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Dumontier C, Braga da Silva J. Nail dystrophy for the surgeon. HAND SURGERY & REHABILITATION 2024; 43S:101635. [PMID: 38367768 DOI: 10.1016/j.hansur.2024.101635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 12/23/2023] [Accepted: 12/24/2023] [Indexed: 02/19/2024]
Abstract
Injuries to the fingertips are the most frequently occurring damage to the hand. The nail is an exceptional structure within the human body that offers both stability and protection, as well as the ability to perform fine and precise movements. Nail dystrophies are numerous, post-traumatic, post-infection or even degenerative. They raise many difficulties for the treating hand surgeon. Which anatomical structure is dystrophic? Is there any secondary fungal superinfection to be treated before surgery? Among the various techniques proposed, which one will help to improve my patient as a complete cure is rarer than partial failures. In this chapter we have chosen to describe the surgical techniques, their difficulties and drawbacks, that are available for the most frequent dystrophies that the hand surgeons may treat.
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Affiliation(s)
- Christian Dumontier
- Centre de la Main, Clinique les EAux Claires, ZAC moudong Sud, 97122 Baie-Mahault, Guadeloupe.
| | - Jefferson Braga da Silva
- Service of Hand and Reconstructive Microsurgery, Hospital São Lucas, Av. Ipiranga, 6690/Centro Clínico PUCRS, Suite 216, RS 90610-000, Porto Alegre, RS, Brazil; Hospital Moinhos de Vento, Av. Ramiro Barcelos 910, Porto Alegre, RS, 90035-000, Brazil
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Rocha BP, Verardino G, Leverone A, D'Almeida LFV, Azulay V, Haneke E, Nakamura RC. Histopathological analysis of chronic paronychia. Int J Dermatol 2023; 62:514-517. [PMID: 36631425 DOI: 10.1111/ijd.16564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 11/06/2022] [Accepted: 12/04/2022] [Indexed: 01/13/2023]
Abstract
BACKGROUND Chronic paronychia is an inflammatory process of the nail folds lasting more than 6 weeks. Clinically, there is hypertrophy and retraction of the folds and absence of the cuticle. Treatment involves clinical measures and, when there is no response or the hypertrophy of the folds is very pronounced, surgical treatment is indicated. Post-surgical histopathology is little studied in the literature. In this sense, we believe that the histopathological study is important not only for the individualized understanding of the patient's chronic disease, avoiding relapses, but also for the understanding of its pathophysiology and treatment possibilities. OBJECTIVE To describe the histopathological changes found in biopsies of the proximal nail fold of patients with chronic paronychia undergoing surgical treatment. MATERIALS AND METHODS A histopathological study of 16 nail folds from 6 patients after surgery was performed at 2 study centers. RESULTS The most prevalent epidermal findings were orthokeratosis, hypergranulosis, acanthosis and spongiosis and the dermal findings were fibrosis and mononuclear inflammatory infiltrate. CONCLUSION The histopathological study allowed us to conclude that chronic paronychia is primarily an inflammatory process, but it is not possible to conclude whether microorganisms such as Candida and bacterial cocci are part of the etiology or just secondary and opportunistic agents.
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Affiliation(s)
- Bruna P Rocha
- Prof. Rubem David Azulay, Nail Studies Center, Dermatology Institute, Rio de Janeiro, Brazil
| | | | - Andreia Leverone
- Prof. Rubem David Azulay, Nail Studies Center, Dermatology Institute, Rio de Janeiro, Brazil
| | - Luiza F V D'Almeida
- Prof. Rubem David Azulay, Nail Studies Center, Dermatology Institute, Rio de Janeiro, Brazil
| | - Vitoria Azulay
- Prof. Rubem David Azulay, Nail Studies Center, Dermatology Institute, Rio de Janeiro, Brazil
| | - Eckart Haneke
- Department of Dermatology, Inselspital, University of Bern, Bern, Switzerland
| | - Robertha C Nakamura
- Prof. Rubem David Azulay, Nail Studies Center, Dermatology Institute, Rio de Janeiro, Brazil
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Abstract
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.
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Affiliation(s)
- Debra K Lee
- Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, TX, USA
| | - Shari R Lipner
- Department of Dermatology, Weill Cornell Medicine New York, NY, USA
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Bansal A, Relhan V. Acute and chronic paronychia revisited: A narrative review. J Cutan Aesthet Surg 2022; 15:1-16. [PMID: 35655642 PMCID: PMC9153310 DOI: 10.4103/jcas.jcas_30_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Paronychia refers to the inflammation of the tissue which immediately surrounds the nail and it can be acute (<6 weeks duration) or chronic (>6 weeks duration). Disruption of the protective barrier between the nail plate and the adjacent nail fold preceded by infectious or noninfectious etiologies results in the development of paronychia. A combination of general protective measures, and medical and/or surgical interventions are required for management. This review explores the pathogenesis, clinical features, differential diagnosis, medical, and surgical management of paronychia. For the purpose of this review, we searched the PubMed, Cochrane, and Scopus databases using the following keywords, titles, and medical subject headings (MeSH): acute paronychia, chronic paronychia, and paronychial surgeries. Relevant review articles, original articles, and case reports/series published till February 2020 were included in this study.
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Ferreira Vieira d'Almeida L, Papaiordanou F, Araújo Machado E, Loda G, Baran R, Nakamura R. Chronic paronychia treatment: Square flap technique. J Am Acad Dermatol 2016; 75:398-403. [DOI: 10.1016/j.jaad.2016.02.1154] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2015] [Revised: 01/26/2016] [Accepted: 02/02/2016] [Indexed: 10/22/2022]
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Abstract
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.
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Affiliation(s)
- Vineet Relhan
- Department of Dermatology, VMMC and Safdurjung Hospital, Delhi, India
| | - Khushbu Goel
- Department of Dermatology, VMMC and Safdurjung Hospital, Delhi, India
| | - Shikha Bansal
- Specialist, VMMC and Safdurjung Hospital, Delhi, India
| | - Vijay Kumar Garg
- Director Professor and Head, MAMC, VMMC and Safdurjung Hospital, Delhi, India
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Abstract
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.
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Gonnelli D, Degardin N, Guidicelli T, Magalon G, Bardot J. [Surgical managing of current cutaneous infections in children]. Arch Pediatr 2010; 17:1373-9. [PMID: 20691574 DOI: 10.1016/j.arcped.2010.06.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2010] [Revised: 06/14/2010] [Accepted: 06/29/2010] [Indexed: 10/19/2022]
Abstract
The cutaneous infectious pathology of the child is varied and frequent. Authors deal with surgical infections seen in current pediatrics, which often have to appeal to a plastic pediatric surgeon for their treatment. Superficial infections of skin and pilo-sebaceous follicles are common in big children. The folliculitis and the boil are the most frequent. Their treatment is medical and surgical and does not require an antibiotic treatment in most of the cases. The primitive abscesses or following an anterior lesion recover from a similar treatment. Some localizations or risky context need a particular follow-up. The whitlow is a particular example and needs to have a particular follow-up because of the risk of hand cellulitis. Nails embodied of the child require a specialized notice because of their numerous clinical forms, which must be distinguished according to the age. Finally the necrotizing cellulitis and fasciitis are surgical emergencies and have a well-codified treatment. These infections in children must benefit from an attentive care because when they are badly treated, they can involve the aesthetic, functional and vital forecast.
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Affiliation(s)
- D Gonnelli
- Service de chirurgie plastique, reconstructrice et esthétique, hôpital de la Conception, 147, boulevard Baille, 13385 Marseille cedex 05, France.
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Baran R, Hay RJ, Garduno JI. Review of antifungal therapy and the severity index for assessing onychomycosis: Part I. J DERMATOL TREAT 2009; 19:72-81. [DOI: 10.1080/09546630701243418] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Abstract
Patients often fear nail surgery because of the pain associated with anesthesia and post-operative care. Potential dystrophic sequelae are of concern to the practitioner. A thorough knowledge of the techniques of anesthesia, nail anatomy, and surgical procedures is a prerequisite for successful nail surgery with almost no pain and minimal scarring. It also is mandatory to involve a dermatopathologist who is familiar with the histologic idiosyncrasies of the nail unit.
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Affiliation(s)
- Bertrand Richert
- Department of Dermatology, University of Liège, Quai Kurth 45 B-4020, Liège, Belgium.
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Grover C, Bansal S, Nanda S, Reddy BSN, Kumar V. En Bloc Excision of Proximal Nail Fold for Treatment of Chronic Paronychia. Dermatol Surg 2006; 32:393-8; discussion 398-9. [PMID: 16640685 DOI: 10.1111/j.1524-4725.2006.32079.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Chronic paronychia is a very recalcitrant dermatosis, which is particularly prevalent in housewives. Medical treatment for this condition is unsatisfactory in a significant number of cases. Surgical approach forms an important part of management, however, this area has received little attention. Various surgical approaches have been tried in the past but a comparative analysis has not been attempted. OBJECTIVES The present study aims at assessing the efficacy of en bloc excision of proximal nail fold (PNF). Moreover, a comparative analysis has been undertaken to assess whether or not simultaneous nail plate avulsion improves the treatment outcome. METHODS Thirty patients of chronic paronychia with nail plate irregularities were randomly divided into two treatment groups (15 patients each). After a detailed evaluation, en bloc excision of PNF with or without nail plate removal was performed. Postoperative measures were advised and the patients were kept under regular follow-up thereafter. Assessment of postoperative complications was also performed. RESULTS Twelve patients in group I and 13 patients in group II completed the treatment protocol. Of these, 70% of patients were cured in group II (en bloc excision with nail avulsion) whereas only 41% were cured in group I (en bloc excision without nail avulsion). CONCLUSION En bloc excision of the PNF is a useful method in recalcitrant chronic paronychia. Simultaneous avulsion of the nail plate improves the surgical outcome. Strict avoidance of irritant exposure is necessary to ensure complete treatment and prevent recurrence.
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Affiliation(s)
- Chander Grover
- Department of Dermatology, Venereology and Leprology, Maulana Azad, Medical College, New Delhi, India.
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En Bloc Excision of Proximal Nail Fold for Treatment of Chronic Paronychia. Dermatol Surg 2006. [DOI: 10.1097/00042728-200603000-00010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Pouaha J, Pinault A, Cholez C, Muller P, Truchetet F. F15 - Traitement chirurgical de la paronychie chronique polydactylique par exérèse du repli sus unguéal. Ann Dermatol Venereol 2005. [DOI: 10.1016/s0151-9638(05)80085-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Abstract
There are two types of fungi (yeasts and molds) both of which can cause superficial infections of the perionychium. Yeasts (such as Candida albicans) grow as single cells and reproduce by asexual budding. In contrast, molds grow in long filaments, called hyphae. There are approximately 100,000 species of fungi that have been characterized. Most of these are ubiquitous. Fortunately only about 200 are human pathogens, and only a handful are commonly found to be associated with human disease. This article discusses causes, symptoms, diagnosis, and treatment of the most common fungal infections of the perionychium, including superficial dermatophytosis, onychomycosis, and chronic paronychia.
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Affiliation(s)
- York J Yates
- University of Missouri, Division of Plastic Surgery, M349, One Hospital Drive, Columbia, MO 65212, USA
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Dominguez-Cherit J, Pichardo-Velazquez P, Cortes-Franco R. Evaluation and treatment of nail disorders utilizing practical nail surgical techniques. Dermatol Ther 2002. [DOI: 10.1046/j.1529-8019.2002.01518.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Affiliation(s)
- E Haneke
- Department of Dermatology, Ferdinand-Sauerbruch-Klinikum Elberfeld, Wuppertal, Germany
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Abstract
A long-term retrospective study of patients with chronic paronychia treated by eponychial marsupialization with or without nail removal is presented. Twenty-eight consecutive fingers with chronic paronychia in twenty-five patients were surgically treated. Symptoms had been present for 28 +/- 7 weeks. Twenty-three of these had nail irregularities. Of this group, the first seven fingers were treated with marsupialization alone. Recurrences developed in two of these. The next sixteen patients with nail irregularities were treated with marsupialization plus nail removal, and there were no recurrences (p less than 0.05). Furthermore, when the two recurrent paronychia were treated with both procedures, one healed completely and the other was markedly improved. All fingers without nail irregularities healed with marsupialization alone. These results confirm that eponychial marsupialization is an effective means of treating chronic paronychia and suggest that nail removal should be done when concurrent nail irregularities are seen.
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Affiliation(s)
- M S Bednar
- Department of Orthopaedics, Hospital for Special Surgery, N.Y., N.Y
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Surgical Treatment of Diseases of the Nail. Prim Care 1986. [DOI: 10.1016/s0095-4543(21)01570-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Baran R. Removal of the proximal nail fold: why, when, how? THE JOURNAL OF DERMATOLOGIC SURGERY AND ONCOLOGY 1986; 12:234-6. [PMID: 3950176 DOI: 10.1111/j.1524-4725.1986.tb01459.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Salasche SJ. Myxoid cysts of the proximal nail fold: a surgical approach. THE JOURNAL OF DERMATOLOGIC SURGERY AND ONCOLOGY 1984; 10:35-9. [PMID: 6690535 DOI: 10.1111/j.1524-4725.1984.tb01170.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
En bloc excision of the proximal and lateral nail folds as described by Baran and Bureau for the treatment of chronic paronychia is successfully adapted for treatment of myxoid cysts of the proximal nail folds.
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