Natural Treatment Options for Nail Disorders

The growing demand for natural treatments has raised concerns among clinicians due to limited scientific evidence supporting their use. This review article addresses the issue by assisting dermatologists and general practitioners in recommending natural treatments for the following common nail disorders: nail brittleness, onychomycosis, periungual verrucae, paronychia, chloronychia, nail psoriasis, nail lichen planus, onychocryptosis, onycholysis, and congenital malalignment of the great toenail. One limitation is the scarcity of existing reviews on natural treatment options for nail disorders in the literature. Through a comprehensive review of existing literature, this article consolidates the available evidence on natural treatment options for these conditions. Although some natural treatments for nail disorders are supported by scientific evidence, the indiscriminate use of such remedies may lead to severe poisoning and health problems. Given the widespread and increasing use of natural treatments, clinicians play a pivotal role in educating patients about evidence-based remedies and debunking misleading claims. By doing so, clinicians can enhance patient safety and improve treatment outcomes. It is essential for healthcare professionals to be well-informed and equipped with the knowledge to differentiate between effective natural treatments and unverified claims, ensuring that patients receive appropriate care.

Surgical interventions for ingrown toenail

BACKGROUND

Paronychia is a prevalent clinical disease affecting the soft tissue surrounding the nails. Most cases of toenail paronychia are commonly associated with ingrown toenails. While conservative treatment is effective for mild cases of ingrown toenails, surgical intervention becomes necessary for moderate to severe cases, particularly when granulomas form.

OBJECTIVE

To provide a systematic understanding of these classic and modified procedures for surgeons to select the appropriate surgical interventions for patients suffering from moderate to severe ingrown toenails and discuss this technology's advantages and limitations for dermatologic surgery.

METHODS

A literature search was performed using PubMed/MEDLINE and Google Scholar databases. Studies discussing surgical intervention for ingrown toenails were included. Moreover, the surgical steps were meticulously depicted by detailed schematic diagrams.

RESULTS

These surgical techniques can be divided into three categories: matrix resection, debulking of periungual soft tissues, and the rotational flap technique. Each approach possesses distinct advantages and limitations.

CONCLUSION

For moderate to severe cases, surgical interventions may exhibit superior outcomes, faster recovery times, and lower recurrence rates. The surgeon must possess a comprehensive understanding and proficient skillset in various surgical techniques for ingrown toenails.

Fingertip Infections

The fingertip is the interface between humans and the world, including the various thorns, dirty needles, and other hazards to be found there. It is unsurprising that this is the site where hand infections most frequently occur. Although commonly encountered by hand surgeons and other physicians, fingertip infections have several mimics, and diagnosis and management is not always straightforward. Early diagnosis and treatment are key to success. As with all infections, they are more common and are more aggressive in immunosuppressed patients. This article reviews fingertip anatomy, common and uncommon fingertip infections and their mimics, and recommendations for management.

Bacterial and viral infections of the nail unit: Tips for diagnosis and management

The nail unit is the most commonly affected area in hand infections, which can be primary infection or superinfection complicating other nail or skin disorders. Trauma, mechanical or chemical, is usually the trigger enabling infiltration of infectious organisms. Artificial nails and nail polish are also a possible cause of bacterial infection, harboring microorganisms. In severe acute bacterial infection, surgical intervention is often needed to prevent morbidity and disability. Abscess should always be drained, but viral infection such as herpetic whitlow, may mimic an abscess and, in contrast, requires non-operative treatment; to prevent sequelae. A more conservative approach is also generally advisable in less severe bacterial infection, other viral infections and in subacute or chronic nail infection. The present review deals with acute, subacute and chronic bacterial and viral infections of the nail unit, with a focus on diagnostic and treatment options. LEVEL OF EVIDENCE: III, systematic review of level III studies.

Acute Paronychia and Onychomadesis after a "Russian" Manicure: A New, Aggressive, and Destructive Form of Manicure for Dermatologists to Recognize

Introduction

Cuticle reduction and removal techniques are commonly performed by nail technicians for nail cosmesis. However, manipulation of the nail cuticle can lead to localized infection and nail dystrophy.

Case Presentation

In this case, a 20-year-old woman from the Philadelphia area in the USA presented with onychomadesis secondary to acute paronychia following a "Russian" manicure. In this technique, an electronic filer is used to completely remove the cuticle, leaving the proximal nail fold exposed and vulnerable.

Conclusion

As this style of manicure is being inaccurately publicized as safe, it is important that dermatologists are aware of this technique and educate our patients about its potential for harm.

Nail Loss in Mild to Moderate Pemphigus Vulgaris

Introduction

Symptoms of pemphigus vulgaris (PV) rarely include nail findings. When ungual involvement does occur, the most common manifestations are paronychia and onychomadesis. Onycholysis is very uncommon, and complete nail loss has not been reported in the literature. Ungual involvement is thought to be closely correlated with disease severity, with only severe PV cases demonstrating nail symptoms.

Case Presentation

We report a case of a 34-year-old female presenting with mild to moderate PV yet severe onycholysis of her first toe leading to secondary nail loss in conjunction with paronychia of her bilateral thumbs. Oral tofacitinib and rituximab infusions led to strikingly rapid improvement in her nail symptoms.

Discussion/Conclusion

This case illustrates the importance of a thorough history and physical exam, as a primary complaint of nail symptoms in these patients may lead to unrecognized PV by even the most skilled practitioners. Tofacitinib and rituximab in combination may rapidly improve nail involvement.

Association between dermatologic adverse events and quality of life in lung cancer patients treated with epidermal growth factor receptor-tyrosine kinase inhibitors

PURPOSE

Epidermal growth factor receptor-tyrosine kinase inhibitors (EGFR-TKIs) are frequently associated with dermatologic adverse events (dAEs), having great impacts on patients' health-related quality of life (HRQoL) and treatment adherence. We aimed to examine the association between various dAEs and HRQoL in patients treated with EGFR-TKI therapy.

METHODS

This was a cross-sectional study including 132 non-small-cell lung cancer (NSCLC) patients treated with gefitinib, erlotinib, afatinib, or osimertinib in Taiwan. The severity level of dAEs was graded by NCI-CTCAE v4.03 and PRO-CTCAE ITEMS v1.0. All participants answered the Functional Assessment of Cancer Therapy-Epidermal Growth Factor Receptor Inhibitors (FACT-EGFRI-18) HRQoL questionnaire.

RESULTS

The clinician-reported severity of pruritus, photosensitivity, alopecia, and Karnofsky performance status was associated with HRQoL (β =  - 6.773, p = 0.046; β =  - 5.250, p = 0.032; β =  - 8.121, p = 0.001; β = 0.327, p = 0.002; respectively). The clinician-reported severity of all dAEs except paronychia had negative correlations with HRQoL. The symptom gradings of CTCAE and PRO-CTCAE had positive correlation.

CONCLUSIONS

The severity of pruritus, photosensitivity, and alopecia was associated with HRQoL of patients receiving EGFR-TKI therapy. Using patient-reported outcome measurements helps clinicians to capture the actual impact of symptoms on physical, social-emotional, and functional well-being.

A multicenter study of skin toxicity management in patients with left-sided, RAS/BRAF wild-type metastatic colorectal cancer treated with first-line anti-EGFR-based doublet regimen: is there room for improvement?

BACKGROUND

Skin toxicity in patients affected by metastatic colorectal cancer (mCRC) treated with epidermal growth factor receptor (EGFR) inhibitors is well known. However, ad hoc ESMO guidelines have only recently been published.

AIM AND METHODS

To describe the management (pre-emptive or reactive) of anti-EGFR-related cutaneous adverse events (AEs), in a real-life clinical context, in a selected population of patients with left-sided, metastatic RAS/BRAF wild-type mCRC treated with doublet chemotherapy plus anti-EGFR monoclonal antibody (i.e., panitumumab or cetuximab) as first-line regimen at 22 Institutions. The measured clinical outcomes were treatment-related adverse events, objective response rate (ORR), progression-free survival (PFS), and overall survival (OS).

RESULTS

Of 515 patients included in the analysis, 173 (33.6%) received a pre-emptive and 342 (66.4%) a reactive treatment. The median follow-up period for the overall population was 30.0 months. A significantly lower incidence of any grade acneiform rash was found in the pre-emptive compared to the reactive cohort both in the overall population (78.6% vs 94.4%, p < 0.001) and in patients treated with panitumumab (76.1% vs 93.7%, p < 0.001) or cetuximab (83.3% vs 95.4%, p = 0.004), respectively. A lower incidence of any grade (41.6% vs 50.9%, p = 0.047) but a higher incidence of G3-G4 (9.2% vs 4.7%, p = 0.042) paronychia/nail disorders were found in the pre-emptive compared to the reactive cohort. Nevertheless, a lower rate of patients within the reactive compared to the pre-emptive cohort was referred to dermatological counseling (21.4% vs 15.3%, respectively, p = 0.001). A higher rate of anti-EGFR therapy modification was needed in the pre-emptive compared to the reactive cohort (35.9% vs 41.6%, respectively, p < 0.001). The pre-emptive approach did not reduce the efficacy of antineoplastic therapy compared to the reactive in terms of ORR (69.2% vs 72.8%), median PFS (12.3 vs 13.0 months), and median OS (28.8 vs 33.5 months).

CONCLUSION

Although recommended by international guidelines, the pre-emptive approach of anti-EGFR-related skin toxicity in mCRC patients still appears less adopted in daily clinical practice, compared to the reactive one. A wider reception and application of this indication is desirable to improve patients' quality of life without compromising the continuity and efficacy of antineoplastic therapy.

Panitumumab-Induced Paronychia: A Case Report and a Brief Review of the Literature

Panitumumab is a recombinant, fully humanized IgG2 monoclonal antibody targeting the epidermal growth factor receptor (EGFR). Panitumumab is indicated for patients with metastatic colorectal cancer with progressive refractory disease. Targeted therapies are well known to be well tolerated; however, they may induce toxicities that are distinct from those of classical chemotherapeutic agents. For instance, EGFR inhibitors (EGFRIs) are associated with some specific dermatological adverse effects, one of which is nail toxicity. Since panitumumab is fully humanized, unlike most of the other EGFRIs, it has been reported to have reduced incidence of adverse reactions. Nail-related adverse effects are frequently observed with EGFRIs. A literature search has yielded a list of reviews describing panitumumab-induced nail toxicity. However, as far as we know, there is no case report detailing this adverse effect of panitumumab. Here, we present a case of panitumumab-induced paronychia in a 60-year-old woman with metastatic colon cancer. With this case report, we would like to review the literature and discuss the possible underlying mechanisms of this condition.

Is lymphangitic streaking associated with different pathogens?

OBJECTIVES

Little is known regarding the differences in microbiology associated with cellulitis or abscess with or without lymphangitic streaking. The objective of our study is to assess whether there are differences in the pathogens identified from wound cultures of patients with paronychia with and without associated lymphangitis.

METHODS

Retrospective cross-sectional study at a tertiary pediatric emergency department over 25 years. We opted to assess patients with paronychia of the finger, assuming that these cases will have a greater variety of causative pathogens compared to other cases of cellulitis and soft tissue abscess that are associated with nail biting. Case identification was conducted using a computerized text-screening search that was refined by manual chart review. We included patients from 1 month to 20 years of age who underwent an incision and drainage (I&D) of a paronychia and had a culture obtained. The presence or absence of lymphangitis was determined from the clinical narrative in the medical record. We excluded patients treated with antibiotics prior to I&D as well as immune-compromised patients. We used descriptive statistics for prevalence and χ2 tests for categorical variables.

RESULTS

Two hundred sixty-six patients met inclusion criteria. The median age was 9.7 years [IQR 4.7, 15.4] and 45.1% were female. Twenty-two patients (8.3%) had lymphangitic streaking associated with their paronychia. Patients with lymphangitis streaking were similar to those without lymphangitis in terms of age and sex (p = 0.52 and p = 0.82, respectively). Overall, the predominant bacteria was MSSA (40%) followed by MRSA (26%). No significant differences were found between the pathogens in the 22 patients with associated lymphangitis compared to the 244 patients without.

CONCLUSION

Staphylococcus aureus represent the majority of pathogens in paronychia, although streptococcal species and gram-negative bacteria were also common. Among patients with paronychia of the finger, there seems to be no association between pathogen type and presence of lymphangitic streaking.

[Successful treatment with silver nitrate chemical cauterization for paronychia and granulation in a patient with chronic lymphocytic leukemia undergoing ibrutinib therapy]

A 72-year-old man with leukocytosis, anemia, and lymphadenopathy was diagnosed with chronic lymphocytic leukemia (CLL) in August 2017 and was carefully monitored in a "watch-and-wait" manner until it became an "active disease." Ibrutinib (IBR) was initiated orally in July 2018 at a dose of 420 mg/day after disease progression due to chromosome 17p deletion (del 17p). The patient showed partial response after transient lymphocytosis while on IBR treatment. IBR induces paronychia and skin disorder due to the disruption of disulfide bonds between cysteine and inhibition of epidermal growth factor receptor due to the off-target effect. This results in reduced quality of life. In February 2019, paronychia (grade 1) developed in the patient's right foot's first toe; hence, topical gentamicin and taping therapy were performed. However, the symptoms persisted without any improvements. In July 2019, paronychia/granulation (grade 2) was aggravated and successfully treated with silver nitrate chemical cauterization and taping therapy. The patient was continuously treated with 420 mg/day IBR without dose reduction or discontinuation, resulting in successful disease control of CLL with del 17p.

Bacterial and Viral Infections of the Nail Unit

Bacterial and viral infections of the nail unit are very common as primary infections, especially bacterial paronychia and warts, but they can also be superinfections complicating other nail disorders. In many nail unit infections, the clinical presentation is nonspecific: in these cases, diagnostic tests are mandatory before treatment, to avoid spread of the infection and drug resistance. The most common forms of bacterial and viral infections that may affect the nail unit are herein described in detail, with diagnostic and treatment options provided.

Retronychia-an uncommon cause of chronic proximal nail fold inflammation

Retronychia is defined as nail plate ingrowth into the proximal nail fold causing pain and perionyxis. We report on a case series of seven patients seen from 2001 to 2020 (mean age 20 years). Xanthonychia was observed in all nails. Total nail avulsion was performed in eight nails. Complete remission was obtained in 100%. During follow-up for up to 24 months, no relapse occurred.

Pediatric Hand Infections

Infections are an important source of morbidity in pediatric hands that come from frequent exposure to mouths and other dangers while exploring the world. Although Staphylococcus aureus is still the most common organism in pediatric hand infections, it is less common than in adults because pediatric patients are more likely to develop mixed aerobic/anaerobic infections or group A Streptococcus pyogenes infection. Pediatric patients with open physes potentially may sustain Seymour fractures of the distal phalanges that may become infected and sources for osteomyelitis if not recognized early.

Fingertip Infections

The fingertip is the most common site of infections in the hand, which frequently are encountered by surgeons, dermatologists, and emergency and primary providers. Their mismanagement may have serious consequences. This review discusses the unique anatomy of the volar fingertip pulp and perionychium and reviews pathophysiology and treatment of acute and chronic paronychia, including the decision for surgical versus medical management, choice of antibiotics, incisional techniques, and postincisional care. Felons and the evidence regarding their management are reviewed. Several infectious, rheumatologic, and oncologic conditions that may mimic common fingertip infections and about which the managing provider must be aware are presented.

Fungal Infections of the Hand

Clinically significant fungal infections of the upper extremity are uncommon but increasing They are classified based on anatomic location and epidemiology. The anatomic categories that affect the hand include cutaneous, subcutaneous, and deep. Cutaneous infections are caused by organisms that metabolize keratin and can cause serious morbidity but are rarely fatal. Subcutaneous infections are similar to the cutaneous infections and are produced by low virulence organisms. Cutaneous and subcutaneous infections are most common and can be treated by primary care physicians and dermatologists. Deep infections are less common but can be fatal. Epidemiologic classifications include endemic and opportunistic infections.

Ungual Tuberculosis: A Unique Clinical Case

Cutaneous manifestations of tuberculosis (TB) are rare, particularly from an exogenous source. Involvement of the nail apparatus is extremely rare and has only previously been reported as a secondary involvement. We report the case of a 76-year-old female patient referred to our department with onychodystrophy with purulent drainage of the first left finger, which had developed during the preceding year. She had no previous traumatic history and had received treatment with multiple cycles of oral antibiotics and antimycotics, with no clinical improvement. Physical examination showed paronychia and onychodystrophy of the entire nail plate. Biopsy evaluation revealed epithelioid granulomas with central foci of necrosis, and laboratory cultures were positive for Mycobacterium tuberculosiscomplex. Chest computed tomography excluded primary pulmonary TB. X-ray of the left hand revealed the presence of dactylitis on the distal phalanx. Based on these findings, the patient was treated with rifampicin, isoniazid, pyrazinamide, and ethambutol for 2 months and with rifampicin and isoniazid for 7 months, resulting in complete resolution of the lesions. Cutaneous TB is a diagnostic challenge, particularly in rare cases such as involvement of the nail apparatus. It should be considered as a diagnostic hypothesis in cases of painless paronychia with refractory purulent drainage and associated onychodystrophy.

Nail Involvement during Pemphigus

BACKGROUND

Pemphigus is an autoimmune bullous disease affecting the skin and mucous membranes. Associated nail involvement is underestimated and is characterized by a variety of clinical manifestations. Our aim was to describe the clinical aspects of nail involvement during pemphigus.

PATIENTS AND METHODS

A retrospective study was conducted of patients with pemphigus over a period of 12 years. The diagnosis of pemphigus was based on clinical and immunopathological data. Clinical data were collected from patient records prior to initiation of treatment.

RESULTS

Overall,141 cases of pemphigus were collected. Of these, 60 patients had nail involvement. After eliminating fungal origin, we selected 37 patients in our study. The main clinical forms were paronychia and dystrophy. Two cases of destruction of the nail apparatus were found in patients with pemphigus vegetans. The disease was bilateral in 11 cases (29.7%). The presence of ungual involvement was correlated with severity of pemphigus, particularly severe oral disease (p = 0.002).

CONCLUSION

Nail lesions were polymorphic in our patients. These signs show accumulated inflammation of the nail after a long evolution of the disease. Nail involvement may precede, be concomitant, or follow the mucocutaneous lesions of pemphigus and be a sign of severity or relapse of the disease.

Paronychia and Periungual Granulation as a Novel Side Effect of Ibrutinib: A Case Report

Ibrutinib is an oral covalent inhibitor of the Bruton's tyrosine kinase pathway and is approved for the treatment of B-cell malignancies including chronic lymphocytic leukaemia, mantle cell lymphoma, and Waldenström's macroglobulinaemia. It is generally a drug of choice for high-risk patients with indolent lymphomas. The safety profile of ibrutinib appears to be tolerable, with well-known side effects such as infections and haematologic complications. Additionally, dermatological adverse reactions with ibrutinib therapy have been reported to encompass maculopapular rash and hair/nail abnormalities. Here, we present a case of ibrutinib-induced paronychia and periungual granulation in a 40-year-old woman. To the best of our knowledge, this is the third description of ibrutinib-induced paronychia and periungual granulation.

Current development in integrative therapy of traditional Chinese medicine for cancer treatment: A mini-review

Cancer is a major public health problem worldwide, and there has been a sustained rise in its incidence in both developing and developed countries. Although there are currently numerous effective therapeutic options for cancer, they sometimes exhibit resistance and obvious side effects. Traditional Chinese medicine (TCM) currently plays a major role in cancer therapy by downregulating the growth of cancer cells through various pathways and by relieving side effects. Studies in cultured human malignant cell lines have demonstrated that Solanum nigrum can control cancer cell proliferation and cancer progression by inducing autophagic and apoptotic cell death. Case–control studies have indicated that TCM can relieve the side effects of cancer therapy. This review provides brief insights into the anticancer effects of TCM, the side effects relieved by TCM, and the role of TCM doctors in cancer treatment.

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Aqueous extracts of Solanum nigrum can control cancer cell proliferation and cancer progression by inducing autophagic and apoptotic cell death.

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TCM can relieve side effects such as hematotoxicity, hepatotoxicity, and paronychia caused by conventional anticancer treatments.

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A TCM doctor consulting and referral system for patients with cancer should be established.

A randomized phase 2 trial of the efficacy and safety of a novel topical povidone-iodine formulation for Cancer therapy-associated Paronychia

Purpose Cancer therapy-associated paronychia (CAP) is a frequent adverse event associated with cytotoxic and targeted therapies that may impact dosing of anticancer therapies and patient quality of life (QoL). There are currently no evidence-based management strategies or approved treatments for CAP. Materials and Methods This was a prospective, multicenter, randomized, double-blind, vehicle-controlled phase 2 study that evaluated the efficacy and safety of 6 to 8 weeks of 1% or 2% povidone-iodine (PVP-I) topical solution versus vehicle-control in adult patients with CAP. Patients were randomized to one of three treatment arms administered twice daily: 1% PVP-I (Cohort A), 2% PVP-I (Cohort B), or vehicle-control (Cohort C). The primary endpoint was a two-grade reduction (or reduction to grade 0 if involved nails were grade 1) on the six-point Paronychia Severity Grading (PSG) scale. Secondary endpoints included safety and the effect on QoL and microbiota. Results A total of 102 patients with cancer were randomized to the study. In Cohort A, 83 of 205 (40.5%, P = 0.6059) affected nails met the primary endpoint versus Cohort C. In Cohort B, 88 of 167 (52.7%, P = 0.0063) affected nails met the primary endpoint versus 64 of 169 (37.9%) in Cohort C. Nineteen of 29 patients (65.5%) in Cohort B reported moderately or very painful nails at baseline that decreased to 15 patients (51.7%) at visit 2 and five patients (17.2%) at visit 3. Conclusions Treatment with twice-daily topical 2% PVP-I was safe and resulted in improvement in CAP compared with control. Clinicaltrials.gov identifier: NCT03207906. https://clinicaltrials.gov/ct2/show/NCT03207906.

Are topical beta-blockers really effective "in real life" for targeted therapy-induced paronychia

Paronychia and periungual pyogenic granuloma represent one of the most common and bothersome dermatologic toxicities observed with ErbB inhibitors. There is no standardized treatment, and management remains challenging. Moreover, conservative management with noninvasive treatment should be promoted for fragile patients in a metastatic setting. Over the last few years, the efficacy of topical blocking agents has been considered for managing cutaneous or mucosal pyogenic granulomas. Very recently, the use of topical propranolol or of timolol has been reported in several patients undergoing treatment with EGFR inhibitors and developing pyogenic granulomas of the nail. We performed a retrospective single-center review of patients with targeted therapy-related paronychia/periungual pyogenic granulomas who had been treated with topical timolol, either alone or in combination with other topical treatments. Nearly two thirds of patients showed at least a partial response after 1 month of therapy, and the use of a topical beta-blocker in our population was associated with a favorable safety profile. Finally, topical timolol may represent a promising treatment option for the management of cancer patients suffering from painful periungual lesions. Comparative clinical trials, however, are still needed.

A Proposal for a New Severity Index for the Evaluation of Chronic Paronychia

Introduction

Chronic paronychia (CP) is an inflammatory disease of the nail folds. Staging of CP is important for clinicians. We developed an objective scale that evaluates each finding of CP separately in addition to evaluating the treatment process and follow-up.

Methods

A new "chronic paronychia severity index scale" was developed to enable dermatologists to examine all features of CP. A previous categorical severity scale and this new scale were used for the evaluation of CP by 6 different dermatologists. The dermatologists evaluated the nails with both scales again 20 days later using randomly ordered photographs.

Results

Using the previous scale, the intra-observer intraclass correlation coefficient (ICC) values between the first and second evaluations were 0.767, 0.860, 0.734, 0.609, 0.900, and 0.840 for the 6 dermatologists. Using the new proposed scale, the intra-observer ICC values between the first and second evaluations were 0.930, 0.931, 0.942, 0.934, 0.938, and 0.920 for the 6 dermatologists. All intra-observer ICC values were higher for the results of the proposed scale than for those of the previous scale. The inter-observer ICC values were also higher for the proposed scale than for the previous scale for the 6 dermatologists.

Conclusion

The new scale is a standardized, more suitable, objective, and valuable method to use in clinical practice and studies on CP.

An Atypical Presentation of Raynaud's Disease

OBJECTIVE

A 57-year-old female with a 33-year history of constant hand discoloration and paronychia had undergone multiple evaluations with a failure to find a diagnosis. She continues to undergo an evolving treatment regimen and diagnostic workup in an effort to find a long-eluded diagnosis.

CLINICAL PRESENTATION

She began to develop superficial ulcerations over the proximal phalanx of her fingers, often pruritic and erythematous, with pain and edema.

INTERVENTION

She has since been managed with nifedipine and sildenafil and intermittent stellate ganglion blocks.

CONCLUSION

Despite still lacking a formal diagnosis, her constellation of symptoms is most likely the result of an atypical presentation of Raynaud's disease.

Paronychia Associated with Ledipasvir/Sofosbuvir for Hepatitis C Treatment

We present a case of medication-associated paronychia involving multiple toenails in a patient undergoing hepatitis C (HCV) therapy with ledipasvir/sofosbuvir. The patient was treated conservatively with topical mupirocin, clobetasol ointment, and acetic acid soaks, resulting in symptom improvement and control. This topical regimen was maintainined throughout the remaining weeks of the patient's antiviral course, with complete symptom resolution occurring only after completion of his ledipasvir/sofosbuvir treatment.

Staphylococcus lugdunensis Infections of the Skin and Soft Tissue: A Case Series and Review

Introduction

Staphylococcus lugdunensis (S. lugdunensis) is a coagulase-negative, Gram-positive bacterium that can be isolated as a component of normal skin flora in humans. However, more recently, it has also been documented as a culprit in skin and soft tissue infections. We describe the clinical features of five individuals with S. lugdunensis-associated skin infections. We review the characteristics of other patients that were previously described with this organism as the causative agent of skin infection.

Methods

Staphylococcus lugdunensis was correlated with the development of significant skin and soft tissue infections in five patients. The Pubmed database was used to search for the following terms: “abscess,” “cellulitis,” “cutaneous,” “lugdunensis,” “paronychia,” “skin,” “soft,” “staphylococcus,” and “tissue.” The relevant and reference papers generated by the search were reviewed.

Results

One woman and four men developed S. lugdunensis-related skin infections from February 19, 2015 to May 30, 2017. The patients’ ages at the onset of the infection ranged from 30 to 82 years; the median age was 70 years. Four patients were older than 65 years. The back was the most common location for the infection, followed by digits. The infection presented as cystic lesions with cellulitis or periungual abscesses. The lesions were incised or spontaneously ruptured. Patients were empirically treated with oral antibiotics; if necessary, the management was adjusted based on the culture-derived sensitivities of the organisms. The infections resolved within 10–30 days after commencing treatment.

Conclusion

Staphylococcus lugdunensis has previously been considered as a nonpathogenic organism and to be a component of normal skin flora. However, S. lugdunensis can result in significant skin and soft tissue infections, perhaps more frequently in older individuals. Its antibiotic sensitivities appear to be similar to those of methicillin-susceptible Staphylococcus aureus.

Acute finger-tip infection: Management and treatment. A 103-case series

INTRODUCTION

Acute fingertip infections (AFTI) are common. Surgical treatment is the norm in case of effusion. There is, however, no consensus on treatment modalities, or on adjuvant antibiotic therapy (AT). We present the results of a consecutive cohort of 103 AFTIs treated in emergency consultation.

MATERIALS AND METHOD

One hundred and one patients were treated by excision and extensive lavage under digital anesthesia, with systematic bacteriological sampling. Patient history, treatment history, location, type of bacteria, complications or recurrences and AT prescription were recorded and analyzed. All patients were reviewed at first dressing (5-7 days) and recontacted at 1 month, to record any pain, stiffness or recurrence. Three groups were distinguished: A: without preoperative AT (n=71); B: under AT before surgery (n=14); C: with postoperative AT (for severe comorbidity) (n=16).

RESULTS

Mean age was 39.7 years (range: 14-84 years). The three main types of bacteria were: Staphylococcus aureus (58.3%), polymicrobial flora (16.5%), and Streptococcus (12.6%). Mean time to first dressing was 5.7 days. There were no recurrences, whatever the bacterial type or patient group. In 5 patients in group A (8.2%), AT was later prescribed at day 5 (3 for hypercicatrization and 2 for maceration). In groups B and C, progression was unproblematic. At 1 month, all patients considered themselves cured; finger-tip sensitivity was conserved in 10, and 16 were awaiting complete nail regrowth.

DISCUSSION

Hospital admission, operative treatment under general anesthesia, and AT are factors exacerbating cost and increase the management burden of AFTI. Treatment in emergency consultation seems perfectly feasible. AT does not seem useful in the absence of severe comorbidities if resection is complete. Analysis of bacterial susceptibility and renewal of the initial dressing at 1 week enable progression to be monitored and treatment changed as necessary.

Recurrent Paronychia as a Presenting Manifestation of Pemphigus Vulgaris: A Case Report

Nail involvement in pemphigus vulgaris (PV) is an unusual clinical finding. The most common clinical manifestations include chronic paronychia and onychomadesis. We report an adult female patient with PV who initially presented with chronic paronychia of multiple fingernails and toenails before the onset of vesiculobullous eruptions. Later on, after complete resolution, there was recurrence of pemphigus presenting as hemorrhagic paronychia of the left index finger. Systemic treatment with corticosteroids and azathioprine led to complete resolution of mucocutaneous lesions as well as nail manifestations. Thus, chronic treatment-resistant paronychia may be an early and important sign of generalized pemphigus in certain patients.

Toenail paronychia

Paronychia is an inflammation of the tissues alongside the nail. It may be acute or chronic and can be seen in isolation or in association with an ingrowing toenail. Acute paronychial infections develop when a disruption occurs between the seal of the nail fold and the nail plate, providing a portal of entry for invading organisms. The treatment of paronychia associated with an ingrowing toenail is aimed at treating the causal toenail. In paronychia not associated with an ingrowing toenail, antibiotics may cure an early infection but surgical drainage of an abscess is often required. In this case, an intra-sulcal approach is preferable to a nail fold incision. Chronic paronychia is less common in the feet than in the hands. It is a form of contact dermatitis and is frequently non-infective, however the chronically irritated tissue may become secondarily colonised by fungi. A dermatology consultation should be obtained for suspected chronic paronychia. Patients with chronic paronychia that is unresponsive to standard treatment should be investigated for unusual causes, such as malignancy. An algorithm for the treatment of paronychia is presented in this review.

Adverse Drug Reactions of the Lower Extremities

Adverse drug reactions (ADRs) are a common cause of dermatologic consultation, involving 2 to 3 per 100 medical inpatients in the United States. Female patients are 1.3 to 1.5 times more likely to develop ADRs, except in children less than 3 years of age, among whom boys are more often affected. Certain drugs are more frequent causes, including aminopenicillins, trimethoprim-sulfamethoxazole, and nonsteroidal antiinflammatory drugs. Chemotherapeutic agents commonly cause adverse reactions to the skin and nails, with certain agents causing particular patterns of reactions. ADRs can involve any area of the skin; the appendages, including hair and nails; as well as mucosa.

Nail Disease for the Primary Care Provider

Nail disorders are a common presenting complaint for both the primary care physician and the dermatologist. Nail diagnoses are broad in scope and include infectious, inflammatory, and neoplastic conditions. Onychomycosis is an especially common nail condition, and treatment should always be preceded by appropriate fungal studies for confirmation of diagnosis. Inflammatory conditions of the nail unit can mimic onychomycosis, and a dermatologist can assist with diagnosis and treatment recommendations. Likewise, subungual tumors often require biopsy, and should be evaluated by a dermatologist who is experienced in nail evaluation and treatment.

Hand infections

Many acute hand and upper extremity infections should be treated as surgical emergencies to avoid stiffness, contracture, pain, and amputation. Proper treatment requires understanding of anatomy and how this influences the behavior of certain infections, common offending organisms, antibiotic treatment, management of host factors, and surgical intervention. This article reviews the microbiology, antibiotic coverage, and surgical treatment of the most common infections in the hand: paronychia, felon, herpetic whitlow, flexor tenosynovitis, deep space infections, septic arthritis, bites from humans and animals, necrotizing fasciitis, mycobacterium infections, and fungal infections. Recommendations are based on the most recent available evidence.