Paronychia--a manifestation of pemphigus vulgaris

Current Knowledge on Nail Involvement in Autoimmune Bullous Disorders

Background

There are few studies, mainly case reports, on the involvement of the nail unit in autoimmune bullous disorders.

Summary

Nail involvement in autoimmune bullous disorders is a significant clinical phenomenon, marked by a range of manifestations, most often not presenting with blisters like on the skin but rather with alterations of the nail unit such as paronychia, onychomadesis, or onycholysis. This involvement is particularly notable due to the unique immunological features of the nail unit, including the expression of various antigens and the presence of Langerhans cells. Conditions like pemphigus vulgaris, bullous pemphigoid, epidermolysis bullosa acquisita, linear IgA disease, and bullous systemic lupus erythematosus can lead to nail abnormalities. The prevalence of nail manifestations varies according to the disorder, and diagnosis often relies on histopathological and immunofluorescence testing. Nail involvement correlates with disease severity and duration, sometimes serving as a herald sign. Further research is needed to guide therapeutic approaches for nail involvement in autoimmune bullous diseases.

Key Messages

Nail involvement in autoimmune bullous nail disorders may be confusing as there are almost never bullae. One should keep the diagnosis in mind when facing an atypical paronychia.

Global trends and hotspots in research of paronychia: A bibliometric analysis

BACKGROUND

Paronychia is a prevalent clinical disease profoundly affecting patients' quality of life. As ongoing evolution in modern living environments, factors contributing to paronychia are becoming increasingly diverse. Therefore, a further understanding about latest trend of paronychia is imperative and pressing.

METHODS

A systematic literature search was performed based on Web of Science Core Collection and Science Citation Index Expanded. The search parameters encompassed keywords associated with paronychia from 1980 to 2023, and rigorous data cleaning procedures were executed to maintain the analysis's relevance and dependability, supplemented by a thorough examination of abstracts and titles. Visibility analysis was conducted with Citespace and VOSviewer tools to explore the publication trends, collaborative networks, and impactful studies.

RESULTS

A total of 595 articles were included in this study. The annual publication trends exhibited a significant increase since 1990, reached a peak of 41 articles in 2021. Collaborative relationships among countries demonstrated strong connections, with the United States leading in both publication volume, citation records and international cooperation. Keyword analysis indicated that in recent years, a substantial body of research has concentrated on paronychia issues caused by epidermal growth factor receptor inhibitors (EGFRI)-class drugs, such as Gefitinib, Erlotinib, and Afatinib, in the context of tumor treatment.

CONCLUSION

In this area, most of the recent hotspots are not focused on the basic research about paronychia due to the basic research about traditional paronychia already reached a relative mature stage. However, with the widespread clinical application of EGFRI anticancer drugs, the incidence of drug-induced paronychia is inevitably on the rise. Therefore, with the expanding diversity in the etiology of paronychia, this area deserves a multiple discipline cooperation with a much wider international communication.

Nail changes in pemphigus: a systematic review and meta-analysis

Pemphigus is a group of autoimmune mucocutaneous bullous disorders characterized by acantholysis resulting from autoantibodies targeting epithelial cell surface antigens. Studies reflect the presence of nail manifestations in some patients and suggest a potential correlation with clinical severity. This study examines the overall prevalence and characterizes the diverse manifestations of nail changes in pemphigus. We searched Cochrane, MEDLINE, EMBASE, and LILACS from 1990 to June 26, 2023 for studies reporting different nail changes in pemphigus patients. Data were collected and pooled to obtain proportions of the prevalence of nail changes in patients with pemphigus and subgroup analysis for pemphigus foliaceous and pemphigus vulgaris. The risk of bias was assessed with the Joanna Briggs Institute Checklist. Of 321 studies screened, 14 studies with 1,208 patients were included. Paronychia (n = 185) and Beau's lines (n = 104) were the most common nail changes identified. The pooled prevalence of nail disease in pemphigus patients was 0.389 (number of studies; [95% CI]: n = 9; [0.160-0.680], with high heterogeneity between studies (I2 = 95.0%, P < 0.001). Subgroup analysis revealed the highest prevalence in pemphigus foliaceous at 0.342 (n = 3; [0.109-0.688]) and pemphigus vulgaris at 0.396 (n = 5; [0.114-0.769]). Nail changes exhibited varied temporal relationships with disease onset and flares, preceding, concurrent, or following these events. Correlation with disease severity was noted, although discrepancies between studies were reported. Nail changes in pemphigus, particularly pemphigus vulgaris and pemphigus foliaceous, may be underrecognized. Observations regarding temporal associations and potential correlations with disease severity highlight the diagnostic and prognostic implications of nail changes in pemphigus. The limitations of this study include study heterogeneity and possible bias. Further research to establish the correlation of the presence and severity of nail changes on the overall disease course would be helpful.

Fixed drug eruptions, bullous drug eruptions, and lichenoid drug eruptions

Drug reactions are among the most common reasons for inpatient dermatology consultation. These reactions are important to identify because discontinuation of the offending agent may lead to disease remission. With the rising use of immunomodulatory and targeted therapeutics in cancer care and the increased incidence in associated reactions to these drugs, the need for accurate identification and treatment of such eruptions has led to the development of the "oncodermatology" subspecialty of dermatology. Immunobullous drug reactions are a dermatologic urgency, with patients often losing a significant proportion of their epithelial barrier; early diagnosis is critical in these cases to prevent complications and worsening disease. Lichenoid drug reactions have myriad causes and can take several months to occur, often leading to difficulties identifying the offending drug. Fixed drug eruptions can often mimic other systemic eruptions, such as immunobullous disease and Stevens-Johnson syndrome, and must be differentiated from them for effective therapy to be initiated. We review the clinical features, pathogenesis, and treatment of immunobullous, fixed, and lichenoid drug reactions with attention to key clinical features and differential diagnosis.

Nail Involvement during Pemphigus

BACKGROUND

Pemphigus is an autoimmune bullous disease affecting the skin and mucous membranes. Associated nail involvement is underestimated and is characterized by a variety of clinical manifestations. Our aim was to describe the clinical aspects of nail involvement during pemphigus.

PATIENTS AND METHODS

A retrospective study was conducted of patients with pemphigus over a period of 12 years. The diagnosis of pemphigus was based on clinical and immunopathological data. Clinical data were collected from patient records prior to initiation of treatment.

RESULTS

Overall,141 cases of pemphigus were collected. Of these, 60 patients had nail involvement. After eliminating fungal origin, we selected 37 patients in our study. The main clinical forms were paronychia and dystrophy. Two cases of destruction of the nail apparatus were found in patients with pemphigus vegetans. The disease was bilateral in 11 cases (29.7%). The presence of ungual involvement was correlated with severity of pemphigus, particularly severe oral disease (p = 0.002).

CONCLUSION

Nail lesions were polymorphic in our patients. These signs show accumulated inflammation of the nail after a long evolution of the disease. Nail involvement may precede, be concomitant, or follow the mucocutaneous lesions of pemphigus and be a sign of severity or relapse of the disease.

Nail changes in autoimmune blistering disorders: A case-control study

Background

Pemphigus and pemphigoid disorders produce blistering cutaneous lesions. Earlier case reports state that nail involvement is uncommon in these autoimmune blistering disorders.

Aims and Objectives

To study nail changes in autoimmune blistering disorders.

Methods

A case-control study was conducted where 40 cases and 40 controls were evaluated for nail changes.

Results

Nail changes were seen in 72.5% of cases and 17.5% of controls. The most common nail findings were paronychia and onychorrhexis.

Limitations

Small sample size; short study duration; nail biopsy could not be done.

Conclusion

Our findings indicate that the inflammatory nature of the blistering cutaneous disease is often reflected conspicuously in the nails.

Involvement of Nail Apparatus in Pemphigus Vulgaris in Ethnic Poles Is Infrequent

Pemphigus vulgaris lesions have a tendency to localize around natural body orifices. The aim here was to analyze the involvement of nail apparatus in pemphigus vulgaris. Sixty seven ethnic Poles suffering from pemphigus vulgaris on photographic files archiving initial presentation were retrospectively evaluated. Pemphigus vulgaris was diagnosed using combination of clinical data, H+E histology, direct immunofluorescence of plucked scalp hair and/or perilesional tissue also for IgG1 and IgG4 deposits evaluation, indirect immunofluorescence on mosaic substrate and/or monkey esophagus, mono-analyte ELISA with desmoglein 1/3 or multi-analyte ELISA. The nail apparatus involvement was found in 9 of 67 patients (13.4%; 3 females and 6 males). Periungual fingernail lesions were found in 6 patients (2 females, 4 males), whereas periungual toenail lesions in just 3 patients (1 female, 2 males). Our patients nail apparatus changes included, by order of frequency, paronychia, nail discoloration, onychorrhexis, Beau lines, periungual hemorrhages, onychomadesis, cross-ridging, onycholysis, and trachyonychia. The average time between the onset, as recalled by patients, and the diagnosis of pemphigus vulgaris with direct immunofluorescence was not statistically different in PV patients with and without nail apparatus lesions. In this article the molecular and immunological rationale for of periungual involvement is discussed. Our single-center study suggests that nail apparatus involvement is infrequent in pemphigus vulgaris in ethnic Poles. Due to the fact that nail apparatus lesions in pemphigus vulgaris may clinically resemble onychomycosis, giving the proper diagnosis can be difficult particularly when other lesions are overlooked or misinterpreted.

Recurrent Paronychia as a Presenting Manifestation of Pemphigus Vulgaris: A Case Report

Nail involvement in pemphigus vulgaris (PV) is an unusual clinical finding. The most common clinical manifestations include chronic paronychia and onychomadesis. We report an adult female patient with PV who initially presented with chronic paronychia of multiple fingernails and toenails before the onset of vesiculobullous eruptions. Later on, after complete resolution, there was recurrence of pemphigus presenting as hemorrhagic paronychia of the left index finger. Systemic treatment with corticosteroids and azathioprine led to complete resolution of mucocutaneous lesions as well as nail manifestations. Thus, chronic treatment-resistant paronychia may be an early and important sign of generalized pemphigus in certain patients.

Nail changes in female pemphigus vulgaris patients on immunosuppressive therapy

Background

Pemphigus vulgaris (PV) patients receiving immunosuppressive therapy may develop nail alterations resulting from infection, skin disorder, or drug regimen.

Objective

This study aims to describe nail changes in PV female patients receiving immunosuppressive therapy and to report the frequency of associated fungal and bacterial growth in the patients’ nails.

Methods

Twenty-five female PV patients who had at least one acquired finger or toenail abnormality and had been administered at least one immunosuppressive drug were included in the study. Nail alterations were recorded. Nail scrapings were collected from abnormal nails for fungal and bacterial examination.

Results

Positive fungal and bacterial cultures were detected in 20 (80%) of patients’ nail samples. Five patients reported nail alterations coinciding with disease onset, whereas 13 reported nail changes after administration of immunosuppressive therapy.

Limitations

Lack of a control group (patients on similar immunosuppressive medications for conditions other than PV) which would have further supported the findings demonstrated in this observational study.

Conclusion

Nail abnormalities in severe PV patients are frequently associated with fungal and bacterial growth. Immunosuppressive therapy potentially initiates such changes.

What is already known on this topic?

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Pemphigus vulgaris (PV) patients receiving immunosuppressive therapy may develop nail alterations resulting from infection, skin disorder, or drug regimen.

What does this article add to our knowledge?

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The duration of disease in severe PV appears to dictate the longevity of nail changes in patients, and immunosuppressive therapy may initiate these nail changes either alone or as a result of opportunistic bacterial and/or fungal growth affecting the nail unit. Accordingly, prompt treatment of PV utilizing a multidisciplinary approach (combined or sequential therapy) would presumably decrease the incidence of nail affection in PV patients on immunosuppressive therapy.

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Limitations of the present work include lack of a control group (patients on similar immunosuppressive medications for conditions other than PV), which would have further supported the findings demonstrated in this observational study.

Acute paronychia heralding the exacerbation of pemphigus vulgaris

Acute paronychia, the suppurative inflammation involving the paronychium of the nails, is usually caused by bacterial or fungal infection and has been rarely reported as a presentation of pemphigus vulgaris (PV). We report a woman with PV who presented with suppurative paronychia of multiple fingernails and toenails, which preceded the exacerbation of other mucocutaneous lesions. A biopsy specimen of the paronychium revealed suprabasal vesicles due to acantholysis. Systemic corticosteroids and adjuvant immunosuppressants were effective in treating mucocutaneous lesions as well as nail disease. We conclude that in patients with PV, acute paronychia could be a manifestation of the disease per se, rather than an infectious process. Only the precise diagnosis with adequate immunosuppressive treatment can lead to good control of disease activity.

Nail manifestations in pemphigus vulgaris

Nail involvement in pemphigus vulgaris is rare. We describe 5 patients with pemphigus vulgaris presenting nail involvement. In this disease, nail manifestations present, by order of frequency, as chronic paronychia, onychomadesis, onycholysis, Beau's lines and trachyonychia. All our 5 cases presented with paronychia, and 1 of them also had Beau's lines. Treatment with prednisone and/or cyclophosphamide controlled mucocutaneous and nail manifestations in all cases.

Nail involvement in pemphigus vulgaris

BACKGROUND

Involvement of the nail unit in pemphigus vulgaris (PV) is thought to be rare.

OBJECTIVES

To determine the frequency of nail changes among patients with PV.

METHODS

Nail changes were recorded in patients with PV and were analysed retrospectively. Biopsies were taken from the nail bed and nail matrix for histological and immunofluorescence observations. Microscopic (potassium hydroxide) examination and fungal culture were performed.

RESULTS

Nail changes were present in 30 of 64 (47%) patients with PV. Sixteen patients had onychomycosis and 14 had nail changes due to PV. These included onychomadesis, discoloration, deformity, onychorrhexis, onycholysis, subungual haemorrhage, subungual hyperkeratosis and paronychia. Onychomycosis affected fingernails and toenails, but changes due to PV occurred only in fingernails, most commonly on the thumb and index finger. No connection was found between the patient's occupation and nail involvement, and there was no correlation with the severity or duration of PV. In a control group of 64 patients of similar sex and age, only two had non-specific fingernail changes.

CONCLUSIONS

Nail changes in PV may be more frequent than previously thought.

Nail involvement in pemphigus vulgaris

Nail involvement in pemphigus vulgaris is relatively rare. We describe a case of severe pemphigus involving both the skin and oral mucosa in which an acute exacerbation was preceded by the onset of nail involvement of all 4 extremities. Nail involvement occurred in the form of hemorrhagic paronychia of multiple digits. Oral, cutaneous, and nail manifestations of the disease were all well controlled by systemic therapy. A review of the literature on nail involvement in pemphigus reveals that this involvement may be manifested in multiple ways, with chronic paronychia and onychomadesis being the most common. Involvement of the nail occurs most frequently either as part of the initial presentation, or just before or concurrent with a flare of pre-existing disease. Nail involvement, when it occurs, is usually present when the disease is severe. Topical therapy is insufficient, and systemic therapy is warranted. In the majority of cases, nail recovery is complete, with no residual damage.

An unusual case of pemphigus vulgaris presenting as bilateral foot ulcers

We describe an unusual presentation of pemphigus vulgaris, an autoimmune intraepidermal blistering skin disease associated with autoantibodies to the desmosome glycoprotein, desmoglein 3. A 60-year-old man presented with bilateral ulceration on the dorsum of the feet. These clinical features persisted for 4 months before more characteristic signs of pemphigus vulgaris, including mouth ulceration and skin erosions, developed. The atypical presentation led to a delay in diagnosis and initiation of the appropriate treatment. Pemphigus vulgaris may have unusual manifestations, such as nail dystrophy, paronychia, or granulation tissue-like lesions, but this case of bilateral foot ulceration highlights a further, perhaps unique, clinical presentation of this autoimmune disease.