Nail changes and association of osteoarthritis in digital myxoid cyst

Nails in older adults

As the world's population of adults greater than 60 years old continues to increase, it is important to manage nail disorders that may impact their daily lives. Nail disorders may have significant impact on quality of life due to decreased functionality, extreme pain, or social embarrassment. In this review, we discuss nail disorders affecting older patients, including physiologic, traumatic, drug-induced, infectious, environmental, inflammatory, and neoplastic conditions. Diagnosis of these conditions involves a detailed history, physical examination of all 20 nails, and depending on the condition, a nail clipping or biopsy and/or diagnostic imaging. Nails grow even more slowly in older adults compared to younger individuals, and therefore it is important for accurate diagnosis, and avoidance of inappropriate management and delay of treatment. Increased awareness of nail pathologies may help recognition and management of nail conditions in older adults.

Digital mucous cysts of the finger without osteoarthritis: optimizing outcome of long needle trajectory aspiration and injection

Digital mucous cysts are common, benign and highly recurrent tumors of the distal interphalangeal joints of the fingers and often associated with osteoarthritis. Multiple treatment modalities have been described, but still no consensus is stated. In the absence of degenerative changes, we promote a novel non-surgical approach. The aim of this study was to examine all patients with digital mucous cysts without underlying osteoarthritis, undergoing this injection technique and to assess outcome and complications of this procedure. This was a single center study (2018-2019) of 17 patients who received a long needle trajectory aspiration and injection for treatment of digital mucous cysts. Exclusion criteria were prior surgical treatment, post-traumatic cyst formation and the presence of radiographic distal interphalangeal joint osteophytosis. A total of 15 patients were found eligible for inclusion. The patient reports were retrospectively analyzed with a follow-up of 6 months. The primary study outcome was resolution of the cyst; secondary outcomes were complications of the procedure. Twelve (80%) resolved completely and three (20%) had limited local recurrence at 6 months. No complications were reported. None of the patients with limited recurrence desired further treatment. We believe that this technique offers a non-invasive, low-cost treatment option for digital mucous cysts, particularly in the subset of patients with ample evidence of degenerative articular changes in the distal interphalangeal joint. The described technique can be performed in an office-based setting and avoids typical surgical as well as aspiration-associated complications.

Ultrasonography in dermatologic surgery: revealing the unseen for improved surgical planning

Ultrasonography (US) is a modern, in vivo imaging method, which is increasingly being used in dermatology as a complementary tool to clinical examination and dermoscopy. At higher frequencies (15 MHz and above), US is an established method for assessing benign and malignant skin lesions, locoregional staging, monitoring the therapeutic efficacy in various inflammatory skin conditions, and patient follow-up. One field, which may increasingly benefit from performant imaging techniques such as US is dermatologic surgery. Preoperative imaging of cutaneous tumors, inflammatory skin conditions (hidradenitis suppurativa, abscesses, etc.), or nail pathology provide dermatologic surgeons with relevant information for an optimal surgical planning, identifying potential complex aspects which might require interdisciplinary approaches, herein sparing unnecessary surgical interventions and increasing patients' compliance. In this review, we discuss the increasing significance of US in the field of dermatologic surgery, as well as the spectrum of cutaneous pathology where sonography can aid in the preoperative setting to provide a more precise, individualized surgical planning for better counseling to our patients and improved surgical results.

The Treatment of Primary Arthritis of the Finger and Thumb Joint

BACKGROUND

Primary finger and thumb joint arthritis is common, with a markedly rising prevalence from age 50 onward. As the population as a whole ages, the need for effective, stage-appropriate treatment of this condition is increasing.

METHODS

This review is based on pertinent publications retrieved by a selective search in the PubMed and Cochrane Library databases.

RESULTS

Pain on movement and morning stiffness are commonly reported symptoms. Thorough physical examination and plain x-rays are mandatory. In the early stages of primary finger and thumb joint arthritis, a conservative, multimodal treatment approach involving the use of splints, physiotherapy, and non-steroidal anti-inflammatory drugs can be helpful. The intraarticular injection of hyaluronic acid or cortisone seems to relieve pain in the short term, but its long-term efficacy in primary finger and thumb joint arthritis is questionable. Arthrodesis (joint fusion) is a reliable surgical treatment option for arthritis of the metacarpophalangeal and interphalangeal joints of the thumb. For mobility-preserving surgery of the metacarpophalangeal joints of the second through fifth fingers, silicone implant arthroplasty remains the gold standard. Symptomatic, advanced arthritis of the distal interphalangeal joint is most effectively treated with arthrodesis.

CONCLUSION

The efficacy of conservative treatment has been documented in high-quality clinical trials, while that of surgical treatment has not. The various surgical methods have yielded benefits in routine clinical use, but these remain to be assessed in randomized and controlled trials.

Digital Mucous Cyst: A Clinical-Surgical Study

Background

It has been suggested digital mucous cysts (DMCs) are associated with osteoarthritis and osteophytes in the elderly, and usually have a communicating pedicle with the joint. Surgical excision is a standard therapy with a high cure rate.

Objective

The purpose of this prospective study is to evaluate the features of DMCs via clinical, radiological and pathological examination and the efficacy of surgical excision of DMCs.

Methods

Between 2010 and 2014, 24 Korean patients were treated with the resection of the cyst and the pedicle. Preoperative X-ray and ultrasonography were performed to detect the presence of the osteophyte and the connection to the joint space. Postoperative patients' satisfaction score was assessed by the visual analogue scale (0~10).

Results

The osteophytes were found in 15.8%. In ultrasonographic findings, there were prominent flow signals between the cyst and the joint space in 13.6%. There were no serious postoperative complications, and recurrences were observed in 16.7%. Mean postoperative satisfaction score was 8.3.

Conclusion

It seems that preoperative X-ray for osteophytes and ultrasonographic study for connection are not always helpful for the treatment of DMCs, and that the surgical excision with a pedicle ligation and electrocoagulation is an effective treatment modality.

Atypical Location and Morphology of a Proximal Nail Fold Nevus Mimicking Other Diseases

Melanocytic nevi result from the proliferation of melanocytes at the dermal-epidermal junction and/or in the dermis and very rarely affect the nail matrix and bed. Intradermal nevi are tumors often diagnosed in routine clinical dermatological practice, with typical clinical and histopathologic aspects, and found in a wide variety of skin sites. We report a case of intradermal melanocytic nevus of the proximal nail fold with uncommon intraoperative gross findings and without involvement of the nail bed or matrix, showing intradermal component only, which draws our attention to the possible different presentation of melanocytic lesions. No description of intradermal nevi at this site has been reported in the literature so far.

Differentiation between osteoarthritis and psoriatic arthritis: implications for pathogenesis and treatment in the biologic therapy era

Rheumatologists have long considered OA and PsA as two completely distinct arthropathies. This review highlights how some forms of generalized OA and PsA may afflict the same entheseal-associated anatomical territories. While degeneration or inflammation may be clearly discernible at the two extremes, there may be a group of patients where differentiation is impossible. Misdiagnosis of a primary degeneration-related pathology as being part of the PsA spectrum could lead to apparent failure of disease-modifying agents, including apparent anti-TNF and apparent IL23/17 axis therapy failure. This is not a reflection of poor clinical acumen, but rather a failure to appreciate that the pathological process overlaps in the two diseases. Whether the category of OA-PsA overlap disease exists or whether it represents the co-occurrence of two common arthropathies that afflict the same anatomical territories has implications for the optimal diagnosis and management of both OA and PsA.

Acral lesions in tuberous sclerosis complex: insights into pathogenesis

BACKGROUND

Patients with tuberous sclerosis complex (TSC) are predisposed to developing ungual fibromas and other acral lesions.

OBJECTIVE

We sought to determine the numbers, types, and locations of acral skin lesions in TSC.

METHODS

We examined and photographed 76 adult women with TSC.

RESULTS

The age of the patients ranged from 20 to 69 years, with a mean age of 39 +/- 11 years. Ungual fibromas were observed in 61 of 76 patients (80%). Periungual fibromas were more common than subungual fibromas, were more common on the feet than the hands, and showed the greatest frequency on the fifth toe. Longitudinal grooves in the nails occurred with or without a visible fibroma. Longitudinal short red streaks--lesions that we term "red comets"--were observed in 22 patients (29%). Longitudinal leukonychia was observed in 14 patients (18%). One patient had isolated digital overgrowth and one patient had pachydermodactyly.

LIMITATIONS

No men or children were included in this study.

CONCLUSIONS

Examination of patients for skin lesions of TSC could be improved by including inspection for longitudinal nail grooves, red comets, longitudinal leukonychia, and splinter hemorrhages in addition to ungual fibromas. The anatomic distribution of TSC ungual fibromas is not random and appears consistent with trauma-promoted tumor formation.