Self-induced nail disorders (SINDs): What do we know so far?

Self-induced nail disorders are a broad group of different clinical manifestations that share the common trait of being caused more or less voluntarily by the patient. These are distinct conditions within the clinical spectrum of onychotillomania. Most patients diagnosed with these disorders have psychiatric co-morbidities, and a multidisciplinary approach is thus highly recommended. The purpose of this review is to describe the most common clinical features encountered during daily nail consultations and to provide useful diagnostic tools and therapeutic tips for the best approach to these conditions.

Updates in treatment and impact of nail psoriasis

INTRODUCTION

Nail psoriasis is an inflammatory disorder without a potential scarring outcome, but the nail signs, even the milder ones, can cause discomfort to patients and severely affect their quality of life. Nail psoriasis may be associated with psoriatic arthritis and when it starts during infancy, it may be a predictor of a more severe disease course in adulthood. All these issues contribute to the high economic burden of psoriasis.

AREAS COVERED

Nail psoriasis is notoriously difficult to treat, even though new treatments are in continuous development. This paper provides an update on new treatments and address the current gaps in care of nail psoriasis.

EXPERT OPINION

A better understanding of the disease pathogenesis and more 'real-life' studies will definitely be helpful to improve treatment results. A lower level of heterogeneity should be advisable among trials when evaluating nail psoriasis. Moreover, the relationship between nail psoriasis and psoriatic arthritis should be the focus of unbiased studies in order to better define the real risk that nail psoriasis patients have to develop arthritis.

Clinical features and natural course of pediatric longitudinal melanonychia: A retrospective cohort study in Korea

BACKGROUND

Large studies on the clinical features and natural course of pediatric longitudinal melanonychia (LM) are lacking.

OBJECTIVE

To investigate the clinical features and natural course of pediatric LM METHODS: Retrospective cohort analysis of pediatric patients (age ≤18 years) with LM RESULTS: We examined 703 LM lesions in 381 children. Single, narrow, and homogeneously pigmented fingernail lesions were most frequently seen. Our results suggested that within 3, 4.5, and 9.5 years after onset, approximately 3%, 5%, and 10% of LM lesions, respectively, will completely regress and that single, left-sided, and homogeneously pigmented lesions are more likely to completely disappear. Age of onset, sex, finger/toe position, Hutchinson's sign, and nail dystrophy were not associated with complete regression. During follow up, most cases showed no change in color or width between the first and last visit, and early darkening/wider before stabilization or lightening/narrowing was common. Pigmentation becoming lighter was associated with complete regression; change in width was not.

LIMITATIONS

Retrospective study at a tertiary center CONCLUSION: Our results suggest that clinicians ought to follow up pediatric LM without intervention for several years, even if lesions grow darker or wider. Single, left-sided, and homogeneously colored lesions are more likely to regress.

Overall Prevalence and Prevalence Compared among Psoriasis Treatments of Onychomycosis in Patients with Nail Psoriasis and Fungal Involvement

BACKGROUND

Whether nail psoriasis can increase the risk of onychomycosis is still being debated, and data relating to the prevalence of onychomycosis among psoriasis patients receiving different treatments is limited.

OBJECTIVES

To investigate the overall prevalence and prevalence compared among psoriasis treatments of onychomycosis in patients with nail psoriasis and fungal involvement.

METHODS

A prospective study of three groups of nail psoriasis being treated with only topical medication, methotrexate, or biologics (25 patients per group, 150 nails) was conducted at Siriraj Hospital (Bangkok, Thailand) during November 2018 to September 2020. Demographic data, psoriasis severity, and nail psoriasis severity were recorded. The nail most severely affected with psoriasis on each hand was selected for mycological testing. Potassium hydroxide, periodic acid-Schiff stain, and fungal culture were performed.

RESULTS

The prevalence of onychomycosis in nail psoriasis was 35.3%. Among the treatment groups, the prevalence of onychomycosis was significantly higher in the methotrexate group than in the topical treatment and biologic treatment groups (p = 0.014). Candida spp. was the main causative organism, followed by Trichophyton rubrum. Thumb was most commonly affected (59.3%). The most common abnormality of the nail matrix and the nail bed was pitted nail (71.3%) and onycholysis (91.3%), respectively. Multivariate analysis revealed diabetes, wet-work exposure, and methotrexate treatment to be predictors of onychomycosis.

CONCLUSIONS

Several factors, including psoriasis treatment, were shown to increase the risk of onychomycosis in nail psoriasis. Further research is needed to determine whether biologic agents, especially interleukin-17 inhibitors, can increase risk of onychomycosis and Candida infection/colonization of the nails.

Nail Psoriasis Does Not Affect Skin Response to Ixekizumab in Patients With Moderate-To-Severe Psoriasis

Background: Presence of nail psoriasis in patients with plaque psoriasis may be an indicator of greater disease severity. Previously, patients with nail psoriasis have had delayed skin clearance after treatment compared to patients without nail psoriasis. Objective: This post-hoc analysis evaluated the efficacy of ixekizumab in clearance of plaque psoriasis in patients with and without nail psoriasis. Methods: Data were integrated from two phase 3 clinical trials (UNCOVER-2 and UNCOVER-3; N=2570) to assess skin response over 12 weeks of treatment with subcutaneous placebo, etanercept, or ixekizumab in patients with and without nail psoriasis. Nail response was assessed using Nail Psoriasis Severity Index (NAPSI) and skin response was assessed as the percentage of patients achieving 75%, 90%, or 100% improvement in Psoriasis Area and Severity Index (PASI 75, PASI 90, PASI 100) or a score of 0 or 1 on the static Physician Global Assessment (sPGA 0 or 0,1). Results: From baseline to week 12, progressive improvement in psoriasis occurred with ixekizumab and etanercept treatment; however, significantly more patients with nail psoriasis than without mild PASI 75 at weeks 8 and 12 and sPGA (0,1) at week 12 with ixekizumab. Significantly more patients with severe nail psoriasis than mild achieved PASI 75 at weeks 8 and 12 with ixekizumab. Conclusion: Patients with and without nail psoriasis responded well to ixekizumab. The presence of nail psoriasis did not negatively affect skin clearance in patients treated with ixekizumab. ClinicalTrials.gov: NCT01597245, NCT01646177 J Drugs Dermatol. 2020;19(8):741-746. doi:10.36849/JDD.2020.5116.

Review of Nail Lichen Planus: Epidemiology, Pathogenesis, Diagnosis, and Treatment

Nail lichen planus is an inflammatory disorder of the nails with potential for significant cosmetic disfigurement and functional impairment. Nail manifestations may be isolated or appear concurrently with other forms of lichen planus. Longitudinal ridging is the most common clinical finding, but progressive disease may result in irreversible scarring (dorsal pterygium) or permanent nail loss (anonychia). Data on treatment are limited to retrospective studies and case reports. The mainstays of treatment are intralesional and intramuscular corticosteroid injections and oral retinoids. There is a need for randomized controlled trials on nail lichen planus to more rigorously assess efficacy and outcomes.

Phenogenon: Gene to phenotype associations for rare genetic diseases

As high-throughput sequencing is increasingly applied to the molecular diagnosis of rare Mendelian disorders, a large number of patients with diverse phenotypes have their genetic and phenotypic data pooled together to uncover new gene-phenotype relations. We introduce Phenogenon, a statistical tool that combines, Human Phenotype Ontology (HPO) annotated patient phenotypes, gnomAD allele population frequency, and Combined Annotation Dependent Depletion (CADD) score for variant pathogenicity, in order to jointly predict the mode of inheritance and gene-phenotype associations. We ran Phenogenon on our cohort of 3,290 patients who had undergone whole exome sequencing. Among the top associations, we recapitulated previously known, such as "SRD5A3—Abnormal full-field electroretinogram—recessive" and "GRHL2 –Nail dystrophy—recessive", and discovered one potentially novel, “RRAGA–Abnormality of the skin—dominant”. We also developed an interactive web interface available at https://phenogenon.phenopolis.org to visualise and explore the results.

Structural, Dermal and Ungual Characteristics of the Foot in Patients with Type II Diabetes

Background and Objectives: Diabetes is a chronic and metabolic disease, considered as an important public health problem. The objective of this study was to determine the prevalence of podiatric pathology in type II diabetic patients. Materials and Methods: An observational descriptive study of prevalence in the endocrinology service of Complexo Hospitalario Universitario A Coruña (CHUAC) (A Coruña-Spain) was carried out (n = 153). Type II diabetic patients included, of legal age who signed the informed consent. Sociodemographic variables were studied (age, sex, body mass index (BMI), smoking habit, alcohol consumption, family history), disease variables (time of evolution of diabetes, treatments, low-density lipoprotein (LDL), high-density lipoprotein (HDL), glucose), podiatric variables: measurement of the footprint, metatarsal and digital formula, nail, skin, hindfoot and forefoot alterations. The data collection was done in 2018 and the data analysis was carried out in 2019. Results: The patients with type II diabetes had greater age, obesity and arterial hypertension it compared to the general population. Diabetic patients had a higher prevalence of flat feet than the general population (71.2% vs. 20.7%, p < 0.001), with a predominance of normal foot according to the podoscope. The predominant podological pathology was the presence of claw toes (94.8%), followed by dermal (78.4%) and nail (71.9%) alterations, and the Hallux Valgus (66.0%). The Clarke angle and the Chippaux index showed a Kappa concordance index of 0.26 with the type of footprint measured with the podoscope. The Staheli index showed a Kappa index of 0.27 associated with an observed agreement of 54%. Conclusions: This study shows that foot problems continue to be prevalent in subjects with type II diabetes mellitus and for this reason, podiatry is essential in its treatment.

Nail ultrasonography for psoriatic arthritis and psoriasis patients: a systematic literature review

To systematically review the role of ultrasound (US) in the assessment of the joint-enthesial-nail apparatus in patients with psoriatic arthritis (PsA) or psoriasis (PSO) in terms of prevalence, diagnosis, prognosis, monitoring and treatment. A systematic literature review was conducted through medical databases (PubMed, Embase) and the grey literature up to February 2018. The main areas of application of nail US were first identified, allowing the development of research questions, which were rephrased following the PICOs methodology to develop inclusion criteria. Of the 585 studies produced by PubMed and Embase searches, 17 studies met the criteria for inclusion. Five additional studies were included: 1 from the hand search and 4 from the 2016-2017 ACR and EULAR congresses. The prevalence of nail plate changes varied from < 10 to 97%, for power Doppler signal from 20-30 to 96% and distal interphalangeal joint (DIJ) involvement from 8.9 to 100%. The performance of US nail/DIJ abnormalities in the diagnosis of PsA and PSO elementary lesions was analysed by five studies, with a wide heterogeneity. Reproducibility and reliability of US nil/DIJ were assessed by interclass correlation coefficient or Cohen's k and their values ranged from 0.6 to 0.9. The value of US nail/DIJ in the monitoring of the lesions was analysed only by a single study. The analysis revealed applications for US nail/DIJ in PsA and PSO and highlights limitations. Validation is strongly needed to demonstrate its appropriateness in the clinical practice and to define its diagnostic and prognostic role.

Nail irregularities associated with Sézary syndrome

Sézary syndrome (SS) is the leukemic form of cutaneous T-cell lymphoma (CTCL) and can be associated with various nail irregularities, though they are infrequently reported. In this retrospective study, we reviewed medical records from a CTCL clinic database at the University of Texas MD Anderson Cancer Center (Houston, Texas) for reported nail abnormalities in patients with a diagnosis of SS. Findings for 2 select cases are described in more detail and are compared to prior case reports to establish a comprehensive list of nail irregularities that have been associated with SS.

Nail Involvement in Alopecia Areata: A Questionnaire-based Survey on Clinical Signs, Impact on Quality of Life and Review of the Literature

Alopecia areata (AA) is an immune-mediated disease causing temporary or permanent hair loss. Up to 46% of patients with AA also have nail involvement. The aim of this study was to determine the presence, types, and clinical implications of nail changes in patients with AA. This questionnaire-based survey evaluated 256 patients with AA. General demographic variables, specific nail changes, nail-related quality of life (QoL), and treatment history and need were evaluated. Prevalence of nail involvement in AA was 64.1%. The specific nail signs reported most frequently were pitting (29.7%, p = 0.008) and trachyonychia (18.0%). Red spots on the lunula were less frequent (5.1%), but very specific for severe AA. Nail-related QoL was only minimally affected by nail changes. In conclusion, nail involvement is common in patients with AA and presents mostly with pitting and trachyonychia. The presence of these nail changes reflects the severity of the disease, with red spots on the lunula as a predictor for severe alopecia.

Distinct Patterns and Aetiology of Chromonychia

Abnormal colouring of the nails may be a sign of underlying systemic or local disorders. This study investigated the prevalence and causes of chromonychia as a whole, as well as of each subtype. Among 163 patients with chromonychia, trauma was the pathogenesis in up to 20.9% (34/163) of cases. The most common subtype was melanonychia (54.0%; 88/163), followed by leukonychia (23.9%), red (8.6%), green (6.7%), yellow (4.9%) and blue (1.8%) nails. Nail matrix naevus (33.3%; 29/88) was the most common cause of melanonychia, while skin diseases (41.0%; 16/39), such as psoriasis (75%, 12/16) and alopecia areata (18.8%; 3/16), in addition to systemic diseases (33.3%; 13/39) including anaemia (38.5%, 5/13) and chronic renal failure (15.4%; 2/13) were the dominant causes of leukonychia. As chromonychia may be the first or only sign of an underlying disorder, it should alert physicians and patients to the need for a prompt and thorough evaluation.

Protection during production: Problems due to prevention? Nail and skin condition after prolonged wearing of occlusive gloves

Wearing of occlusive gloves during the whole working shift is considered a risk factor for developing hand eczema, similar to wet work. Moreover, the increased hydration due to glove occlusion may lead to brittle nails. Two hundred and seventy clean room workers, wearing occlusive gloves for prolonged periods, and 135 administrative employees not using gloves were investigated. This included a dermatological examination of the nails and the hands, using the Hand Eczema ScoRe for Occupational Screening (HEROS), measurement of transepidermal water loss (TEWL), and a standardized interview. Of the clean room workers, 39%, mainly women, reported nail problems, mostly brittle nails with onychoschisis. Skin score values showed no significant differences between HEROS values of both groups. TEWL values of exposed subjects were similar to TEWL values of controls 40 min after taking off the occlusive gloves. In a multiple linear regression analysis, male gender and duration of employment in the clean room were associated with a significant increase in TEWL values. The effect of occlusion on TEWL seems to be predominantly transient and not be indicative of a damaged skin barrier. This study confirmed the results of a previous investigation showing no serious adverse effect of wearing of occlusive gloves on skin condition without exposure to additional hazardous substances. However, occlusion leads to softened nails prone to mechanical injury. Therefore, specific prevention instructions are required to pay attention to this side effect of occlusion.

[Osteochondromas: introducing the subungual osteochondroma]

INTRODUCTION

Subungual osteochondromas are benign tumors of the sub- or periungual region, causing lifting, ulceration and deformity at that level.

OBJECTIVE

To research the incidence of subungual osteochondromas in a specific pediatric population.

MATERIAL AND METHODS

Retrospective, transversal, descriptive and observational study based on the review of records with a histopathological result of osteochondroma from 2001 to 2014.

RESULTS

The pathological assessment featured four osteochondromas that corresponded to the subungual presentation, with an equal gender distribution of 1:1, an average age of 9.5 years, right: left ratio of 3:1; the 4th finger was the most affected.

DISCUSSION

Subungual osteochondroma has an incidence of 8.5% of all osteochondromas.

Incidence, clinical manifestations and clipping of nail psoriasis in the dermatology center of the Hospital Universitário Evangélico de Curitiba

BACKGROUND

Psoriasis is a chronic inflammatory skin disease that often progresses with nail alterations. It is suspected that there is a correlation between nail psoriasis and enthesitis of the distal interphalangeal joint, seeming to serve as a predictor.

OBJECTIVES

To analyze the profile of patients with nail psoriasis and correlate the presence of nail alterations with psoriatic arthritis, quality of life, extent of psoriasis and the histopathology of the nail.

METHODS

An observational cross-sectional study with 40 patients with a diagnosis of psoriasis and without systemic treatment. The patient profile was researched, including quality of life and evaluated for the presence of psoriatic arthritis. The severity of the skin psoriasis and the presence of nail lesions were evaluated. Nail fragments were collected and analyzed through clipping. It obtained 100% of positivity for psoriasis in the histopathology exam of the nail plate.

RESULTS

Of the 40 patients, 65% were diagnosed with nail psoriasis. Suggestive findings of psoriatic arthritis in hands were present in 33%, being more frequent in those with nail alteration (p = 0.01). In 92.3% of patients diagnosed with psoriatic arthritis in the hands there was some nail injury. The most frequent injuries were pitting and onycholysis.

CONCLUSIONS

Patients with nail psoriasis are usually men, with worse quality of life and higher chance of psoriatic arthritis. The correlation between the nail involvement of psoriasis and psoriatic arthritis in hands confirms the association between these two forms. The clinical diagnosis of nail psoriasis did not correlate with the histological diagnosis.

[Species distribution and antifungal susceptibility of Candida spp. causing superficial mycosis. Coro, Falcon state, Venezuela]

Candida species other than C. albicans are often described as causative agents of superficial mycosis and are more resistant to treatment with azoles. In order to determine the distribution of species and in vitro antifungal susceptibility of Candida spp., one ambispective study, which analyzed 18 yeast isolates obtained from samples from patients diagnosed with superficial mycosis, was performed. Taxonomic identification was performed by macroscopic visualization of the growth characteristics in chromogenic agar and by conventional methods. The susceptibility to fluconazole and voriconazole was evaluated by the disc diffusion method. Most of the isolates (88.8%), came from nail samples. C. parapsilosis was the most common species, followed by C. tropicalis, C. albicans and C. krusei, which confirmed the prevalence of non-albicans species as a cause of superficial mycoses. The pattern of susceptibility to fluconazole and voriconazole was similar: all isolates of C. parapsilosis and C. albicans were susceptible, while 83.3% of C. tropicalis showed sensitivity to both antifungals. C. krusei, fluconazole-resistant species showed intermediate susceptibility io voriconazole. The use of chromogenic agar allowed to detect mixed infections in nail samples, involving Candida spp. and C. tropicalis in one case, the latter with resistance to both fluconazole and voriconazole. The results demonstrate the importance of species identification and susceptibility testing to avoid therapeutic failures in superficial mycoses.

Nail involvement in adult patients with plaque-type psoriasis: prevalence and clinical features

BACKGROUND

Psoriasis is a disease of worldwide distribution with a prevalence of 1 to 3%. Nail psoriasis is estimated in 50% of patients with psoriasis, and in the presence of joint involvement, it can reach 80%.

OBJECTIVE

To study the nail changes - and their clinical implications - presented by patients with psoriasis vulgaris under surveillance in a university hospital from the south of Brazil.

METHODS

his cross-sectional study evaluated 65 adult patients from January 2012 to March 2013. Cutaneous severity was assessed according to the Psoriasis Area and Severity Index (PASI). The Nail Psoriasis Severity Index (NAPSI) was used to evaluate patient's nails. The diagnosis of psoriatic arthritis was established according to the Classification Criteria for Psoriatic Arthritis (CASPAR).

RESULTS

The prevalence of NP was 46.1%. These patients had a median [interquartilic range (IQR)] NAPSI of 1 (0-15). A total of 63.3% of patients reported aesthetic discomfort or functional impairment related to their nails. Onycholysis was the most common feature (80%). When compared with patients without nail involvement, patients with NP had lower mean age at psoriasis onset [21 (18-41) vs. 43 (30-56) years, p=0,001]; longer disease duration [15.5 (10-24) vs. 6 (2-12) years, p=0.001]; higher PASI [9.2 (5-17) vs. 3.7 (2-10), p=0.044], higher frequency of psoriatic arthritis (43.3 vs. 3.7, p = 0.002) and more often reported family history of psoriasis (40% vs. 7.4%, p = 0.011).

CONCLUSION

Onycholysis was the most frequent finding and most patients feel uncomfortable with the psoriatic nail changes that they experience.

Frequency, pattern, and extent of skin diseases in relation to CD4+ cell count among adults with human immunodeficiency virus infection or acquired immunodeficiency syndrome in Osogbo, southwestern Nigeria

BACKGROUND

Skin diseases characterize all stages of human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome (AIDS) and contribute significantly to associated morbidity and mortality.

OBJECTIVES

The aim of this study was to document the prevalences, patterns, and extents (severity) of skin diseases and their relationships with immunologic status in HIV/AIDS patients.

METHODS

A total of 140 HIV/AIDS patients in different stages of HIV infection and 140 controls were recruited. Skin diseases were documented and CD4+ cell counts determined in all subjects. Severity was assessed according to the body surface area affected (using the Wallace rule of nines and the rule of palm) for lesions that tended to be widespread. The number of digits involved was counted for lesions involving the nails. Intensity of pain was graded for specific conditions such as herpes zoster. Chi-squared statistics and Pearson correlations were determined.

RESULTS

Mean±standard deviation age was 35.04±8.83 years in the patient group and 32.21±8.30 years in the control group. The prevalences and patterns of skin diseases in HIV/AIDS patients were similar to those reported in previous studies. Most commonly found dermatoses were oral candidiasis (n=28, 20.0%), pruritic papular eruption (n=27, 19.3%), xeroderma (n=23, 16.4%), dermatophytosis (n=22, 15.7%), and fluffy hair (n=19, 13.6%). The presence of specific skin lesions represented a better correlate with immunosuppression than cutaneous extents. However, the extents of viral warts and multiple blue–black nails correlated significantly with CD4+ cell count. The presence of a lighter hair color phenotype signifies a lower CD4+ cell count than a softer hair phenotype.

CONCLUSIONS

The presence of specific skin lesions correlates more strongly with a low CD4+ cell count than does the extent of their distribution, except in cases of viral warts. The presence of and higher numbers of nails affected with blue–black nail hyperpigmentation suggest severe immunosuppression.

Subungual Glomus Tumor: Clinical Manifestations and Outcome of Surgical Treatment

Surgical excision is the treatment of choice for subungual glomus tumor. However, the anatomical location has inherent difficulties. We report the outcomes of surgical treatments for subungual glomus tumor. Sixteen patients, who were seen over an eight-year period (1995-2003) and confirmed as gloums tumor by histopathologic examination were reviewed. The most common subjective symptom was pain induced by contact in 81%. The tumor presented as a discolorated spot or subungual nodule and 38% of tumors were acccompanied with nail dystrophy. All tumors showed discolorated spots or subungual nodules. As shown in the Table 2, the dystrophic nail change was found in 38% of tumors. Differently oriented incisions were made according to the location of tumor, matrix, or bed. The original nail plate was restored in eight patients. Thirteen patients (81%) had cosmetically excellent nail plates, and three patients (19%) had partial distal splits of nail plates. There was no recurrence. Our series suggests that a transungual approach with nail avulsion and an incision selected according to the tumor location can produce an excellent outcome with minimal postoperative complications. Dressing with a trimmed nail plate may also be beneficial in managing the wound and preventing postoperative nail deformity.

Gender differences in alopecia areata

Alopecia areata (AA) is a common, non-scarring, autoimmune hair-loss disorder with a complex genetic and environmental etiology. A higher incidence rate of AA in the female population is well described. It is unclear why females are more likely to be diagnosed with AA and what, if any, differences in disease phenotype exist between males and females. The identification of gender specific characteristics of disease may help clinical management and patient education in cases of AA. Accordingly, we recruited 481 North-American Caucasian AA patients (336 female, 145 male) to assess age of onset, autoimmune and atopic co-morbidity, nail involvement, family history of AA and autoimmune disease, and disease subtype. There was a female predominance (female to male ratio 2.3:1) in this AA study population. We found that male AA patients are more likely to be diagnosed in childhood (age <10 years, P= 0.067) and have a family history of AA (P= 0.004). On the other hand, female AA patients are more likely to be diagnosed in adolescence (age 10-20 years, P= 0.083), have co-morbid nail involvement (P= 0.0257), and have concomitant autoimmune disease (P= 0.014), particularly thyroid disease (P= 0.058). The clinical implications of disease heterogeneity between males and females remains to be determined.

Nail dystrophies, scalp and intergluteal/perianal psoriatic lesions: risk factors for psoriatic arthritis in mild skin psoriasis?

AIM

In the literature, clinical features of psoriasis associated with psoriatic arthritis (PsA) onset have not been clarified, even if high Psoriasis Area and Severity Index (PASI) was found to be directly related with PsA.

METHODS

The study was conducted between November 2008 and April 2009 on consecutive psoriatic outpatients referred to a service of dermatological consultations, on indication of other hospital specialists. Participants were affected by mild skin psoriasis, in particular with nail dystrophies and/or scalp and/or intergluteal/perianal lesions. The questionnaire provided by the Classification of Psoriatic Arthritis (CASPAR) study group was proposed to all patients and we added a question about the time of psoriasis onset.

RESULTS

Eighty-seven subjects (34 males and 53 females) aged between 18 and 91 years (mean age 48 years) with such psoriatic features were recruited. Other 30 refused to take part to the study. Forty-seven per cent of these participants were found to suffer from PsA, in particular 83% of those with nail and scalp psoriasis, 40% of subjects with intergluteal/perianal involvement and 37% of patients with just scalp lesions. We present the first exploratory and observational study focused on a population with mild skin psoriasis, in order to evaluate if nail dystrophies, scalp or intergluteal/perianal psoriatic lesions might be indicative of a higher risk of PsA even in cases with mild skin psoriasis.

CONCLUSION

Nail psoriasis is probably a suggestive feature of joint involvement. The scalp psoriasis, as well as intergluteal/perianal psoriatic lesions, is likely to be less associated to PsA, but may be an important comorbidity factor for the development of PsA. Further investigations in a larger population are encouraged to assess a potential link between PsA, site-specific and mild skin psoriasis.

Alopecia Areata: news on diagnosis, pathogenesis and treatment

This review focuses on recent changes in the clinical, pathogenetic and therapeutic developments with regards to Alopecia Areata. Some new clinical forms and some phenomena have been described for the first time in recent years. Several phenomena previously observed such as the Renbok, the Koebner and the possibility that an exclamation mark hair can resume its physiological growth have been confirmed. The pathogenetic role of cytotoxic cells is increasingly evident, as well as the deficit of cells and the factors regulating the autoimmune response. The concept of immune privilege of the hair follicle has had further confirmation and have been identified some of the molecular mechanisms such as the expression of the receptors for killer lymphocytes on the trichokeratinocytes of the Outer Root Sheat. There is a renewed interest on the possible role of mast cell as a key element in the acute and chronic phases of the disease. New therapies are focused on the inhibition of the killer cells directed against antigens not yet fully specified of the hair follicle and on the restoration of the immune privilege of this structure. Alopecia Areata is a disease with high emotional impact, able to reduce the quality of life of patients and their family entourage. It is often frustrating for those affected and for the therapists due to its evolution quite unpredictable and the mixed response to the few validated therapies. Investment in research originate almost exclusively from voluntary associations of patients, which need to be known and supported.

Onychophagia and onychotillomania: prevalence, clinical picture and comorbidities

Onychophagia is defined as chronic nail biting behaviour, which usually starts during childhood. Onychotillomania results from recurrent picking and manicuring of the fingernails and/or toenails, leading to visual shortening and/or estraction of nails. The aim of this study was to assess the prevalence of onychophagia and onychotillomania in young adults, and the comorbidity of these conditions with anxiety disorders and obsessive compulsive disorders (OCD), as well as to determine factors related to these behaviours. A total of 339 individuals were interviewed with a structured questionnaire. Onychophagia was present in 46.9% of participants (including 19.2% active and 27.7% past nail biters), and an additional 3 people (0.9%) had onychotillomania. The majority of subjects (92.2%) described nail biting as an automatic behaviour. Tension before nail biting was reported by 65.7% of nail biters, and feelings of pleasure after nail biting by 42%. Among the participants with lifetime onychophagia, 22.5% met criteria of anxiety disorder and 3.1% of OCD, while in the group without onychophagia at least one anxiety disorder was diagnosed in 26.2% and OCD in 5.0%. We did not find any correlation between nail biting and other anxiety disorders or OCD. In conclusion, no single condition was associated with nail biting or influenced such behaviour; multiple psychological factors were involved.

Foot problems in Maori with diabetes

AIM

The prevalence of diabetes and its associated manifestations is higher in New Zealand Maori than New Zealand Europeans. There is no current evidence regarding podiatric clinical characteristics of Maori with diabetes. The aim of this study was to determine the clinical and foot characteristics of Maori with diabetes using a podiatry-specific assessment tool.

METHOD

This study used a cross-sectional design. Participants with diabetes were recruited from two Maori Primary Health Organisations. Podiatric-specific characteristics (vascular, neurological and musculoskeletal) were recorded. Patient demographics and general medical conditions were also recorded.

RESULTS

Fifty-three participants were recruited and displayed risk factors for diabetes-related complications (mean disease duration 12 years, mean HbA1c 8.3%) including 49% of participants with hypertension. Podiatric-specific characteristics revealed unremarkable neurovascular results. However, many participants presented with pre-ulcerative lesions and current pedal ulceration (53% and 8% respectively). Although many participants had good foot-care knowledge (>85%), a modified classification tool of foot risk status determined that a high percentage of participants required regular podiatric management and screening (60%).

CONCLUSION

Despite this population living with a chronic condition for more than 10 years and displaying poor long-term glycaemic control, there was no evidence of microvascular or macrovascular complications in the lower limb. However, there was a high prevalence of pre-ulcerative lesions which unmonitored and undetected may predispose the foot to ulceration. The detection of current ulceration in this study alongside other risk factors for diabetes-related complications necessitates the need for appropriate podiatric screening and podiatry management.

Childhood nail alterations in Polish population

The epidemiology and nature of childhood nail apparatus pathology is not well known. The aim of our study was to investigate the frequency and nature of nail alterations in Polish pediatric patients. Among 1588 patients diagnosed and treated at our clinic due to nail alterations, 82 (5.16%) patients under age 16 were selected. The most frequent (36.59%) diagnosis were variants of normal nails, which were observed in 30 patients. The most common pathology were viral warts (19.51%). Differences in the distribution of onychomycosis and viral warts in children and adults were statistically significant. Onychomycosis was more common in adults (60.39% vs. 9.76%), whereas viral warts were more common in children (19.51% vs. 5.86%; P<0.0001). Melanonychia was diagnosed in one (1.22%) case. Benign and malignant tumors were not observed. In conclusion, distribution of nail apparatus pathology in children is different comparing with adults. In the group of children under 6 years of age, there were mainly variants of normal nails, whereas in older children viral infection and acquired structural disorders were recorded. The risk of nail apparatus malignancy in childhood seems to be extremely low.

[Dermatoses in patients with acute myeloid and lymphoid leukemia. Cohort follow-up in a tertiary care hospital]

INTRODUCTION

Cutaneous manifestations in patients with acute leukemia (AL) cover a broad spectrum, including those due to leukemia per se, to chemotherapy and other drugs and those inherent to hospital care.

MATERIAL AND METHODS

This is a cohort study in a tertiary hospital setting where the development of dermatoses was followed for 2 years in 22 patients with the diagnosis of AL.

RESULTS

During the study, all patients developed some type of dermatosis, mostly due to chemotherapy.

Onychomadesis outbreak linked to hand, foot, and mouth disease, Spain, July 2008

In July 2008 an onychomadesis outbreak in a nursery setting was reported in Saragossa (Spain). Some of the cases had previously suffered from hand, foot and mouth disease (HFMD). In order to study the outbreak and to determine the relation between the two diseases, two epidemiological studies were conducted: a descriptive study focused on cases and a retrospective cohort study. Samples from stool, pharynx and nails were obtained from cases for microbiological analysis. During the study period, 27 children fulfilled the case definition. The average age was 1.8 years. A case shed on average four nails (minimum one maximum twelve). Twenty-four of the 27 cases had previously presented with HFMD which started an average of 40 days before the onset of onychomadesis (relative risk: 14). Unidentified non-polio enterovirus (n=10), coxsackie B1 (n=4) and coxsackie B2 virus (n=3) were isolated in 28 specimens obtained from 14 cases. The analysis showed a strong association between HMFD and onychomadesis. Microbiological results have not been conclusive; consequently more studies are necessary to determine the causal agent of infectious onychomadesis.

Delayed onychodystrophy of incontinentia pigmenti: an evidence-based review of epidemiology, diagnosis and management

Incontinentia pigmenti (IP) is an X-linked dominant disorder that is seen in females. Although the medical literature has focused strongly on the skin manifestations of IP, there is lack of comprehensive reviews focused on delayed nail lesions of IP. The authors thus tabulated reported nail changes in IP with a focus on diagnosis and management of this delayed nail presentations. This review emphasizes several observations with strong clinical relevance to management of IP. In particular, nail lesions may be additional clue to vague or late-presenting cases of IP. Nail lesions are most common on the first three digits of the hands, can affect multiple digits on multiple limbs, present from three to 45 years of age, and present on average over 20 years after skin lesions present. Clinically, nail lesions can be subtle and often are indicators of underlying tumor. Finally, nail lesions are delayed and destructive in nature, despite the clinically resolved cutaneous lesions, and require continual vigilance by pediatricians and dermatologist.

[Nail diseases in cosmetology]

Clinical symptoms attributed to the nail apparatus and observed in cosmetology include atrophic or hypertrophic lesions, pathologic nail coloration, abnormalities of the nail surface, and disorders of the nail plate and bed junction. These symptoms may reflect pathologic processes limited to the nail apparatus or may be the consequence of a dermal or systemic disease. Even though the etiology of nail lesions is variegated, diseases of the nails are simply classified as infectious or non-infectious. The aim of this work was to present the most common diseases of the nail apparatus encountered in cosmetology. Often, nail diseases worsen the quality of life of the patient. In addition, the variegated symptomatology demonstrates that nail lesions should be viewed in a wider perspective because they often are important signs of pathologic processes taking place in the organism of the patient.

Dermatological conditions presenting at an emergency department in Singapore

INTRODUCTION

In Singapore, a significant proportion of patients receive specialist dermatological services via referrals from points of primary care, such as polyclinics and emergency departments (ED). The study hospital, Tan Tock Seng Hospital, is an acute care general hospital with a large catchment area, and has the busiest ED in Singapore. The aim of this paper was to describe the types of dermatological conditions presented at the ED in the year 2007. This information is useful for the future education of junior doctors working in the department, as well as for the allocation of future resources in the treatment of the more common conditions.

METHODS

The ED patient database was searched for all dermatological conditions by ICD-9 code and by keywords in the diagnosis description. The two lists were merged and duplications were eliminated. The consultation notes of the patients were reviewed in cases where the diagnosis was ambiguous. Patient demographics were then filtered and analysed.

RESULTS

A total of 4,061 patients were seen in the ED with a primary dermatological complaint, out of a total of 157,527 attendances in 2007. The commonest conditions seen were chickenpox and herpes zoster (20.8 percent). Dermatitis/eczema (11.6 percent) and urticaria (11.4 percent), nail conditions including trauma and infections (10.2 percent) and drug rashes (9.7 percent) were also common. Venereal diseases (1 percent) were uncommonly seen in the ED. Interestingly, men (65.3 percent) were seen in the ED for dermatological conditions twice as often as women (34.7 percent).

CONCLUSION

The recognition and management of the common conditions should be core modules in the training of doctors and nurses.

Factors associated with underlying malignancy in a retrospective cohort of 121 patients with dermatomyositis

Demographic, clinical, and laboratory features that predict underlying malignancy in patients with dermatomyositis (DM) are poorly known. We conducted a retrospective study in all adult patients with a definite (n = 75) or probable (n = 32) diagnosis of DM according to Bohan and Peter criteria or with amyopathic DM (n = 14) who were referred to 2 departments during a 13-year period. The diagnosis of malignancy-associated DM was retained if DM occurred in a context of recently diagnosed malignancy or if a malignancy was diagnosed during the 5 years following the diagnosis of DM. The Kaplan-Meier method was used to assess the cumulative incidence rates of underlying malignancy during the first 5 years of DM. Factors associated with malignancy in patients with DM were identified by Cox proportional hazards models. During the study period, 121 patients fulfilled the inclusion criteria (median age, 52 yr; range, 19-77 yr; women: 70%). For 29 of them, the diagnosis of malignancy-associated DM was retained. The cumulative incidence rate of malignancy was 21 +/- 4% and 28 +/- 5%, 1 year and 5 years after the diagnosis of DM, respectively. The median duration of follow-up of the 92 patients with no malignancy diagnosed was 36 months (range, 1-140 mo). In multivariate analysis, independent factors associated with an underlying malignancy in patients with DM were an age at diagnosis >52 years (hazard ratio [HR], 7.24; 95% confidence interval [CI], 2.35-22.31), a rapid onset of skin and/or muscular symptoms (HR, 3.11; 95% CI, 1.07-9.02), the presence of skin necrosis (HR, 3.84; 95% CI, 1.00-14.85) or periungual erythema (HR, 3.93; 95% CI, 1.16-13.24), and a low baseline level of complement factor C4 (HR, 2.74; 95% CI, 1.11-6.75). Lastly, low baseline lymphocyte count (<1500/mm(3)) was a protective factor of malignancy (HR, 0.33; 95% CI, 0.14-0.80). Taken together, these data may help physicians focus on a group of patients who might benefit from extensive evaluation for malignancy.

Association between morphological changes of nail and nail arsenic level in patients with arsenicosis

This case-control type of analytical study was conducted in the Department of Dermatology and Venereology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh to find out the association between morphological changes of nail and nail arsenic level in arsenicosis patients. Majority of arsenicosis patients were male (56.67%). The mean age of the cases was 43.07+/-13.73 years. Nail changes were found in 26.67% of cases, most were nail dystrophy (23.33%) and rest were Mee's line (3.34%). There was significant difference between cases with or without nail changes and nail arsenic level. But cases with or with out nail changes had a significant difference between duration of intake of arsenic contaminated water. There was no correlation between nail changes and nail arsenic level for nail dystrophy and Mee's line. The study result failed to establish association between the morphological changes of nail and nail arsenic level.

[Diagnosis and management of nail psoriasis]

Nail psoriasis has traditionally been considered as one of the most difficult forms of psoriasis to treat. The most recent studies have found a higher prevalence of fungal infections in psoriatic nails and therefore cultures before and during treatment are necessary. Over the last few years, novel psoriatic therapies have been developed, some of which are effective for both skin and nail lesions (cyclosporine and biologic agents). Of the topical agents, vitamin D and A derivatives as well as nail lacquer containing 8 % clobetasol propionate can help improve lesions of both the nail bed and matrix.

Occurrence of Scopulariopsis and Scedosporium in nails and keratinous skin. A 5-year retrospective multi-center study

A 5-year retrospective multicenter study was performed for microascaceous moulds (Microascaceae, Ascomycetes) in Finnish clinical specimens. The files from 1993-1997 of six clinical mycology laboratories in Finland were searched for reports of these fungi, mainly Scopulariopsis and Scedosporium anamorphs in keratinous specimens. From the 521 primary findings, 165 cases were selected for further study based on direct microscopy, colony numbers and accompanying fungi. The clinical records of 148 cases (141 Scopulariopsis, 7 Scedosporium) were studied. Of the nail infections from which Scopulariopsis was recovered, 39 cases were further separated which showed clinical or laboratory-based evidence of dermatophytosis. In the remaining 90 'non-dermatophyte' nail cases, Scopulariopsis spp. were the only documented fungal agents (c. 6 cases/million/year). The patients were mainly elderly, 66% of whom had problems involving their big toe nails. For 74% of them, the nail problem was mentioned as their reason for visiting the physician. However, only 18% had documented benefit from treatment. The Scopulariopsis nail infections seem to be treatment-resistant and the pathogenesis and etiological role of Scopulariopsis remain poorly understood.

Nail disorders in patients with chronic renal failure and undergoing haemodialysis treatment: a case-control study

BACKGROUND

Few controlled studies have compared nail disorders in patients with chronic renal failure (CRF) and haemodialysis (HD)-dependent individuals with a healthy population.

OBJECTIVE

The aim of this study was to compare the prevalence of nail disorders in patients with CRF and patients undergoing HD treatment with a healthy population, and evaluate the relationship between nail changes and various demographic, medical and laboratory parameters in these groups.

METHODS

In this case-control study we recruited 73 patients affected with CRF, 77 patients undergoing regular HD and 77 healthy individuals. All patients were examined for the presence of nail disorders. Various parameters [age, gender, type of kidney disease, regular medications, duration of renal failure and HD, dialysis efficacy (Kt/v), haemoglobin, neutrophil count, calcium, phosphorus, albumin, creatinine, urea, alkaline phosphatase and parathyroid hormone (PTH) levels] of the patients were determined by multivariate analysis and compared.

RESULTS

Forty-four patients (60.3%) with CRF and 48 patients (62.3%) undergoing HD treatment had at least one type of nail pathology. The most common nail alterations found in patients with CRF and those undergoing HD were absence of lunula (AL) and half-and-half nails (HHN), respectively. Prevalence of nail disorders among patients with CRF was influenced significantly by PTH level (P = 0.03). In the HD group, male sex, age above 65 years and comorbidities (diabetes mellitus, hypertension and heart failure) were significantly associated with nail pathologies.

CONCLUSION

Patients with CRF and those undergoing HD therapy have higher rates of nail disorders when compared to a healthy population. Efficient HD does not improve nail changes.

Acral lentiginous melanoma: a clinicoprognostic study of 126 cases

BACKGROUND

Although the histopathological subtype of melanoma has not been clearly proven to carry independent prognostic significance, acral lentiginous melanoma (ALM) seems to confer a poorer prognosis mainly because disease is often more advanced at the time of diagnosis.

OBJECTIVES

To investigate the distinctive epidemiological and clinical characteristics of ALM, a peculiar histological entity, and to identify prognostic factors.

METHODS

We performed a register-based review of cases from a single large referral centre, the University Hospital Department of Dermatology, Lyons, France. We reviewed patient demographics, the initial presentation of the lesion, and clinical outcome. ALM-specific and disease-free survival were estimated using the KaplanMeier method and compared using the log-rank test. A Cox model was used to identify prognostic factors.

RESULTS

One hundred and twenty-six patients were identified as having histopathology-proven ALM in our melanoma patient register from 1996 to 2004. There were 46 (37%) subungual ALM and 80 (63%) ALM on soles, palms and nonvolar sites. The mean age at diagnosis was 63 years. There were 44 (35%) men and 82 (65%) women, sex ratio M/F 1 : 1.86. The mean Breslow thickness was 2.51 mm (range: in situ to 20 mm). There was no evidence of overexposure to ultraviolet radiation, nor was there found a predisposing genetic trait. Only 16 (13%) patients recalled a history of trauma. Thirty-four ALM (28%) were unpigmented. The median ALM-specific and disease-free survival were 13.5 and 10.1 years, respectively. The 5-year survival rate was 76%. Multivariate analysis identified tumour thickness, male gender and amelanosis as independent clinical prognostic factors for both ALM-specific and disease-free survival.

CONCLUSIONS

Our study provides specific information on the clinical characteristics and outcome of this uncommon histological subtype of melanoma. However, the pathogenesis remains unknown. Breslow thickness, male gender and amelanosis were significantly associated with a poorer prognosis.

Comparison of Clinical Features of HLA-Cw*0602-Positive and -Negative Psoriasis Patients in a Han Chinese Population

HLA-Cw6 is strongly associated with psoriasis and has been suggested to be the PSORS1 gene that confers susceptibility to early-onset psoriasis. In this study of the clinical features of HLA-Cw*0602-positive and -negative psoriasis patients in a Han Chinese population, we typed HLA-C in a cohort of 679 patients and compared the two groups. Cw*0602-positive patients (n=345) had an earlier disease onset (p < 1 x 10(-5)), more severe disease (p < 1 x 10(-3)), higher frequency of guttate psoriasis (p < 1 x 10(-9)), more affected legs and trunk (p < 1 x 10(-5)), higher incidence of Köbner's phenomenon (p=0.005) and of trauma history (p=0.009). Cw*0602-negative patients (n= 334) had more palmoplantar pustulosis (p=0.004), nail changes (p=0.001) and scalp involvement (p=0.007). However, there was no statistically significant difference between the two groups regarding age, gender, incidence of plaque psoriasis, erythrodermic, inverse, psoriatic arthritis, and the precipitation factors stress and infection. The study showed that Cw*0602-positive patients had some obvious clinical differences from Cw*0602-negative patients in a Han Chinese population, which provides evidence for an HLA-Cw*0602-associated phenotype in psoriasis.

The mucocutaneous manifestations associated with celiac disease in childhood and adolescence

This study was performed to detect the prevalence of mucocutaneous manifestations of celiac disease in childhood and adolescence and to investigate the relationship between these findings and duration of disease and a gluten-free diet. The study included 55 children and adolescents with a mean age of 10.0 +/- 4.61 years (2-19 years). Mucocutaneous manifestations were evaluated with respect to age, gender, duration of illness, and of gluten-free diet and compliance with this diet. Cutaneous, mucosal, nail, and hair findings were detected in 74.5%, 27.3%, 20.0%, and 7.3% of patients, respectively. The most prevalent dermatologic diagnosis was xerosis (69.1%). No significant relationship was detected between the cutaneous findings and the duration of illness (p > 0.05). However, the duration was longer in patients with mucosal findings compared to those without mucosal findings (p < 0.05). It was found that all patients without cutaneous findings were on a strict gluten-free diet (p < 0.05). Ours is one of the few studies describing skin findings in children with celiac disease. We believe that both pediatricians and dermatologists should be aware of the various mucocutaneous manifestations of celiac disease, because a careful skin, mucosa, nail, and hair examination may lead to a diagnosis of celiac disease, particularly in atypical presentations.

Onychomatricoma: benign sporadic nail lesion or much more?

Onychomatricomas (OM) are rare subungual tumors first described just over a decade ago. Surprisingly, these lesions still rarely are reported in the literature. This may be because of a lack of awareness, understanding, or interest in these perceivably benign lesions. In this review, we discuss the current literature and understanding of OM. We attempt to ascertain predilections and patterns in an attempt to establish a stronger appreciation of OM, and to encourage future reports. We emphasize the importance of reporting such lesions; with a larger literature base, prevalence, etiology, and pathogenesis can be better determined.

Hand dermatitis and nail disorders of the workplace

Dermatitis and nail bed disorders form a large percentage of occupational conditions that affect the hands. This article briefly discusses some of the more common causes and presentations of these conditions. Most of these of the conditions can occur in the workplace and outside of it, so a careful evaluation is necessary to determine the work relatedness of a given condition.

The nail under fungal siege in patients with type II diabetes mellitus

Few studies have examined the prevalence of onychomycosis among diabetic patients. Given the morbidity linked to onychomycosis, and the ever-growing size of the diabetic population, a better recognition of this nail infection is welcome. To revisit the relative prevalence of dermatophyte, yeast and non-dermatophytic mould onychomycoses in diabetic adults in a prospective study using combined histomycology and cultures. Toenail clippings were collected for 3 years in 190 type II diabetic patients (136 men and 54 women) and from an age- and gender-matched group of non-diabetic subjects. All sampled nails showed clinical alterations reminiscent of onychomycosis. Histomycology and cultures were performed on each sample to distinguish onychomycosis from non-infectious onychodystrophy. Compared to non-diabetic subjects with nail alterations, diabetics showed a higher proportion of onychomycosis relative to non-fungal onychodystrophy. Diabetic men suffered more frequently from onychomycosis and onychodystrophy than diabetic women. When considering the nature of the fungal pathogens, dermatophytes predominated largely over yeast and non-dermatophytic moulds, both in diabetic and non-diabetic patients. Diabetic patients, particularly men, are at increased risk of developing onychomycosis. The morbidity linked to this disorder, and its impact on the foot status in diabetic subjects merit to be better appreciated by clinicians.