according to the underlying cause.

Drug reactions affecting the nail unit: diagnosis and management

Several drugs may be responsible for the development of nail abnormalities, but only a few classes are consistently associated with nail symptoms. Drug-induced nail abnormalities result from toxicity to the matrix, the nail bed, the periungual tissues, or the digit blood vessels. Pharmacologic agents that most frequently produce nail abnormalities include retinoids, indinavir, and cancer chemotherapeutic agents.

Nail toxicity associated with epidermal growth factor receptor inhibitor therapy

As the use of epidermal growth factor receptor inhibitors becomes more widespread, increasing data are being collected regarding both efficacy and toxicity. Cutaneous toxicities are emerging not only as the most relevant class-related events, but also as potentially important markers of response to therapy. Although a follicular eruption is the most frequent cutaneous manifestation of epidermal growth factor receptor inhibition, ingrown nails, paronychia, and xerosis and desquamation of the digits, all of which occur in a substantial number of patients, require attention from treating oncologists and dermatologists. These nail disorders are mostly mild to moderate in severity, but, if not properly managed, can result in significant pain and interfere with activities of daily living. Descriptions of the nail and periungual toxicities associated with epidermal growth factor receptor inhibitor therapy and prevention and treatment strategies are presented.

[Skin signs associated with epidermal growth factor inhibitors]

BACKGROUND

Inhibitors of epidermal growth factor receptors (EGFR) constitute a new alternative treatment for patients presenting certain advanced stage solid cancers (bowel, breast, ovary). Adverse cutaneous effects of these drugs are now starting to be described.

OBSERVATIONS

Our study involved 2 men and 2 women with no previous history of acne included in a treatment protocol comprising EGFR inhibitors. Mean age was 52 years. The primary cancers were breast, ovary, bowel and unidentified. The EGFR inhibitors used were gefitinib (ZD1839) (2 cases), carnetinib (Cl1033) and cetuximab (IMC-C225). Skin lesions appeared after 7 days and included erythematous papules and follicular pustules of the face, back and upper chest. No comedons were seen, and there were no nodules or cysts. The severity of the rash resulted in discontinuation of treatment in 2 patients with complete disappearance of skin lesions in both cases. In one patient, reduction of the dosage of gefitinib (IMC-C225) led to gradual resolution of the rash. Histological examination of papules and pustules concluded on an acute suppurative folliculitis. Smears and cultures ofa nasal lesion and pustules revealed coagulase-positive Staphylococcus aureus in 2 patients. Combined doxycycline 100 mg daily and benzoyl peroxide was prescribed for 3 months and a favourable outcome was achieved after a mean 2 weeks.

DISCUSSION

EGFR inhibitors act by inhibiting mechanisms oftumour proliferation in certain cancers at advanced stages or refractory to other treatments. Our findings in these four patients are similar to the published cases in terms of rapid onset of monomorphous, papulopustular, follicular eruption without comedons. Rapid response to cyclines and benzoyl peroxide is also reported in literature. This treatment must be instituted rapidly and patients must be informed about the cutaneous side-effects of EGFR inhibitors before the start of therapy. The pathophysiology of these eruptions is still unknown. Skin signs are probably due to interaction with EGFR functions, including overexpression of EGFR in keratinocytes and hair follicles.

Drug-induced Nail Diseases

Although many nail disorders have been associated with drug intake, most reports are anecdotal. Most nail changes caused by drugs are the outcome of acute toxicity to the nail epithelia; nail symptoms depend on which nail structure is damaged. The most com-mon symptoms include Beau's lines/onychomadesis, melanonychia, onycholysis, and periungual pyogenic granulomas. Drug-induced nail abnormalities are usually transitory and disappear with drug withdrawal, but sometimes persist over time. This article reviews drugs that have been consistently associated with nail abnormalities.

Drug-induced nail abnormalities

A large number of drugs may be responsible for the development of nail changes, including cancer chemotherapeutic agents and retinoids, however, only a few classes of drugs are consistently associated with nail symptoms. Drug-induced nail abnormalities result from toxicity to the matrix, the nail bed, the periungual tissues or the digit blood vessels. The most common symptoms include Beau's lines, onychomadesis, melanonychia, onycholysis and periungual pyogenic granulomas. Drug-induced nail changes usually involve several or all of the nails. In most cases, nail abnormalities are asymptomatic, but can sometimes cause pain and impair manual activities.

Antiretrovirals, Part 1: Overview, History, and Focus on Protease Inhibitors

This column is the first in a series on HIV/AIDS antiretroviral drugs. This first review summarizes the history of HIV/AIDS and the development of highly active antiretroviral therapy (HAART) and highlights why it is important for non-HIV specialists to know about these drugs. There are four broad classes of HIV medications used in varying combinations in HAART: the protease inhibitors, nucleoside analogue reverse transcriptase inhibitors, the non-nucleoside reverse transcriptase inhibitors, and cell membrane fusion inhibitors. This paper reviews the mechanism of action, side effects, toxicities, and drug interactions of the protease inhibitors.

[Paronychia in patients infected with HIV treated with indinavir]

A retrospective study of cases of paronychia associated with anti-retroviral therapy diagnosed in two general hospitals is here reported. Lesions appeared from 3 and 48 months after institution of therapy. At diagnosis, 84.6% of patients were on indinavir therapy. CD4 values ranged from 120 and 1,332 cells/mm3 and viral load was lower than 200 copies/ml in 92.3 of cases. Conservative therapy was applied in 7 patients and surgery in 6. In all patients indinavir therapy was discontinued, and cure was achieved 16 weeks later. The "retinoid" effect of indinavir is discussed as likely pathogenic explanation for this complications. We advocate for topic therapy and change of anti-retroviral therapy, reserving surgery for patients not responding to therapy. Pain and functional limitation caused by this non uncommon complication (1.6% of our patients treated with anti-retroviral agents) makes its knowledge necessary and an active search by clinicians in patients receiving indinavir therapy.

Cutaneous side-effects in cancer patients treated with the antiepidermal growth factor receptor antibody C225

BACKGROUND

C225 is an antibody to the epidermal growth factor receptor (EGFR), and inhibits growth of various tumour cells. The antibody is currently being used as a therapeutic agent in several clinical trials of patients with carcinomas. Objectives To determine and investigate the cutaneous side-effects in cancer patients treated with C225. Methods We clinically examined 10 patients treated with C225, and performed immunohistochemical and in situ hybridization studies on skin biopsies. Results The most common cutaneous reaction to C225 therapy was the development of an acneiform follicular eruption, which was most pronounced on the face, chest and upper back and typically manifested a week after the onset of treatment. The consistency of the morphology and timing of the clinical findings in 10 different patients following monotherapy with C225 strongly suggested a direct biological effect of the antibody. Additional dermatological side-effects included focal areas of tender paronychial inflammation of toes and fingers and small aphthous ulcers of the oral mucosa. Serial punch biopsies of chest skin before and after treatment (at 8 days) revealed two main reaction patterns: a superficial dermal inflammatory cell infiltrate surrounding hyperkeratotic and ectatic follicular infundibula, and a suppurative superficial folliculitis. In two biopsies focal intraepidermal acantholysis was found. Microbiological cultures failed to reveal an infectious aetiology. Immunohistochemical and in situ hybridization studies on a subset of the biopsies showed an increase in the expression of p27Kip1 in epidermal keratinocytes after treatment with C225. Conclusions Our findings support the concept that p27Kip1 plays a part in the in vivo regulation of follicular and epidermal homeostasis by EGFR.