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Trevisan F, Veasey JV, Werner B. Nail Clipping with PAS Stain and Correlation with Fungi Isolated in Culture: A Valuable Exchange in the Diagnosis of Onychomycosis. Skin Appendage Disord 2022; 8:399-405. [PMID: 36161087 PMCID: PMC9485992 DOI: 10.1159/000523966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Accepted: 02/25/2022] [Indexed: 11/19/2022] Open
Abstract
Introduction The etiological agents of onychomycosis are dermatophyte fungi, nondermatophyte filamentous fungi (NDFF), and yeasts. Nail clippings are an accurate tool for diagnosing onychomycosis. The objective of this study was to correlate the characteristics of fungi observed in nail clipping examinations with the results for agents isolated in culture, indicating whether the fungus found on microscopy is a dermatophyte, NDFF, or yeast. Methods An observational descriptive study of onychomycosis nail clippings stained with PAS comparing culture results with microscopic criteria of fungi morphology, arrangement/orientation, and location of organisms in the nail and presence of neutrophils, serous lakes, and bacterial colonies was conducted. Results Thirty-three nail clippings from 29 participants were analyzed. A statistically significant correlation (p < 0.05) was found between smooth/thin/long hyphae with a "combed" pattern and dermatophyte agents (sensitivity 89.4%, specificity 91.5%), and between irregular/thick/short anarchic distributed hyphae and nondermatophytes (sensitivity 61.5%, specificity 89.4%). No statistical association with region where fungi were in the nail or with the presence of neutrophils, serous lakes or bacteria was found. Small, rounded, yeast-like organisms correlated with Candida infection. Conclusions Although not a substitute for culture, microscopic analysis of fungal structures offers good accuracy for differentiating agents of onychomycosis.
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Affiliation(s)
- Flávia Trevisan
- Medical Clinic Department, Hospital of Clinics, Federal University of Paraná, Curitiba, Brazil
| | - John Verrinder Veasey
- Dermatology Department, Clinic of Dermatology, Santa Casa de Sao Paulo School of Medical Sciences, São Paulo, Brazil
| | - Betina Werner
- Medical Pathology Department, Hospital of Clinics, Federal University of Paraná, Curitiba, Brazil
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Mishlab S, Avitan-Hersh E, Bergman R. Histopathological Findings in Nail Clippings With Periodic Acid-Schiff-Positive Fungi. Am J Dermatopathol 2021; 43:338-341. [PMID: 32956097 DOI: 10.1097/dad.0000000000001800] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Periodic acid-Schiff (PAS) staining of nail clippings is an adjunct diagnostic tool for onychomycosis. OBJECTIVE To detect histopathological findings as clues to the presence of PAS-positive (+) fungal elements in nail clippings. METHODS Four hundred sixteen consecutive nail clippings suspected of onychomycosis were stained with hematoxylin and eosin, and with PAS stains. All cases were studied histopathologically. The clinical files of the cases with neutrophils were reviewed. RESULTS PAS+ staining for fungi were demonstrated in 159 (38%) of the nail clippings. Neutrophils, parakeratosis, plasma globules, and bacteria were observed in 43 (27%), 108 (67%), 80 (50%), and 80 (50%) of the PAS+ cases, respectively, and in 17 (6%), 109 (41%), 84 (32%) and 140 (54%) of the PAS- cases, respectively (P < 0.01). Neutrophils showed by far the highest specificity (93%), although with low sensitivity (27%) for the presence of PAS+ fungi. Among the 43 PAS+ and 17 PAS- specimens with neutrophils, only 1 (2.3%) and 3 (17%) had overt psoriasis, respectively. CONCLUSION Neutrophils in nail clippings may serve as a clue for onychomycosis. PAS staining with neutrophils is not necessarily associated with psoriasis.
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Affiliation(s)
- Salih Mishlab
- Department of Dermatology, Rambam Health Care Campus, Israel; and
| | - Emily Avitan-Hersh
- Department of Dermatology, Rambam Health Care Campus, Israel; and
- The Bruce Rappaport Faculty of Medicine, Rambam Medical Center, Technion, Haifa, Israel
| | - Reuven Bergman
- Department of Dermatology, Rambam Health Care Campus, Israel; and
- The Bruce Rappaport Faculty of Medicine, Rambam Medical Center, Technion, Haifa, Israel
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Ortner VK, Holmes J, Haedersdal M, Philipsen PA. Morphometric Optical Imaging of Microporated Nail Tissue: An Investigation of Intermethod Agreement, Reliability, and Technical Limitations. Lasers Surg Med 2020; 53:838-848. [PMID: 32770696 DOI: 10.1002/lsm.23304] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 06/17/2020] [Accepted: 07/20/2020] [Indexed: 01/07/2023]
Abstract
BACKGROUND AND OBJECTIVES While optical imaging is a useful technique to quantitate morphological differences and treatment effects, comparative investigations of the various techniques are lacking. This study aimed at evaluating intermethod agreement, reliability, and technical limitations of wide-field microscopy (WFM), reflectance confocal microscopy (RCM), and optical coherence tomography (OCT) for morphometry by assessing fractionally ablated nail tissue. STUDY DESIGN/MATERIALS AND METHODS Fifty healthy nail clippings were processed with a fractionated CO2 -laser (20 mJ/microbeam, density 15%), measured with calipers, and imaged using WFM, OCT, and RCM. Images were assessed for nail plate thickness, micropore dimensions, degree of poration, and artifacts. Repeated measurements (2-5) were taken to evaluate method repeatability using Cronbach's α and coefficients of variation (CoV), and estimate the intermethod correlation through linear correlation assessment (Pearson correlation coefficient [PCC]), ranked correlation (Kendall's tau; tau-c), and intraclass correlation (Shrout-Fleiss reliability coefficient; ICC). RESULTS The repeatability varied substantially between methods and target measurements. The level of intermethod agreement for thickness measurements performed with calipers, WFM, and OCT was high (tau-c ≥ 0.7; ICC ≥ 0.8; PCC ≥ 0.9). RCM could only image 28 out of 50 samples due to its limited penetration depth. OCT demonstrated the highest repeatability of all imaging techniques (CoV 4-7%) and nail thickness showed the highest measurement reliability (α = 0.92). Micropore dimensions correlated strongest between OCT and RCM (tau-c/ICC/PCC ≥ 0.5). All modalities were prone to artifacts, which may have adversely affected measurement variation and intermethod agreement. CONCLUSION Intermethod agreement and reliability appear to be highly dependent on the specific modality and target measurement. To reap the benefits of each technique while mitigating their limitations, an integrated approach to optical imaging is recommended. Lasers Surg. Med. © 2020 Wiley Periodicals LLC.
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Affiliation(s)
- Vinzent K Ortner
- Department of Dermatology and Wound Healing Centre, Copenhagen University Hospital, Bispebjerg and Frederiksberg, Copenhagen, Nordvest, 2400, Denmark
| | - Jon Holmes
- Michelson Diagnostics Ltd., Eclipse House, Eclipse Park, Maidstone, Kent, ME14 3EN, UK
| | - Merete Haedersdal
- Department of Dermatology and Wound Healing Centre, Copenhagen University Hospital, Bispebjerg and Frederiksberg, Copenhagen, Nordvest, 2400, Denmark
| | - Peter A Philipsen
- Department of Dermatology and Wound Healing Centre, Copenhagen University Hospital, Bispebjerg and Frederiksberg, Copenhagen, Nordvest, 2400, Denmark
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Tanaka AA, Werner B, Farris C, Tornesy C. Microscopic Examination of Nail Clippings from Patients with Palmoplantar Pustulosis. Dermatopathology (Basel) 2019; 6:213-219. [PMID: 31828062 DOI: 10.1159/000503704] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Accepted: 09/25/2019] [Indexed: 01/27/2023] Open
Abstract
This study describes the clinical characteristics and microscopic findings of nails from 25 patients with palmoplantar pustulosis. Methods This is a cross-sectional study of adult patients with clear-cut palmoplantar pustulosis. Onychodystrophy severity was evaluated in fingernails using the nail psoriasis severity index (NAPSI). A fragment of the most dystrophic fingernail was collected from each patient and submitted to routine histotechnical processing. The following microscopic parameters were evaluated: nail plate and subungual region thickness, presence or absence of parakeratosis, number of layers of parakeratosis, and presence of neutrophils, serous lakes, bacteria, blood, and fungi. Results Twenty-one patients (84%) presented onychodystrophy with a mean NAPSI score of 12.67. The most common nail change was pitting (76.19% of patients). On average, nail plate thickness and subungual region thickness measured 0.42 and 0.14 mm, respectively. Neutrophils and fungi were not observed, but serous lakes were found in 4.7%, bacteria in 28.57%, blood in 4.76%, and parakeratosis in 19.05% of the patients. Conclusions although palmoplantar pustulosis is a disease with great amounts of neutrophils in the epidermis, those cells were not found in the nail clippings studied herein. Furthermore, when clinical aspects and microscopic findings of palmoplantar pustulosis are compared to those of similar studies in psoriasis vulgaris, they show different characteristics.
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Affiliation(s)
- Anber Ancel Tanaka
- Department of Dermatology, Evangélica Faculty of Paraná, Curitiba, Brazil
| | - Betina Werner
- Department of Pathology, Federal University of Paraná, Curitiba, Brazil
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Neves JM, Cunha N, João A, Lencastre A. Neutrophils in Nail Clipping Histology: A Retrospective Review of 112 Cases. Skin Appendage Disord 2019; 5:350-354. [PMID: 31799261 DOI: 10.1159/000499542] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Accepted: 03/10/2019] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Nail clipping histology is more sensitive than mycology for detecting nail fungi. However, in the absence of fungi, established diagnostic clues for this and other nail dystrophy causes are lacking, namely for nail psoriasis. Neutrophils have been reported in onychomycosis and nail psoriasis samples but have been insufficiently characterized. OBJECTIVES The aim of this paper is to differentiate neutrophil-containing nail clipping samples in nail psoriasis and onychomycosis regarding histology. METHODS We performed a 3-year retrospective review of all nail clipping test results included in our department's database and re-analyzed samples containing neutrophils. RESULTS In total,112 neutrophil-containing nail clipping samples were accounted. Onychomycosis was the commonest diagnosis (74.1%), followed by nail psoriasis (18.8%). Onychomycosis samples had more abundant neutrophils, more often arranged in collections (60.2%) (p = 0.002) and with smaller quantities of parakeratosis, in a lamellar distribution. In nail psoriasis, neutrophils were mostly aggregated (57.1%) with parakeratosis in all samples, in increased amounts, and showing no predominant pattern. CONCLUSIONS Neutrophils are present in both nail psoriasis and onychomycosis, warranting careful interpretation. However, less dense aggregates of neutrophils with more abundant parakeratosis are clues of nail psoriasis when all other fungal tests are negative.
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Affiliation(s)
- José Miguel Neves
- Department of Dermatology and Venereology, Hospital de Santo António dos Capuchos, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal
| | - Nélia Cunha
- Department of Dermatology and Venereology, Hospital de Santo António dos Capuchos, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal
| | - Alexandre João
- Department of Dermatology and Venereology, Hospital de Santo António dos Capuchos, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal
| | - André Lencastre
- Department of Dermatology and Venereology, Hospital de Santo António dos Capuchos, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal
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Trevisan F, Werner B, Pinheiro RL. Nail clipping in onychomycosis and comparison with normal nails and ungual psoriasis. An Bras Dermatol 2019; 94:344-347. [PMID: 31365667 PMCID: PMC6668936 DOI: 10.1590/abd1806-4841.20198301] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Accepted: 06/04/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Of all nail disorders seen in dermatology offices, half of them are due to onychomycosis. The main differential diagnosis is nail psoriasis. The objective of this study was to compare the microscopic findings, other than the presence of fungi, in the clipping of onychomycosis versus normal nails and nail psoriasis. METHODS Cross-sectional study of onychomycosis cases, analyzed by clipping and compared with data on normal nails and those with nail psoriasis. RESULTS Sixty-two onychomycosis samples were compared with 30 normal nails and 50 nails with psoriasis. In onychomycosis, measurement of subungual region, serous lakes, neutrophils and number of layers of parakeratosis are more intense than in psoriasis. Onychocariosis is less common in psoriasis, while bacteria are more frequent. The nail transition zone is more commonly blurred and irregular in onychomycosis. CONCLUSION Clipping helps in the differential diagnosis of onychomycosis and nail psoriasis and may be useful even when fungi are not found.
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Affiliation(s)
- Flávia Trevisan
- Department of Dermatology, Hospital de Clínicas,
Universidade Federal do Paraná, Curitiba (PR), Brazil
| | - Betina Werner
- Department of Pathology, Hospital de Clínicas, Universidade
Federal do Paraná, Curitiba (PR), Brazil
| | - Rosangela Lameira Pinheiro
- Department of Microbiology and Mycology, Diagnostic Support Unit,
Hospital de Clínicas, Universidade Federal do Paraná, Curitiba (PR),
Brazil
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Uber M, Carvalho VO, Abagge KT, Robl Imoto R, Werner B. Clinical features and nail clippings in 52 children with psoriasis. Pediatr Dermatol 2018; 35:202-207. [PMID: 29314259 DOI: 10.1111/pde.13402] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND/OBJECTIVES Nail clipping, the act of cutting the distal portion of a nail for microscopic analysis, can complement the diagnosis of skin diseases with nail involvement, such as psoriasis. This study aimed to describe histopathologic findings on 81 nails from 52 children and adolescents with skin psoriasis and to determine whether these changes correlated with the severity of skin and nail involvement. METHODS Children with psoriasis were enrolled in this cross-sectional study to obtain Psoriasis Area and Severity Index (PASI) and Nail Psoriasis Severity Index (NAPSI) scores. The most altered nails were processed using periodic acid-Schiff with diastase staining. RESULTS Fifty-two patients with a median age of 10.5 years were included. The median Nail Psoriasis Severity Index score of the 20 nails from these patients was 17 (range 3-80). The most common findings were pitting (94.2%), leukonychia (73.0%), and longitudinal ridges (63.5%). Eighty-one nail fragments were collected by clipping. Neutrophils were found in 6 samples (7.6%) and serous lakes in 15 (19%). Median nail plate thickness was 0.3 mm (range 0.1-0.63 mm). Patients whose nails had neutrophils had a higher median PASI score (6.1 vs 2.0, P = .03). Patients whose nails had serous lakes had higher median PASI (5.3 vs 1.9, P = .008) and NAPSI (median 45.0 vs 18.0, P = .006) scores. CONCLUSION There seems to be a correlation between some microscopic nail features in children with psoriasis and their PASI and NAPSI scores, so nail clippings from children with suspected psoriasis may help with diagnosis, especially in the presence of neutrophils, and in excluding onychomycosis.
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Affiliation(s)
- Marjorie Uber
- Division of Pediatric Dermatology, Hospital de Clínicas, Universidade Federal do Paraná, Curitiba, Brasil
| | - Vânia O Carvalho
- Division of Pediatric Dermatology, Hospital de Clínicas, Universidade Federal do Paraná, Curitiba, Brasil
| | - Kerstin T Abagge
- Division of Pediatric Dermatology, Hospital de Clínicas, Universidade Federal do Paraná, Curitiba, Brasil
| | - Renata Robl Imoto
- Division of Pediatric Dermatology, Hospital de Clínicas, Universidade Federal do Paraná, Curitiba, Brasil
| | - Betina Werner
- Division of Pathology, Hospital de Clínicas, Universidade Federal do Paraná, Curitiba, Brasil
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Microscopy of Common Nail Cosmetics. Am J Dermatopathol 2017; 39:819-823. [DOI: 10.1097/dad.0000000000000809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Bertanha L, Chiacchio ND. Nail clipping in onychomycosis. An Bras Dermatol 2017; 91:688-690. [PMID: 27828655 PMCID: PMC5087240 DOI: 10.1590/abd1806-4841.20164968] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2015] [Accepted: 08/25/2015] [Indexed: 11/22/2022] Open
Abstract
Onychomycosis is the most prevalent onychopathy and it requires a correct early diagnosis. Currently, the diagnostic gold standard is the association of direct mycological test with culture; however, it shows variable sensitivity. The histopathological examination of the distal nail plate, called clipping, has shown to be an adjuvant in diagnosing onychomycosis. This is an easy-to-perform, relatively cheap examination that is little dependent of the examiner, rapidly provides results, has high sensitivity, and for patients it is painless and harmless.
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Affiliation(s)
- Laura Bertanha
- Hospital do Servidor Público Municipal de São Paulo (HSPM-SP) - São Paulo (SP), Brazil
| | - Nilton Di Chiacchio
- Hospital do Servidor Público Municipal de São Paulo (HSPM-SP) - São Paulo (SP), Brazil
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Fonseca GP, Werner B, Seidel G, Staub HL. Comparative microscopic analysis of nail clippings from patients with cutaneous psoriasis and psoriatic arthritis. An Bras Dermatol 2017; 92:21-25. [PMID: 28225951 PMCID: PMC5312173 DOI: 10.1590/abd1806-4841.20175056] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2015] [Accepted: 03/05/2016] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The nail involvement in psoriasis is related to psoriatic arthritis and may
represent a predictor of the disease. OBJECTIVES To analyze, through nail clipping, clinically normal and dystrophic nails of
patients with cutaneous psoriasis and psoriatic arthritis. METHODS This is a cross-sectional multicenter study, conducted between August 2011
and March 2012. Patients were divided into four groups: patients with
cutaneous psoriasis and onychodystrophy, patients with cutaneous psoriasis
and clinically normal nails, patients with psoriatic arthritis and
onychodystrophy and patients with psoriatic arthritis and clinically normal
nails. We calculated NAPSI (Nail Psoriasis Severity Index) of the nail with
more clinically noticeable change. After collection and preparation of the
nail clipping, the following microscopic parameters were evaluated:
thickness of the nail plate and subungual region, presence or absence of
parakeratosis, serous lakes, blood, and fungi. RESULTS There were more layers of parakeratosis (p=0.001) and a greater thickness of
the subungual region in patients with cutaneous psoriasis and
onychodystrophy (p=0.002). Serous lakes were also more present in the same
group (p=0.008) and in patients with psoriatic arthritis and normal nails
(p=0.047). The other microscopic parameters showed no significant difference
between normal and dystrophic nails or between patients with psoriatic
arthritis or cutaneous psoriasis. STUDY LIMITATIONS Small sample size and use of medications. CONCLUSIONS Nail clipping is a simple and quick method to assess the nails of patients
with nail psoriasis although does not demonstrate difference between those
with joint changes or exclusively cutaneous psoriasis.
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Affiliation(s)
| | - Betina Werner
- Dermatology and Pathology Departments of the Universidade Federal do Paraná (UFPR) - Curitiba (PR), Brazil
| | | | - Henrique Luiz Staub
- Department of Rheumatology of the Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS) - Porto Alegre (RS), Brazil
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Raj HJ, Majumdar B, Jain A, Maiti PK, Chatterjee G. A Clinico-Mycological Study on Suspected Cases of Chromoblastomycosis: Challenges in Diagnosis and Management. J Clin Diagn Res 2016; 9:WC01-4. [PMID: 26816977 DOI: 10.7860/jcdr/2015/16199.6963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Accepted: 10/30/2015] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Verrucous plaques mimicking chromoblastomycosis are frequently seen in dermatology outpatient departments (OPD). However, no scientific evaluation has been carried out till date from eastern India. So this present endeavour is aimed at a thorough study of those cases to readdress the challenges in diagnosis and management in chromoblastomycosis from this part of the country. AIM The study is to observe the incidence of proved chromoblastomycosis cases from clinically mimicking conditions and to note therapeutic prospects by use of different antifungal agents. MATERIALS AND METHODS Twenty clinically suspected cases attending dermatology OPD were included in this study. Relevant histories were taken. Apart from routine hematological and biochemical investigations, scrapings from lesions were examined by direct microscopy with KOH wet mount, calcoflour white mount and fungal culture. Histopatholgical examination was also done. Any fungal growth was identified by growth characteristics and morphological features. RESULTS Sclerotic bodies were detected in five samples. Of them three were found to be culture positive. Two growths were identified as Fonsecaea pedrosoi and one as Cladosporium carrionii. Rest 12 cases were diagnosed as either lupus vulgaris (3 cases; 15%), atypical mycobacterial infections (3 cases, 15%), Hypertrophic lichen planus (2, 10%), Hypertrophic DLE plaque (2; 10%), Wart (1, 5%) or fixed cutaneous sporothricosis (1, 5%), zygomycosis (1, 5%). Three cases (15%) were lost in follow up. Cases of chromoblastomycosis were managed with prolonged use of antifungal alone or in combination with saturated solution of potassium iodide and/or debridement. They were followed up for at least six months post treatment. CONCLUSION A database comprising diagnostic clues and effective therapeutic intervention have been proposed for these rare subcutaneous mycoses.
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Affiliation(s)
- Hirak Jyoti Raj
- Assistant Professor, Department of Microbiology, IPGME&R , Kolkata, India
| | - Banashree Majumdar
- Post Graduate Trainee, Department of Dermatology, IPGME&R , Kolkata, India
| | - Atul Jain
- Post Graduate Trainee, Department of Dermatology, IPGME&R , Kolkata, India
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