Ultrastructure of the human toenail. I. Proximal nail matrix

Physiology of the nail apparatus: Surgical consequences

Knowledge of nail physiology is mandatory to understand nail pathologies, and to know what to repair and what to expect from your repair. Unfortunately, nail physiology in humans is not completely understood. However, there are some data that have been validated and must be known before treating patients. The nail plate is mostly made of keratins. It is produced solely by the nail matrix. The nail bed is mostly responsible for nail pate adhesion. At the hyponychium, the plate loses its adherence. The hyponychium is the first barrier of defense preventing bacteria and fungi from invading the subungual area. All these structures, along with the nail folds, are responsible for the orientation of nail-plate growth. However, many questions, such as whether to replace the nail plate at end of procedure, remain open.

An Evidence-Based Approach to Pediatric Melanonychia

Melanonychia including melanonychia striata in children poses a diagnostic dilemma. Atypical clinical features often raise the possibility of malignancy, and a nail unit biopsy may be recommended. Commensurate with atypical clinical features, the histopathology may also appear alarming. However, accumulating data illustrate that most cases of melanonychia striata are benign and suggest that an alternate approach is often warranted for pediatric patients. Herein, we review the existing data regarding pediatric melanonychia striata and offer an evidence-based approach to its evaluation and management.

Iontophoresis to Overcome the Challenge of Nail Permeation: Considerations and Optimizations for Successful Ungual Drug Delivery

Iontophoresis is a widely used drug delivery technique that has been used clinically to improve permeation through the skin for drugs and other actives in topical formulations. It is however not commonly used for the treatment of nail diseases despite its potential to improve transungual nail delivery. Instead, treatments for nail diseases are limited to relatively ineffective topical passive permeation techniques, which often result in relapses of nail diseases due to the thickness and hardness of the nail barrier resulting in lower permeation of the actives. Oral systemic antifungal agents that are also used are often associated with various undesirable side effects resulting in low patient compliance. This review article discusses what is currently known about the field of transungual iontophoresis, providing evidence of its efficacy and practicality in delivering drug to the entire surface of the nail for extended treatment periods. It also includes relevant details about the nail structure, the mechanisms of iontophoresis, and the associated in vitro and in vivo studies which have been used to investigate the optimal characteristics for a transungual iontophoretic drug delivery system. Iontophoresis is undoubtedly a promising option to treat nail diseases, and the use of this technique for clinical use will likely improve patient outcomes.Graphical abstract.

A Compendium of Specific Histopathological Bodies in Dermatology

The spectrum of histopathological variations of most of the Dermatological conditions is so wide and overlapping that even with our current vast knowledge of this discipline, it seems to be a tough task for clinicians as well as Dermatopathologists to arrive at a conclusive diagnosis in many cases. However, with the aid of special stains and advanced diagnostic techniques, some characteristic histopathologic features have been defined over the time, among which histopathological bodies or inclusion bodies serve as specific clues. With this perspective in view, an attempt has been made to collate and describe the well-known as well as the lesser-known histopathological bodies seen in various dermatological diseases. The underlying pathogenesis and ultramicroscopic features of these structures have also been outlined in brief.

Nail biology and nail science

The nail plate is the permanent product of the nail matrix. Its normal appearance and growth depend on the integrity of several components: the surrounding tissues or perionychium and the bony phalanx that are contributing to the nail apparatus or nail unit. The nail is inserted proximally in an invagination practically parallel to the upper surface of the skin and laterally in the lateral nail grooves. This pocket-like invagination has a roof, the proximal nail fold and a floor, the matrix from which the nail is derived. The germinal matrix forms the bulk of the nail plate. The proximal element forms the superficial third of the nail whereas the distal element provides its inferior two-thirds. The ventral surface of the proximal nail fold adheres closely to the nail for a short distance and forms a gradually desquamating tissue, the cuticle, made of the stratum corneum of both the dorsal and the ventral side of the proximal nail fold. The cuticle seals and therefore protects the ungual cul-de-sac. The nail plate is bordered by the proximal nail fold which is continuous with the similarly structured lateral nail fold on each side. The nail bed extends from the lunula to the hyponychium. It presents with parallel longitudinal rete ridges. This area, by contrast to the matrix has a firm attachment to the nail plate and nail avulsion produces a denudation of the nail bed. Colourless, but translucent, the highly vascular connective tissue containing glomus organs transmits a pink colour through the nail. Among its multiple functions, the nail provides counterpressure to the pulp that is essential to the tactile sensation involving the fingers and to the prevention of the hypertrophy of the distal wall tissue, produced after nail loss of the great toe nail.

Expression of Cadherin/Catenin Cell—Cell Adhesion Molecules in a Onychomatricoma

Onychomatricoma is a rare nail tumor with a distinctive architecture. Proximally, there are serum-filled invaginations of nail matrix epithelium into the stroma, and distally, dermal protrusions perforate the nail plate. Because other matrical tumors of follicular and odontogenic origin express nuclear β-catenin, we examined the expression of cadherin/catenin proteins in this onychomatricoma case. The patient presented with a toenail yellow streak, and the biopsy revealed an onychomatricoma. E-cadherin and β-catenin were at the cell membrane in the epithelial invaginations. P-cadherin was restricted to basal cells. In contrast to other matrical tumors, nuclear β-catenin was not present. These results suggest that onychomatricoma may lack the transcriptional activating role of β-catenin that characterizes follicular and odontogenic matrical tumors. This is the first report on the expression of cadherin/ catenin cell—cell adhesion proteins in this rare nail tumor.

Immunology of the Human Nail Apparatus: The Nail Matrix Is a Site of Relative Immune Privilege

The nail apparatus is constantly exposed to environmental damage. It requires effective immune responses to combat infection, while avoiding the loss of nail production and regeneration by autoaggressive immunity. By immunohistology, we define here previously unknown characteristics of the normal human nail immune system (NIS). Compared with other regions of nail epithelium, human leukocyte antigen (HLA)-A/B/C expression is prominently down regulated on both keratinocytes and melanocytes of the proximal nail matrix (PNM), whereas HLA-G(+) is upregulated here. Together with the expression of macrophage migration inhibitory factor in PNM, this may serve to inhibit an natural killer (NK) cell attack on major histocompatibility complex (MHC) class Ia-negative PNM. PNM also displays strong immunoreactivity for potent, locally generated immunosuppressants such as transforming growth factor-beta1, alpha-melanocyte stimulating hormone, insulin-like growth factor-1, and adrenocorticotropic hormone, exhibits unusually few CD1a(+), CD4(+), or CD8(+), NK, and mast cells. Finally, MHC class II and CD 209 expression on CD1a(+) cells in and around the PNM is reduced, indicating diminished antigen-presenting capacity. Thus, the NIS strikingly differs from the skin immune system, but shows intriguing similarities to the hair follicle immune system, including the establishment of an area of relative immune privilege in the PNM. This nail immune privilege may offer a relative safeguard against autoimmunity. But, the localized intraepithelial defect of innate and adaptive immunity in the PNM revealed here also may impede effective anti-infection defense.

Early malignant melanoma manifested as longitudinal melanonychia: subungual melanoma may arise from suprabasal melanocytes

A 51-year-old woman developed longitudinal melanonychia of 3 months' duration on the right index fingernail. A biopsy specimen revealed that atypical melanocytes were distributed in the lower third of the matrix epithelium but were few in number at the basal layer. The involved nail matrix was resected because of continual growth of the lesion after the biopsy. It has been proven in normal nail matrices that melanocytes are distributed not only in the basal layer but also in the lower half of the epithelium. It is therefore understandable that malignant melanoma of the nail matrix can arise from melanocytes situated in the squamous epithelium above the basal layer. The present case is a good example in which malignant melanoma of the nail matrix may arise from the intraepithelial region where melanocytes normally reside.

Anatomic distribution of melanocytes in normal nail unit: an immunohistochemical investigation

Very few histologic reports describe normal melanocytes of the nail unit. Previous studies predominantly address the distal nail matrix melanocytes; we found no review of nail-bed melanocytes in the literature. The proximal nail matrix melanocytes are difficult to identify; the cells cannot be identified by L-DOPA staining. More recently, their scarcity was confirmed by immunohistochemistry with a large panel of antibodies directed against melanocytes. We wished to detect the proximal nail matrix dormant melanocytes and compare their density and distribution with that of the other melanocytes in the distal matrix and nail bed and to establish criteria of normality that may help clarify the pathologic features of benign nevoid melanonychia in the nails of whites. A panel of five monoclonal antibodies (MoAbs), including HMB45 and TRP1 directed against antigens localized in early melanosomal vesicles, was investigated in frozen sections of six nail specimens from whites. Both vertical and horizontal sections were assessed to determine the presence of dormant melanocytes. Results showed that the proximal nail matrix melanocytes were clearly identified with MoAbs HMB45 and tyrosinase-related protein-1 (TRP-1). By contrast, melanocytes stained by MoAb against tyrosinase and L-DOPA reaction were evident, especially in the distal matrix. With MoAb TRP-1, the epithelial sheets showed counts of approximately 217+/-84/mm2 in the proximal matrix and of 132+/-34/mm2 in the distal matrix; the nail bed counts were only 45+/-25/mm2. The split epithelial sheets had 103+/-17/mm2 L-DOPA-positive melanocytes in the distal third of the matrix, but only a few of them were detected in the proximal matrix and none were noted in the nail bed. We clearly identified proximal nail melanocytes using MoAb HMB45 and TRP1. The total number of matrix melanocytes can be estimated as approximately 217/mm2. In proximal matrix, the dormant melanocytes compartment was predominant. In the distal matrix, two compartments were identified: a functionally differentiated and a dormant compartment. Contrary to classical opinion, longitudinal melanonychia originates more frequently in the distal matrix, not secondary to the larger melanocyte density but because only the distal matrix contains an active melanin synthesis compartment. Furthermore, the superficial distribution of proximal nail melanocytes in vertical sections showed a histologic feature that may simulate the pagetoid pattern of melanoma in situ.

The onychomatricoma: an electron microscopic study

The electron microscopic findings in the onychomatricoma are described. In the proximal zone of the onychomatricoma, basal cells have various aspects, some being lacunar while others have only a limited cytoplasmic rim containing mitochondria and tonofilaments. In the parakeratotic cell columns the cells elongate and homogenized tonofilaments appear. Around the lacunae the cells are poorly differentiated and their cytoplasm is granular. It can be concluded that in an onychomatricoma the basal cells have a decreased amount of tonofilaments and desmosomes and that their evolution is not uniform. The tumour can be considered as being the result of a disturbed differentiation of nail matrix cells.

The lunula

The lunula is the visible portion of the distal nail matrix that extends beyond the proximal nailfold. It is white, half-moon-shaped, appears by week 14 of gestation, has unique histologic features. The lunula has a primary structural role in defining the free edge of the distal nail plate. Lunular anomalies include changes in form and structure and in color. Lunular dysmorphologic features can be characterized by macrolunula, microlunula or anolunula, and nonconvex lunula. Lunular dyschromias can be confluent or spotted or can be characterized by longitudinal colored bands that traverse the lunula. Alterations in the morphologic features or color (or both) of the lunula can be an indication of either a cutaneous or a systemic disorder.

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.

Fine structure of the dorsal lingual epithelium of the domestic, newborn kitten, Felis catus

The tip and the body of the tongue of the domestic kitten, Felis catus, were examined by light and transmission electron microscopy. On the tip of the tongue, no filiform papillae were observed, but the connective tissue papillae of the lamina propria were recognized. On the lingual body, there were filiform papillae composed of an anterior, a posterior and interpapillar epithelium. Under the transmission electron microscope, the epithelium on the tip of the kitten tongue was found to be of the stratified squamous type. The epithelium contained no cells filled with keratin fibers. In the lingual body, the interpapillar epithelium contained very few keratohyalin granules, and no cells with keratin fibers. In the epithelium on the anterior side of the filiform papillae, numerous keratohyalin granules appeared in the intermediate layer. In the surface layer, a thin layer of typical keratinized cells was visible. In the epithelium on the posterior side of the filiform papillae, a thick layer of keratinized cells was located on the surface layer.

The Merkel cell and associated neoplasms in the eyelids and periocular region

Merkel cells are clear oval cells in the epidermis and outer root sheaths of hair follicles, which are probably of epithelial origin, share ultrastructural features with neuroendocrine cells, and are found in association with touch receptors. In the eyelid, they occur singly in the epidermis and external root sheaths of hairs and eyelashes, and in specialized touch spots alternating with eyelashes. Their typical electron microscopical and antigenic features include dense-core granules, intranuclear rodlets, spinous processes, and a positive reaction for specific cytokeratins, epithelial membrane antigen, neuron-specific enolase, chromogranin and synaptophysin. Merkel cell carcinoma probably develops from precursor cells which give rise to keratinocytes and Merkel cells, and nearly one out of ten Merkel cell carcinomas occur in the eyelid and periocular region. They tend to be bulging lesions near the lid margin of elderly patients, reddish in color, and erythematous with telangiectatic vessels. The diagnosis is based on the frequent presence of neurofilaments and paranuclear aggregates of intermediate filaments in addition to features typical of normal Merkel cells. The tumor often mimics lymphoma or undifferentiated carcinoma and frequently invades lymphatic vessels. One third of Merkel cell carcinomas recur, almost two thirds give rise to regional node metastases, and up to one half metastasize widely and result in death. Initial treatment should be prompt and aggressive, with wide resection and routine postoperative irradiation. Although metastatic lesions often respond to radiation therapy and cytostatic drugs, these treatments are mainly of palliative value.

Longitudinal melanonychia (melanonychia striata): diagnosis and management

Longitudinal melanonychia presents a difficult clinical challenge because subungual melanoma must always be included in the differential diagnosis and because the cause of longitudinal melanonychia is usually not apparent. Accordingly, biopsy is often necessary to establish the cause. This review attempts to expedite management by providing suggestions for the examination of patients with this disorder. The causes of longitudinal melanonychia are enumerated and clues to arrive at the various causes are discussed. Similarities between longitudinal melanonychia and subungual melanoma are discussed in an effort to clarify their differences and similarities; clues to the diagnosis of subungual melanoma are also discussed. Various biopsy techniques applicable to longitudinal melanonychia are considered and the indications for different surgical approaches are emphasized. The importance of the pathologist in interpreting nail biopsy specimens is emphasized.

Dermal Merkel cells in the nevus of Ota and leopard syndrome

We observed dermal Merkel cells around vellus hair follicles in one patient with nevus of Ota and one with leopard syndrome. These Merkel cells were in contact with Schwann cells and nerve endings in the dermis. The question of whether or not Merkel cells exist normally in adult dermis remains unanswered. However, their presence in these abnormal conditions suggests that normally they do occur in the dermis but go undetected because their numbers are so few or they are in a form not readily identifiable by currently available methods.

Treatment of ingrown toenail

A plan is presented which brings together three elements: the clinical stage of disease, the age of the patient, and the treatment regimes available. It is a practical and systematic yet flexible approach to the successful treatment of a given ingrown toenail. A general outline and specific detail of conservative and surgical technique are offered.

Melanonychia striata longitudinalis. A case report

Melanonychia strata longitudinalis is a pigmented (dark brown-tan-black) band running in the long axis of the nail. This abnormal color of the nail plate is caused by a focal increase of melanin because of increased number and/or function of normal or abnormal melanocytes in the nail matrix. Pigmented streaks in nails due to melanocytic hyperplasia are said to be so exceedingly common in black persons as to be normal and the phenomenon is benign in the majority of cases. In our white patient reported here the pigmentation is due to epithelial hyperpigmentation without melanocytic hyperplasia or evidence of malignancy, hormonal abnormality, or other adventitious influence.

Fine structural and morphometric studies of the Merkel cell during fetal and postnatal development

The morphological and morphometric changes of the Merkel cells during fetal and postnatal development were studied in the glabrous digital pads of rats. In 20-day-old fetus rats, the Merkel cells we observed were present in the lower spinous and basal layers, and not associated with axon terminals. The Merkel cell granules were few and sparse. The Merkel cell had clumps of fibrils and formed many desmosomes with surrounding keratinocytes. In postnatal rats, innervation was followed by an increase in the number of Merkel cell granules, and their specific accumulation. The fibrils of the Merkel cells were not prominent. It was found by t-test that the numerical density of the Merkel cell granules significantly increased from the fetal stage to 4-day-old postnatal rats. These results suggest that the Merkel cells are present in the epidermis without nerve contact in 20-day-old fetus rats, and that innervation is necessary for the increase of cellular activity in Merkel cells.

Nail growth direction revisited. Why do nails grow out instead of up?

In some investigations Kligman has been thought to have shown that the cul-de-sac in which the nail is formed determines that it should grow outward instead of upward. However, results obtained during the course of nail surgery for chronic paronychia and electron microscopic studies, along with genetic evidence, fail to confirm his observation on the effect of the proximal nail fold on nail growth direction. The whole subject of direction of nail growth remains questionable and worthy of further consideration.

Ultrastructural resemblance of basal cell epithelioma to primary epithelial germ

Six examples of basal cell epithelium were compared to fetal and adult skin. Five parameters were used in this study: abnormally large aggregates of melanosomes in epithelial cells; the paucity of half-desmosomes; the increase of microfilaments in the cell periphery; clustered membrane-limited granules; and desmosome-like structures of stromal fibroblasts. All of these indicators were positive in both basal cell epithelioma and fetal hair follicle; but they were negative in both fetal and adult epidermis. Therefore, it was concluded that basal cell epithelioma seems to mimic fetal primary epithelial germ. Interestingly, stromal fibroblasts of basal cell epithelioma phagocytize collagen fibers, and membrane-limited granules were found both inside and outside the tumor cells facing the digested collagen stroma. In view of the collagenolytic activity of the homogenate of basal cell epithelioma, membrane-limited granules might represent zymogen granules for collagenases.

Ultrastructural studies of human gingiva. V. Microfibrils of elastic nature and their direct penetration of the basal lamina in chronic periodontitis

In this study, microfibrils widely distributed in the connective tissue of the gingival wall of periodontal pockets were examined by electron microscopy, Theirdistribution, ultrastructural characteristics, close association with fibroblasts and direct communication with the basal lamina were shown. The microfibrils in our specimens were observed in three different groupings (Types A, B, and C). They were believedto represent different stages of maturation of elastic fibera. There was a striking ultrastructural resemblance between oxytalan microfibrils, and the immature or imcompletetype of elastic fiber shown in this report.