Dermoscopy in the Evaluation of Nail Disorders

Intense pulsed light versus pulsed dye laser in the treatment of nail psoriasis: Intra-patient left to right comparative controlled study

Background Until now, the management of psoriatic nails has not been satisfactory. Pulsed dye laser (PDL) as well as intense pulsed light (IPL) have been evaluated separately for the management of psoriatic nails and proved to be effective. Aim This study aimed to measure and compare the usefulness as well as the safety of intense pulsed light versus pulsed dye laser for the management of psoriatic nails. Methods The psoriatic fingernails of 20 patients were managed using intense pulsed light on one hand and pulsed dye laser on the other. Two to three psoriatic nails were left without treatment as controls. The therapeutic sessions were conducted monthly for a period of 6 months. Evaluation of the clinical outcomes was assessed by a blinded dermatologist depending on the total, nail bed, nail matrix, modified and target NAPSI scores. Patient global assessment, in addition to Nail Psoriasis Quality of Life (NPQL10), was performed to assess the response to the therapy. Results A significant reduction in the total, target and modified NAPSI scores from baseline to the end of the study was detected, but no significant differences were detected between the two treatments. The responses of the nail matrix and bed lesions to both modalities were nearly the same. All patients stated that the two devices were efficient and improved their quality of life. The intense pulsed light treatment was more painful. Complete clearance of nail lesions was not obtained. Limitations Lack of long-term follow-up of cases and preset laser parameters were the major limitations of this study. Conclusion Intense pulsed light, like pulsed dye laser, is safe and efficient in treating nail psoriasis; however, the former is more painful. Dermoscopy had an additive function in analysing the response of nail psoriasis to therapy.

Ultrasound clinical references of the healthy toenail unit

The toenail unit, commonly called the nail, is one of the most frequently examined and treated structures in clinical podiatry. Ultrasound is a standard clinical technique because it is a noninvasive, painless, and rapid diagnostic tool. The main objective of this study was to obtain morphometric data of the healthy toenail unit by ultrasound for clinical application. The nails of 76 participants (152 hallux nails; 38 men, 38 women, average age 26.83 ± 12.20) were examined using a VINNO E35 ultrasound system and an X6-16L linear probe with a frequency of 18 MHz. Five ultrasound measures of the healthy toenail unit were obtained, of which only the distance from the center of the distal phalange to the nail plate varied with age, sex, weight, and foot (p-values ≤ 0.050). The other four parameters were less influenced by the variables analyzed, except sex, which influenced nearly all (p-values ≤ 0.050). In one of these variables, indications of significance were observed (p-values = 0.060), with greater distances in the men than in the women, except for nail plate curvature, which showed a higher value. The other variables studied did not influence the parameters analyzed. High-frequency ultrasound can be used to examine the healthy toenail unit and define anthropometric reference measurements that can be used for more accurate and comparative diagnosis.

Nailfold capillaroscopy as a prognostic marker for connective tissue diseases: An observational clinico-epidemiological study

Background Nailfold capillaroscopy (NFC) is useful in the diagnosis and assessment of various connective tissue diseases. In this study, NFC findings were studied in patients of systemic sclerosis (SS), systemic lupus erythematosus (SLE) and dermatomyositis. Aims To study the nailfold capillaroscopic findings in patients with connective tissue disorders, their correlation with disease severity, and changes in findings following treatment or disease progression. Methods This observational prospective time-bound clinico-epidemiological study was conducted in 43 patients over 20 months at Topiwala National Medical College and BYL Nair Ch. Hospital, Mumbai. NFC was performed using the polarising mode of a USB 2.0 video-dermatoscope in all 10 fingernails at 50X and 200X. It was repeated at three follow-up visits to look for changes in findings. Results Among SLE patients, eleven (52.4%) had non-specific NFC patterns and eight (38.1%) had SLE patterns. Among systemic sclerosis patients, eight (42.1%) cases had active and late SS patterns respectively, while one (5.3%) each had SLE, non-specific and early SS patterns. After three follow-ups, 10 out of 11 (90.9%) cases with improvement in NFC also showed clinical improvement; this figure was significantly more than 11 out of 23 (47.8%) cases who had no change in NFC but showed clinical improvement. Two of the three dermatomyositis patients showed a non-specific pattern while one showed a late SS pattern at baseline. Limitations A larger sample size would have yielded results with more validity. Standardisation of the interval between baseline and last follow-up to equal to or more than six months would have yielded results with more accuracy. Conclusion Capillary findings change significantly over time and reflect changes in the clinical status of patients of both SLE and systemic sclerosis, and hence are an important prognostic marker. Rather than an overt change in NFC pattern, reduction or increase in abnormal capillaries is a better predictor of change in disease activity.

Onychoscopy of Nail Lesions in Dermatological Disorders: A Cross-Sectional Observational Study

Background

Nail disorders account for about 10% of all dermatological conditions. Onychoscopy is useful not only for their diagnosis but also for assessing severity/progression and monitoring the response to therapy.

Aims and Objectives

Describing dermoscopic features of nail disorders in patients reporting to the dermatology OPD of our tertiary care hospital and recording the sociodemographic profiles thereof.

Materials and Methods

This cross-sectional observational study was carried out on 176 patients with effect from August 2019 to August 2021.

Results

Males (99; 56.25%) outnumbered females (77; 43.75%); males: female: 1.28: 1; their mean age was 35.8 years. Fingernails were affected more oftener (84.09%) than toenails (38.64%). Onychomycosis, the commonest (58;32.95%) condition, revealed findings of aurora borealis pattern (75.86%), subungual hyperkeratosis (72.41%), and onycholysis with jagged edges and spikes (68.97%). The next frequent (32;18.18%) condition was nail psoriasis which revealed pits (81.25%); onycholysis (62.5%) and dilated globose nail fold vessels on capillaroscopy (25%).

Limitations

The small sample size proved inadequate for the evaluation of statistical significance in the less common conditions and the correlation of disease severity of many. Ideally, confirmatory diagnostic tests should have been done in every patient, as indicated. The magnification of our dermoscopy was 10X; 20- and 40X permit better capillaroscopy.

Conclusions

Onychocopy can minimize the need for biopsy by highlighting subtle changes and helps narrow down the differentials. It is potentially a diagnostic test of choice in younger children. Our study helped to grade the severity of connective tissue disorders and establish the benignity of melanonychia. Photographic documentation facilitates record-keeping.

Pigmented Nail Lesions: When to Observe, When to Biopsy, When to Widely Excise, and When to Amputate?

Pigmented nail lesions are challenging problems. The differential diagnosis is broad and ranges from common self-limiting conditions, such as subungual hematoma and infection, to potentially fatal conditions, such as subungual melanoma. Clinical assessment and adjuncts, such as dermoscopy and imaging, are usually insufficient to establish a diagnosis, and a nail bed biopsy is often required. However, this is not an innocuous procedure and may result in permanent nail deformity. In addition, subjecting every patient with nail pigmentation to a biopsy will result in an unacceptably high rate of negative test results. Furthermore, histopathologic diagnosis of subungual melanoma remains challenging for several reasons. Once the diagnosis of subungual melanoma is established, the definitive treatment is controversial because the existing guidelines have largely been adapted from those for cutaneous melanoma. This review presents an approach to the diagnosis and management of pigmented subungual lesions and subungual melanoma, in particular, on the basis of the latest available evidence.

Dermoscopy of glomus tumor: A cross-sectional study of 86 cases

BACKGROUND

glomus tumors (GTs) are benign cutaneous neoplasms derived from the neuromyoarterial apparatus with a strong predilection for acral sites, especially the subungual space. Current data regarding dermoscopy of these lesions are very limited.

OBJECTIVES

to analyze the dermoscopic structures and patterns seen in a large series of subungual (SUGTs) and extraungual glomus tumors (EUGTs) and to determine their diagnostic significance.

METHODS

Clinical and dermoscopic images of 86 histopathologically proven cases of GTs (47 SUGTs and 39 EUGTs) collected from 9 Hospitals in Spain, France, Italy, and Brazil were evaluated for the presence of dermoscopic structures and patterns. Likewise, 189 and 185 dermoscopic images of other ungual tumors and other extraungual non-pigmented tumors, respectively, were evaluated for the same structures and patterns. Finally, we evaluate diagnostic testing accuracy calculating sensitivity (S), specificity (Sp), positive and negative predictive values of the different patterns for the diagnosis of GT.

RESULTS

regarding SUGTs, four patterns were built from the combination of different structures. The pattern composed of a structureless purplish/red subungual spot with or without vessels reached the highest S (S1, 78.8%). The combination of a structureless purplish/red subungual spot and longitudinal erythronychia (LE) (S2) is highly specific (96.3%). Patterns S3 (proximal purplish/red subungual spot, LE and distal notch) and S4 (bed subungual spot and onycholysis) are the most specific and exclusive of matrix and bed tumors, respectively. The most consistent pattern in EUGTs is composed of a structureless purplish-white to reddish-white homogeneous area and unfocused linear vessels (E) (S: 61.5%, Sp: 95.7%). EUGTs did not show lacunae, unlike other vascular tumors.

CONCLUSIONS

dermoscopy is helpful in improving the diagnostic accuracy of GTs, not only in SUGTs, but also when these lesions arise out of the ungual apparatus.

Examination of Subungual Hematomas and Subungual Melanocytic Lesions by Using Optical Coherence Tomography and Dermoscopy

INTRODUCTION

Examination of subungual pigmented lesions is sometimes a diagnostic challenge for clinicians.

OBJECTIVES

The study was aimed to investigate characteristic patterns in optical coherence tomography (OCT) of subungual hematomas and determine distinctive features that can differentiate them from subungual melanocytic lesions.

METHODS

VivoSight® (Michelson Diagnostics, Maidstone, UK) was used to examine 71 subungual hematomas and 11 subungual melanocytic lesions in 69 patients (18 female and 51 male patients).

RESULTS

On OCT, bleeding was related to sharply defined black sickle-shaped (p < 0.001) or globular regions (not significant [ns]) with a hyperreflective margin (0.002), a grey center (0.013), hyperreflective lines in the area (ns) or periphery (p = 0.031), peripheral fading (p = 0.029), and red dots in the area (p = 0.001). In the 1 case of melanoma in situ examined, we found curved vessels with irregular sizes and distribution on the dermis of the nailbed, while subungual hematomas and subungual benign nevi presented as clustered red dots and/or regularly distributed curved vessels.

CONCLUSION

Our findings indicate that the use of OCT in addition to dermoscopy provides high-resolution optical imaging information for the diagnosis of subungual hematoma and facilitates the differential diagnosis of subungual hematomas and subungual melanocytic lesions.

Diagnosing Onychomycosis: What’s New?

An overview of the long-established methods of diagnosing onychomycosis (potassium hydroxide testing, fungal culture, and histopathological examination) is provided followed by an outline of other diagnostic methods currently in use or under development. These methods generally use one of two diagnostic techniques: visual identification of infection (fungal elements or onychomycosis signs) or organism identification (typing of fungal genus/species). Visual diagnosis (dermoscopy, optical coherence tomography, confocal microscopy, UV fluorescence excitation) provides clinical evidence of infection, but may be limited by lack of organism information when treatment decisions are needed. The organism identification methods (lateral flow techniques, polymerase chain reaction, MALDI-TOF mass spectroscopy and Raman spectroscopy) seek to provide faster and more reliable identification than standard fungal culture methods. Additionally, artificial intelligence methods are being applied to assist with visual identification, with good success. Despite being considered the ‘gold standard’ for diagnosis, clinicians are generally well aware that the established methods have many limitations for diagnosis. The new techniques seek to augment established methods, but also have advantages and disadvantages relative to their diagnostic use. It remains to be seen which of the newer methods will become more widely used for diagnosis of onychomycosis. Clinicians need to be aware of the limitations of diagnostic utility calculations as well, and look beyond the numbers to assess which techniques will provide the best options for patient assessment and management.

Description of the most severe signs in nail lichen planus: a strategy to contribute to the diagnosis of the severe stage

BACKGROUND

Severe nail lichen planus (NLP) does not respond well to treatment and is often poorly considered and described in detail.

OBJECTIVE

We sought to describe the characteristics of severe NLP.

METHODS

A retrospective data analysis was performed, including the photographic records of the most compromised nails of patients with NLP over 18 years old, who consulted between 2009 and 2019 at the Instituto de Dermatologia Professor Rubem David Azulay in Rio de Janeiro, Brazil. Descriptive and statistical analysis using Fisher's exact test was performed to verify the hypothesis of independence between characteristics (P < 0.05).

RESULTS

A total of 102 patients were included. Anonychia was associated with severe thinning of the nail plate, retraction of the nail bed or nail plate, residual nail plate, loss of proximal nail fold limits, and onychoatrophy. Dorsal pterygium was associated with loss of proximal nail fold limits, onychoatrophy, and distal splitting greater than 50%.

CONCLUSION

We provide descriptions of the most severe signs in order to facilitate the clinical diagnosis when a biopsy is not feasible and suggest an update of current NLP classifications.

Application of a three‐dimensional scanner to the quantitative assessment of the nail plate condition after a hybrid manicure procedure—Preliminary study

BACKGROUND

About 90% of women worldwide use nail care products, including manicure ones. A manicure procedure results in nail damage, therefore it is necessary to search for new, objective methods of assessing the impact of the procedures and products applied within the nail plate. In this study, an attempt was made to quantify the impact of manicure procedures on the nail plate condition.

MATERIALS AND METHODS

Twenty thumb nail plates were examined. Before the manicure procedures, alginate casts were prepared for each of the subjects. The analysis of the three-dimensional (3D) nail surface structure included the assessment of the nail sections and the assessment of differences in the nail structure after superposition of 3D images of the nail plates before and after the manicure procedures.

RESULTS

The obtained results show that the nail plate structure changed to a similar extent in each measured section after the manicure procedure. A change in the height of the nails is not a desirable phenomenon as it suggests damage to the nail caused by the substances included in the preparations applied to the nails, acetone, or filing the nail plate. This proves the great influence of the technique of removing artificial nails on the structure of the natural plate.

CONCLUSION

The use of a 3D scanner allows for precise, biometric, quantitative, and repeatable measurements of changes in the nail structure after a manicure procedure. The use of the hybrid and gel manicure procedure causes significant damage to the nail plate, especially in its distal portion.

Leukonychia: What Can White Nails Tell Us?

Changes in nail color can provide important clues of underlying systemic and skin disease. In particular, white discoloration (leukonychia) has a high prevalence with a wide array of potential relevant causes, from simple manicure habits to life-threatening liver or kidney failure. Therefore, a reliable assessment of the patient with leukonychia is essential. In the past, two classifications for leukonychia have been presented. The morphological classifies the nail according to the distribution of the white lines: total, partial, transversal, and longitudinal leukonychia. Mees’ and Muehrcke’s lines are examples of transversal leukonychia, while Terry’s and Lindsay’s nails are examples of total and partial leukonychia. The anatomical classifies according to the structure responsible for the white color: the nail plate in true leukonychia, the nail bed in apparent leukonychia, and the surface only in pseudoleukonychia. In this review, both morphological and anatomical features have been combined in an algorithm that enables clinicians to approach leukonychia efficiently and effectively.

Onychophagia: detailed clinical characteristics

BACKGROUND

Onychophagia is a common disorder affecting 20% to 30% of the general population. It is defined as habitual nail biting and can cause various changes in the nail units. However, to date, there has been a paucity of data focusing on nail deformities related to onychophagia. This study was performed to investigate the clinical characteristics of onychophagia in Korea.

METHODS

This study included 53 patients with onychophagia who visited the Pusan National University Hospital (Busan and Yangsan) over a 10-year period (2011-2020). We retrospectively reviewed medical records and clinical and dermoscopic photographs.

RESULTS

All 10 fingernails were affected in 37.7% of the patients. The left thumbnail was the most predominantly affected site (81.1%). Clinical findings showed that short nails with ragged distal borders were the most common presentation (100.0%), followed by generalized or patchy rough areas (50.9%), linear and pinpoint hemorrhage (32.1%), longitudinal melanonychia (30.2%), transverse groove (28.3%), brittleness (28.3%), macrolunula (24.5%), washboard nail (13.2%), and pterygium (3.8%). Of the patients, 88.7% had periungual complications, such as periungual exfoliation (77.4%), absent or ragged cuticle (52.8%), hyponychial hyperkeratosis (37.7%), and paronychia (15.1%).

CONCLUSIONS

Although onychophagia is a common disorder, its clinical characteristics have not been reported in the literature. The results of this study may be helpful in managing patients with onychophagia.

The value of dermoscopy of the nail plate free edge and hyponychium

The non-invasive examination of the nail unit using a dermoscope is known as onychoscopy. This technique has become increasingly appreciated to facilitate the clinical diagnosis of nail disorders, opening up a valuable second front with a potential to avoid invasive diagnostic procedures. During a nail consultation, the nail unit should always be examined with the aid of a dermatoscope in all its components. The aim of this paper is to provide practical information about onychoscopy of the nail plate free edge and hyponychium, two components of the nail unit difficult to evaluate at naked eye and often forgotten, but of paramount importance.

Three-Dimensional Structure Analysis of Mouse Nails using Synchrotron Radiation

Until now, studies on nail disease have been performed through microscopic diagnosis and microscopic computed tomography (micro-CT). However, these kinds of conventional methods have some limitations. Firstly, the microscopic method is considered the gold standard for medical diagnosis. However, due to the use of fluorescent materials, the sample is damaged and it takes a long time to get results. Secondly, while micro-CT is a non-invasive method to get inner structure images of the sample with high resolution, the penetration and spatial resolution are insufficient for studying the microstructures of the sample, such as the sponge bone and the muscle fibers. In contrast, synchrotron radiation (SR) X-ray imaging technology has the advantage of very vividly demonstrating the anatomic structure of the sample with high penetration, sensitivity, and resolution. In this study, we compared the optical microscopic method using hematoxylin and eosin (H&E) staining and SR imaging to analyze the nail tissue in a mouse model. The results showed that SR could depict the inner structures of a mouse nail without physical damage. Additionally, we could divide the important anatomical structures nail unit into three parts with three-dimensional images: the nail bed, nail matrix, and hyponychium. The images showed that SR could be used for analyzing nails by visualizing the relatively clear and medically semantic structures in a three-dimensional section. We expect that the results of this study will be applied to study nail diseases and pharmaceutical research on their treatment.

Recent developments in dermoscopy for dermatology

BACKGROUND

Dermoscopy is considered to be a bridge between clinical observation and histopathological examination, allowing the in vivo examination of skin microstructures that are not visible to the naked eye, from the epidermis to the superficial dermis. Dermoscopy has undergone rapid development, witnessing the history from natural light to polarized light, from handheld dermoscopy to videodermoscopy, and from classic dermoscopy to digital dermoscopy. Its application extends from the initial differential diagnosis of pigmented skin diseases (melanocytic and nonmelanocytic) to general dermatology, including appendage (nail and hair) abnormalities and diseases related to infection and inflammation.

AIMS

We aimed to provide the latest developments in dermoscopy from the perspective of handheld dermoscopy, videodermoscopy, fluorescence-advanced videodermatoscopy, polarized transilluminating dermoscopy, and digital dermoscopy.

METHODS

In this review, we searched the PubMed, Embase, Web of Science, and Cochrane Library databases for reviews, case reports, and observational studies on dermoscopy.

RESULTS

We provided an updated review of dermoscopy based on published literature.

CONCLUSION

Dermoscopy is an indispensable diagnostic tool in dermatology, and it is expected to be further developed in the future.

Uncovering subtle nail involvement in lichen planus with dermoscopy: a prospective, controlled study

Introduction

There are very few studies investigating the dermoscopic aspect of nail involvement in lichen planus and these studies described dermoscopic features of only clinically visible nail involvement in lichen planus.

Aim

To reveal subtle dermoscopic nail findings in patients with lichen planus.

Material and methods

The study included 40 patients with lichen planus and 40 healthy volunteers. All fingernails of the patients and healthy volunteers were examined by a handheld dermoscope and the findings detected were recorded. The patients were grouped by age, gender, disease duration and extent of the disease. The statistical analysis was performed using Chi square test.

Results

82.5% of the patients and 17.5% of the healthy volunteers showed at least one dermoscopic nail finding. The frequency of multiple splinter haemorrhage (p < 0.05), multiple leukonychia (p < 0.05), longitudinal erythronychia (p < 0.05), prominent hyponychial vascular structures (p < 0.05) and onycholysis (p < 0.05) observed in the patients group was statistically significant. The other findings included distal short longitudinal lines, onychorrhexis, solitary splinter haemorrhage and solitary punctate leukonychia and showed no statistically significant differences between the two groups.

Conclusions

To the best of our knowledge, this is the first study focusing on uncovering subtle nail involvement in lichen planus. The presence of dilated hyponychial vascular structures in lichen planus was first described in the present study. It can be concluded that the frequency of nail involvement in lichen planus is more than known. Dermoscopic imaging of the nails of all patients with lichen planus may help establish early diagnosis and treatment to avoid permanent nail damage.

Blue nevus of the nail: A case report and review

Blue nevus (BN), in all its clinical variants, rarely affects the nail bed. This leads to difficulty in the diagnosis of BN within the nail bed as well as to challenges with regard to its treatment and follow-up management, not solely attributed to the intrinsic difficulty of the anatomical site. We present the first case in the literature of an acquired cellular BN entirely confined within the nail bed, in a female Caucasian patient. We propose diagnostic and therapeutic options based on personal clinical and surgical experience.

Retrospective Case Series on Risk Factors, Diagnosis and Treatment of Pseudomonas aeruginosa Nail Infections

BACKGROUND

Pseudomonas aeruginosa is the most common pathogen causing bacterial nail infections, producing a classic blue-green pigment, known as chloronychia. Clinical examination and dermoscopic findings, as well as diagnosis and treatment, have not been well characterized.

OBJECTIVE

The aim was to characterize the clinical and dermoscopic findings of P. aeruginosa infection of the nails and assess treatment efficacy.

METHODS

This is a retrospective study of patients with P. aeruginosa nail infection diagnosed between January 27, 2017 and May 28, 2019. Demographics, history, clinical and dermoscopic findings, diagnostics tests, and treatment were documented and analyzed.

RESULTS

Twenty-six patients with P. aeruginosa nail infections were analyzed, with 21 patients completing treatment, two lost to follow-up, and three still undergoing treatment. Clinical examination findings were notable for onycholysis in 76.9% of patients. Green discoloration was seen in 38.5% of patients and green-brown discoloration in 30.8%. A majority of the patients had only one nail involved (73.1%). Dermoscopic findings were significant for greenish pigmentation in 37.5% of patients and 88.9% of cases presenting with a fading border. Wound cultures of nail plates were more sensitive (40%) than dermatopathology (16.7%), but the difference was not statistically significant (p value = 0.1596). All patients were treated with ophthalmic 0.3% gentamicin topical solution nightly for a 3-month period and those who completed therapy had complete resolution of their infection.

LIMITATIONS

The limitations of the study were the retrospective design and the small cohort size.

CONCLUSION

Clinical examination findings of onycholysis coupled with a green or green-brown discoloration involving one or more digits and dermoscopic findings of greenish discoloration with a fading border are consistent with a diagnosis of Pseudomonas nail infection. Gentamicin topical solution is an effective, inexpensive, easy-to-use treatment for this condition. Larger randomized clinical trials are necessary to compare efficacy with other therapeutic options.

Clinical Observation and Follow-Up of Subungual Splinter Hemorrhages of Toenails in Chinese Adults

Background:

Subungual splinter hemorrhage (SSH) is a common nail disorder and is difficult to differentiate from other nail diseases because of their similar characteristics. The epidemiological study of SSH is lacking and it is unclear whether SSH needs treatment or not.

Aims:

The aims of this study were to observe the clinical characteristics of SSH of toenails in Chinese adults and to provide a reference for the diagnosis and prognosis of patients with SSH.

Materials and Methods:

We collected and followed up 63 SSH patients who were diagnosed through dermoscopic examination. The clinical and dermoscopic characteristics, disease course, and recovery results were recorded. Data sets were analyzed through the use of SPSS 16.0. Literature concerning SSH were reviewed and compared with the results in this study.

Results:

Sixty-three SSH patients were included with an age range of 17–58 years. Nearly 93.7% of SSH patients occurred in the right, left, or right and left first toenails; 66.7% of SSH patients occurred only in one toenail; there were 60.3% of SSH patients with a clear stimulus causing it and 31.8% of SSH patients with five types of comorbidities. The common characteristics of dermoscopy showed a reddish brown or brown stain with a clear boundary visible under the nail in which the color gradually faded outward from the center, with no blue or white structure. After following up for 24 weeks, the disappearance of hemorrhage was observed in 95.2% of SSH patients. For the recovered SSH patients, data analysis showed no significant difference in the course of SSH in males and females (P = 0.645); the statistical analysis showed that there was no significant correlation (r² = −0.002) between age and course in recovered SSH patients (P = 0.986).

Conclusions:

It is unnecessary to do any special treatment during the 1^st year. Measures ought to be taken for SSH patients if the course of the disease exceeds more than 1 year.

Macroscopic and dermoscopic evaluation used to differentiate subungual haemorrhage from melanocytic lesions

INTRODUCTION Subungual haemorrhage describes blood located between the nail matrix and nail plate caused by trauma. Lack of recalled trauma and long duration of nail pigmentation results in specialist referrals to rule out malignant pathology. AIM This report aims to describe the macroscopic and dermoscopic characteristics of subungual haemorrhage and to highlight its clinical differentiation from melanocytic lesions. METHODS Ninety-eight nails were assessed. Pigmentation in fifty-nine was due to subungual haemorrhage and was melanocytic in the remainder (identified by a longitudinal pigmented band). RESULTS Pigmentation in subungual haemorrhage had a clear proximal margin (73%) and the dermoscopic pattern was homogenous (97%), globular (78%) or streaky (34%). Features included peripheral fading (68%) and periungual haemorrhage (5%). Malignancy could be excluded in these cases by careful clinical evaluation. DISCUSSION A combination of macroscopic and dermoscopic characteristics help make a confident diagnosis of subungual haemorrhage. A two-stage process can aid clinical diagnosis by looking for known features of subungual haemorrhage and identifying absence of malignant features.

Nail lichen striatus: Is dermoscopy useful for the diagnosis?

BACKGROUND/OBJECTIVES

Lichen striatus is a unilateral inflammatory dermatosis that rarely affects the nail unit. When the inflammation involves the nail unit, classic lichenoid nail changes are easily detectable, more often limited to only one portion of the nail. Usually the nail dystrophy coexists with periungual skin papules following Blaschko's lines, but it could also be an isolated feature. Because a nail unit biopsy presents difficulties in execution, especially in a child, the aim of our study has been to describe the nail unit dermoscopy features of lichen striatus hoping to provide a valid aid to clinicians in the diagnosing this rare disorder.

METHODS

We reviewed the images of five pediatric patients with a clinical diagnosis of lichen striatus. Data about sex, age, localization, predisposing/triggering factors, and associated disorders are reported.

RESULTS

The diagnosis of lichen striatus can be challenging as there are clinically overlapping features with related dermatoses. A common diagnostic pitfall occurs with inflammatory linear verrucous epidermal nevus and lichen planus. Involvement of only one part of the nail plate with linear longitudinal fissuring, ridging, and distal splitting, especially if seen with perionychial skin lesions, is characteristic of lichen striatus.

CONCLUSIONS

Nail lichen striatus is rare, and there is sparse published literature on it. When the changes in lichen striatus are limited to the nail, the diagnosis may easily be missed. We therefore believe that dermoscopy is an important diagnostic maneuver, which should be integrated into the evaluation of patients with potential lichen striatus, and in particular is helpful for clinicians unwilling or unable to perform a nail unit biopsy.

Onychoscopy with red light for vascular pattern identification: a study of 33 patients

BACKGROUND

Nail dermoscopy (onychoscopy) during physical examination assists in correct diagnosis. Often further magnifications are necessary for an effective differential diagnosis. With the addition of a red light to the dermoscope, important vascular features can be visualized.

OBJECTIVE

To describe common features observed at onychoscopy with a new device that combines the regular white light with the red light illumination, demonstrating that it is useful for diagnosis of nail disorders.

METHODS

We enrolled 33 consecutive patients referred to the Nail Diseases Dermatology Unit of the University of Modena and Reggio Emilia and to the Outpatient Consultation for Nail Disease of the Dermatology Unit of the University of Bologna. Patients were assessed with a standard hand-held dermoscope and at the red light dermoscope. Dermoscopic images were collected.

RESULTS

The new prototype was used during daily clinical practice and allowed a more accurate visualization of some details that classic onychoscopy can miss. In particular, with the help of the red light it was possible to better visualize nail lesions that were characterized by some kind of colour change or vascular alterations.

CONCLUSION

The new device of red light for vascular pattern onychoscopy can be a new investigation method to observe nail alterations, especially due to vascular pattern, even with low magnification, without the necessity to use higher resolutions.

Onychoscopy of non-infectious nail abnormalities in patients after allogeneic haematopoietic stem cell transplantation

Nail abnormalities after allogeneic haematopoietic stem cell transplantation procedure (alloHSCT) are often reported. Usually, they are related to chronic graft-versus-host disease (cGvHD). So far, only clinical manifestations of selected nail abnormalities have been described, without the presentation of dermoscopic images. In this article, we present morphologic and dermoscopic manifestations of potential non-infectious nail abnormalities in patients after alloHSCT procedure based on reviewed literature and our own experience with dermoscopic iconography. In majority of studies published till now, nail changes are not connected to severity of other cGvHD symptoms; however, e.g. the presence of pterygium inversum unguis may be an indicator of lung dysfunction. As nail changes may be an early sign of cGvHD and always present in association with other manifestations, routine clinical assessment should include nails examination. Knowledge of possible presentation of nail involvement after alloHSCT may be valuable for treating physician.

Chilblain Lupus with Nail Involvement: A Case Report and a Brief Overview

Chilblain lupus erythematosus is a rare, chronic variant of cutaneous lupus erythematosus that occurs during cold or damp periods on the hands, fingers, or feet. It is often associated with other forms of cutaneous lupus and about 20% of patients develop systemic lupus erythematosus. Various medications have been put forward, including steroids, mycophenolate mofetil, calcium channel blockers, and hydroxychloroquine, but the symptoms do not remit completely.

Alternative uses of dermoscopy in daily clinical practice: An update

Dermoscopy is a noninvasive diagnostic tool that is currently being used for neoplastic skin lesions, several inflammatory and infectious diseases, and skin appendage disorders. As the clinical applications of dermoscopy beyond pigmented lesions are constantly increasing, the aim of this article is to provide an update on this topic. This comprehensive review substantiates how several diseases may show peculiar dermoscopy features so as to enhance the diagnosis and avoid (in selected cases) unnecessary histologic confirmation. In other cases, dermoscopy features may be shared with other conditions, with the advantage of narrowing down the differential diagnosis by ruling out those dermatoses with similar clinical aspect but different dermoscopic presentation.

Nail Biopsy: A User's Manual

Nail biopsy is a procedure not routinely resorted to; but when indicated, it is often the only clue left for diagnosis. At such times, it pays to be conversant with it. It is an investigation that not only provides etiologic, diagnostic, and prognostic information but also aids in understanding the pathogenesis of nail diseases. It can be of therapeutic value, especially with respect to nail tumors. This article compiles the procedural techniques for nail biopsy of various types and attempts to summarize the evidence available in the literature. The objective of nail biopsy is to clinch a precise diagnosis of nail pathology with a simple and safe surgical procedure, avoiding pain or permanent nail damage. Patient selection is of utmost importance, wherein, the patient does not have typical skin lesions, yields inadequate information on routine nail investigations, and has no peripheral vascular compromise. The patient needs to be explained about the risks associated, the expected functional handicap, the time required for regrowth, a possibility of permanent nail dystrophy, and a possibility of not achieving a diagnosis even after the biopsy. Techniques and types of various nail biopsies are being discussed in this article. The specimen could be collected as an excision biopsy, punch biopsy, shave biopsy, or longitudinal biopsy. The trick lies in choosing the appropriate area for biopsy. Various biopsy types discussed in this article include nail plate biopsy (easiest and least scarring); nail bed biopsy (elliptical excision or punch); nail matrix biopsy (elliptical excision, punch excision (≤3 mm) or tangential/shave excision); and nail fold biopsy. Complications reported along with means to minimize them are also discussed.