Acquired nail beading in patients receiving itraconazole--an indicator of faster nail growth? A study using optical profilometry

Evaluation of nail surface topography using a three-dimensional in vivo optical skin imaging system

BACKGROUND

The analysis of nail surface topography is a subject of ever-increasing interest in dermatology, especially in cosmetic studies. However, there is no accurate and scientifically sound instrumental method that can identify and provide quantitative data on nail surface topography.

MATERIALS AND METHODS

The right index fingers of 78 healthy individuals were examined. The severity of nail roughness was rated by two independent dermatologists on a scale of 1 to 3. Using the phaseshift rapid in vivo measurement of the skin (PRIMOS) system, three-dimensional microtopography was performed, and the roughness parameter values were calculated and evaluated. The relationship between clinical nail roughness grade and nail roughness parameter values obtained utilizing PRIMOS was evaluated.

RESULTS

A moderate correlation was found between the roughness parameter values and the clinical roughness grade. Our study showed that an overall relationship exists between the nail roughness parameter values obtained using PRIMOS and clinically observed nail surface changes.

CONCLUSION

With further studies, PRIMOS could be a valuable tool for clinicians and researchers for conducting an accurate and objective patient assessment in daily practice and demonstrating effectiveness of different therapies for nail dystrophy or evaluating cosmetic effects of various topical treatments in future clinical trials.

A Rare Cause of Exudative Pleural Effusion in a Female

Yellow nail syndrome is an extremely rare syndrome that presents with a clinical triad of thickened yellow nails, lymphedema, and recurring pulmonary manifestations (pleural effusion, chronic cough, or bronchiectasis), usually in the population above the age of 50 years. We describe a case of yellow nail syndrome in a 48-year-old lady who presented with the typical classical triad of this syndrome.

Urate in fingernail represents the deposition of urate burden in gout patients

Urate in the fingernails of gout patients and healthy volunteers was successfully detected by high-performance liquid chromatography (HPLC) with ultraviolet (UV) in our previous research. This study aimed to further investigate whether nail urate could be a proxy for the burden of monosodium urate (MSU) crystals deposits in gout. To this end, we conducted a study in two parts. Firstly, we successfully detected urate in the nail by HPLC-UV and evaluated nail urate concentrations in control subjects and patients with gout. As expected, we found that levels of nail urate were significantly higher in patients with gout than in healthy controls, and the nail urate level was significantly correlated with the volume of MSU crystals deposits measured by dual-energy CT (DECT). Secondly, we found that nail urate can reflect changes in urate levels in the body during urate lowering therapy through a 3-month follow-up study. Our results provide the possibility of quantification of urate in human fingernails as a non-invasive alternative for assessing MSU crystals deposits in gout.

Nails: The Window to the Nose? Update on Yellow Nail Syndrome

Background

Yellow nail syndrome is a rare condition characterized by typical nail alterations and variable presence of lymphedema and respiratory disease. The pathogenesis is still obscure, with most of the literature deriving from case reports and few investigations. The most reported respiratory conditions associated with yellow nail syndrome are pleural effusion and bronchiectasis, whereas association with rhinosinusitis is rarer.

Objectives

To describe a case of yellow nail syndrome and to provide a literature review regarding this disorder, discussing pathogenetic hypothesis, associated conditions, and therapeutic options.

Patients/Methods

A 49-year-old man presented with arrested growth and alterations of his nails, without any history of previous trauma or inflammation but with a severe nasal septum deviation and a history of chronic rhinosinusitis. A diagnosis of yellow nail syndrome was made.

Results

Six months after undergoing rhinoseptoplasty and treatment with oral vitamin E, the patient's nails were cured.

Conclusions

This case emphasizes the role of the dermatologist in detecting systemic conditions. The correct diagnosis led to complete resolution of both nail alterations and associated respiratory disorders.

Itraconazole in the Treatment of Nonfungal Cutaneous Diseases: A Review

INTRODUCTION

The anti-inflammatory and pro-kinetic properties of antibiotics have been widely reported. However, the non-antifungal properties of antifungal agents are less well known and less explored in clinical practice. The purpose of this review was to survey the literature on the non-antifungal use of itraconazole in dermatological practice and the possible modes of action of this agent.

METHODS

The PubMed database was searched for relevant articles published up to January 2017. The references in the articles identified by the search were then hand-searched for additional relevant publications.

RESULTS

Itraconazole displays a great diversity of non-antifungal activity and has been used to treat a broad spectrum of diseases. The results of our survey reveal that itraconazole has the potential to be an alternative agent for treating patients with advanced cancer (either alone or in combination with other cytotoxic chemotherapeutic drugs), especially those refractory to traditional treatments. Moreover, itraconazole acts as an anti-angiogenesis agent, induces nail growth, and modulates inflammatory or immune diseases.

CONCLUSION

Oral antifungal agents have many non-antifungal properties. However, the body of evidence on individual agents often remains limited due to the lack of large-scale randomized controlled studies. Although some of the findings published to date seem promising, pharmacological vigilance should be taken for off-label use in real-world practice.

Yellow nail syndrome: a review

Yellow nail syndrome (YNS; OMIM 153300, ORPHA662) is a very rare disorder that almost always occurs after 50 years of age but a juvenile or familial form has also been observed. YNS is diagnosed based on a triad associating yellow nail discoloration, pulmonary manifestations (chronic cough, bronchiectasia, pleural effusion) and lower limb lymphedema. Chronic sinusitis is frequently associated with the triad. YNS etiology remains unknown but a role of lymphatic impairment is usually evoked. YNS is more frequently isolated but may be associated in rare cases with autoimmune diseases, other clinical manifestations implicating lymphatic functions or cancer and, hence, is also considered a paraneoplastic syndrome. YNS management is symptomatic and not codified. YNS can resolve spontaneously. Oral vitamin E alone or even better when associated with triazole antifungals may achieve partial or total disappearance of nail discoloration. Pleural effusion can be treated surgically, with decortication/pleurectomy or pleurodesis. Antibiotic prophylaxis is prescribed for bronchiectasia with chronic sputum production. Lymphedema treatment is based on low-stretch bandages and the wearing of elastic compression garments combined with skin care, exercises and, as needed, manual lymph drainage.

Surface image analysis of nail alterations in juvenile pityriasis rubra pilaris

BACKGROUND/AIMS

Juvenile pityriasis rubra pilaris (PRP) is a rare disease that may alter the nail aspect. Image analysis after nail shadowing was used to quantify trachyonychia associated with juvenile PRR Methods: The mean roughness (Ra) and the mean depth of roughness (Rz) of fingernails were measured three times at 3-month intervals in nine children suffering from PRR The same measures were taken in 25 age-matched normal individuals.

RESULTS

Both profilometric parameters had higher values in the PRP group than in healthy subjects. The abnormal Ra and Rz values in patients showed variations unrelated to chronobiological cycles.

CONCLUSIONS

Nail shadowing image analysis is a reliable method to assess inconspicuous to moderate nail surface irregularities. In contrast with some other diseases, the aspect of polymorphic nails in PRP does not seem to be under chronobiological influence.

Psoriatic Nail Changes Are Associated With Clinical Outcomes in Psoriatic Arthritis

BACKGROUND

Nail changes are common in psoriatic arthritis (PsA), with varying relationships existing between skin, nail, and joint disease.

OBJECTIVE

To further characterize relationships between nail changes, psoriasis, and joint involvement in PsA patients.

METHODS

One hundred eighty-eight PsA patients had skin, fingernail, and rheumatological assessments completed. Hand and fingernail photographs were taken and reviewed by a dermatologist.

RESULTS

Higher swollen joint counts were associated with distal interphalangeal (DIP)/periungual psoriasis (P=.001), more splinter hemorrhages (P=.006), and any nail bed change (P=.03). Higher tender joint counts were associated with rough onychorrhexis (P<.001), DIP/periungual psoriasis (P=.03), red lunula (P=.001), nail crumbling (P=.046), any nail matrix (P=.03), and nail bed change (P=.03). Joint involvement was associated with same-digit nail changes; strongest association was swollen or tender DIP with subungual hyperkeratosis, odds ratio=26.6 (95% CI, 5.1-139.1).

CONCLUSION

The DIP/periungual psoriasis and specific nail changes were associated with higher joint counts and certain nail changes with same-digit joint involvement.

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.

Atypical Presentation of Congenital Yellow Nail Syndrome in a 2-Year-Old Female

Background:

Yellow nail syndrome (YNS) is a rare clinical entity of unknown etiology that is characterized by a triad of yellow nails, respiratory manifestations, and lymphedema. The condition appears in the mid- to later years of life and only rarely in childhood. We describe a rare case of YNS with an atypical clinical presentation consisting of only yellow and dystrophic nails in a 2- year-old female since birth.

Objective:

A case of congenital YNS with only dystrophic and yellow nails is reported.

Methods and Results:

A 2-year-old female presented with yellow nails since birth. There was no positive family history. Physical examination revealed 20 thickened, dystrophic, yellow nails with onycholysis. There was no evidence of respiratory manifestations or lymphedema.

Conclusion:

Although rare, YNS can present as a congenital clinical entity and persist after birth. Pediatric patients with YNS show different clinical manifestations than the classic adult patient. The presence of yellow and dystrophic nails in the absence of respiratory and lymphatic manifestations may be the only sign of pathology and warrants close monitoring as progression to more serious complications can occur.

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.

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.

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.

Modulation of linear nail growth to treat diseases of the nail

Diseases affecting the nail can cause significant distress and interfere with an individual's self-esteem, personal relationships, and professional life. Often, hand and foot function is adversely affected. Certain diseases are characterized by accelerated nail growth while others show a decrease. In this review, drugs known to influence the growth rate of nails are examined, highlighting their potential use as adjunctive therapy in the treatment of nail disease. This approach, described recently in the context of the yellow nail syndrome,(1) may be extended to other common disorders such as nail psoriasis, brittle nails, and onychomycosis.

Systemic itraconazole in the yellow nail syndrome

Although a number of treatments have been reported to be effective with yellow nail syndrome (YNS), vitamin E at high doses is the only one that has been successfully utilized in a consistent number of patients affected by YNS. Recent data indicate that itraconazole pulse regimen may be effective in this disease. We report our experience with itraconazole treatment in patients affected by YNS. Systemic itraconazole was administered in eight patients (five males and three females; mean age 55.2 years), at a dosage of 400 mg daily for 1 week a month for 6 months. Nail growth was measured every 3 months. Complete cure was achieved in two of eight patients, with mild improvement in two and no improvement in four. The results of our study show that itraconazole cannot be considered effective for YNS, especially if compared with vitamin E, the efficacy and tolerability of which is already proven.

Diseases of the generative nail apparatus. Part I: Nail matrix

Disorders of the generative structures of the nail produce a characteristic set of outcomes. The matrix is the seat of nail development and diseases or insults of this germinative epithelium will tell a story in the signs that unfold in the ensuing nail growth. This story will be influenced by the intensity, duration and extent of this pathology. A method of categorizing changes associated with the generative matrix of the nail will be presented.

Yellow nail syndrome: the nail that grows half as fast grows twice as thick

We report a case of a 51-year-old man with yellow nail syndrome (YNS).1 During a 23-week period of study, the dynamics of thumbnail growth were compared between one affected thumb and the normal contralateral thumb. Longitudinal nail growth was normal (0.46 mm/week) in the normal thumb and double that of the affected thumb (0.23 mm/week). Thickness of nail at the free edge in the affected thumb (0.97 mm) was twice that of the normal thumb (0.57 mm). Within the nail plate in the dorso-ventral axis there were 50% more cells in the affected thumb (358) in comparison with the contralateral control (242). This case illustrates that rate of longitudinal growth does not necessarily reflect nail plate production.

The effect of compression force on surface structure, crushing strength, friability and disintegration time of erythromycin acistrate tablets

The surface roughness of erythromycin acistrate tablets was studied by non-contact laser profilometry. Seven roughness parameters and 3D fractal dimension were examined. The mechanical properties (including crushing strength, friability and disintegration time) were determined, and SEM data were taken from the tablets. According to the results, the crushing strength and the disintegration time of the tablets increased with increasing compression force. At higher compression forces the crushing strength reached a constant level. The friability of the tablets behaved quite unexpectedly and minimum friability was observed at a compression force of 14 kN. Except for fractal dimension, the roughness parameters behaved very much in the same way as the friability of the tablets. The SEM data supported the friability and surface roughness data of the tablets.

Current management of onychomycosis. An overview

Until recently pedal onychomycosis, particularly when it affected several nails or involved a large nail plate area, was often regarded as untreatable. The advent of new therapies such as itraconazole, terbinafine, and fluconazole has been a significant and welcome addition to the armamentarium of therapies at the disposal of the physician. These drugs appear in the nail plate within days of starting oral therapy, being taken up by both the nail matrix and the nail bed. The duration required for effective therapy has been reduced, while the efficacy rates and cost-effectiveness have increased compared with the older treatments, such as griseofulvin. Some of the newer agents appear to have a wider spectrum of activity. Thus far, the newer agent have exhibited a low risk to benefit ratio. I may be possible to combine oral therapies with topical and surgical treatments, thereby further increasing efficacy rates and the cost-effectiveness while decreasing adverse effects and duration of oral therapy.

Intermittent fluconazole dosing in patients with onychomycosis: results of a pilot study

BACKGROUND

Therapeutic limitations of griseofulvin in treating onychomycosis have led to a search for alternative antimycotic agents. An optimal dosing regimen for fluconazole has yet to be defined.

OBJECTIVE

Our purpose was to evaluate the intermittent use of fluconazole (either once-weekly or alternate-day dosing) without concurrent nail avulsion in patients with moderate to severe onychomycosis.

METHODS

Eleven patients with mycologically confirmed onychomycosis of the toenails or fingernails (43 infected nails) were treated with intermittent fluconazole until clinical cure was obtained. Eight patients received fluconazole 300 mg once weekly, one patient received 200 mg once weekly, and two patients received 100 or 200 mg of fluconazole every other day. Eight patients also used an adjunctive topical antimycotic preparation.

RESULTS

All six patients with toenails involved (32 infected nails) were clinically cured after a mean treatment duration of 6 months, and all five patients with fingernails involved (11 infected nails) were cured after 3.7 months. There were no significant clinical or laboratory adverse events.

CONCLUSION

Intermittent fluconazole, taken once weekly or on alternate days, is a well-tolerated and efficacious method to treat onychomycosis.