Isolated nail lichen planus: An expert consensus on treatment of the classical form

Lichen planus is a benign inflammatory disorder of unknown etiology that may affect the skin, mucosae, scalp, and nails. When the nails are affected, it may lead to permanent destruction with severe functional and psychosocial consequences. Therefore, prompt diagnosis and early treatment are essential, even in mild cases. There are currently no guidelines for the management of nail lichen planus and the published literature on treatment is limited. The aim of this review is to provide practical management recommendations for the classical form of nail lichen planus, especially when restricted to the nails. Topical treatment has poor short-term efficacy and may cause long-term side effects. Instead, intralesional and intramuscular triamcinolone acetonide should be considered first-line therapies. Oral retinoids are second-line choices, and immunosuppressive agents may also be considered.

Expanding the Nude SCID/CID Phenotype Associated with FOXN1 Homozygous, Compound Heterozygous, or Heterozygous Mutations

Human nude SCID is a rare autosomal recessive inborn error of immunity (IEI) characterized by congenital athymia, alopecia, and nail dystrophy. Few cases have been reported to date. However, the recent introduction of newborn screening for IEIs and high-throughput sequencing has led to the identification of novel and atypical cases. Moreover, immunological alterations have been recently described in patients carrying heterozygous mutations. The aim of this paper is to describe the extended phenotype associated with FOXN1 homozygous, compound heterozygous, or heterozygous mutations. We collected clinical and laboratory information of a cohort of 11 homozygous, 2 compound heterozygous, and 5 heterozygous patients with recurrent severe infections. All, except one heterozygous patient, had signs of CID or SCID. Nail dystrophy and alopecia, that represent the hallmarks of the syndrome, were not always present, while almost 50% of the patients developed Omenn syndrome. One patient with hypomorphic compound heterozygous mutations had a late-onset atypical phenotype. A SCID-like phenotype was observed in 4 heterozygous patients coming from the same family. A spectrum of clinical manifestations may be associated with different mutations. The severity of the clinical phenotype likely depends on the amount of residual activity of the gene product, as previously observed for other SCID-related genes. The severity of the manifestations in this heterozygous family may suggest a mechanism of negative dominance of the specific mutation or the presence of additional mutations in noncoding regions.

Nail abnormalities identified in an ageing study of 30 inbred mouse strains

In a large-scale ageing study, 30 inbred mouse strains were systematically screened for histologic evidence of lesions in all organ systems. Ten strains were diagnosed with similar nail abnormalities. The highest frequency was noted in NON/ShiLtJ mice. Lesions identified fell into two main categories: acute to chronic penetration of the third phalangeal bone through the hyponychium with associated inflammation and bone remodelling or metaplasia of the nail matrix and nail bed associated with severe orthokeratotic hyperkeratosis replacing the nail plate. Penetration of the distal phalanx through the hyponychium appeared to be the initiating feature resulting in nail abnormalities. The accompanying acute to subacute inflammatory response was associated with osteolysis of the distal phalanx. Evaluation of young NON/ShiLtJ mice revealed that these lesions were not often found, or affected only one digit. The only other nail unit abnormality identified was sporadic subungual epidermoid inclusion cysts which closely resembled similar lesions in human patients. These abnormalities, being age-related developments, may have contributed to weight loss due to impacts upon feeding and should be a consideration for future research due to the potential to interact with other experimental factors in ageing studies using the affected strains of mice.

Nicolau Syndrome following Intramatricial Triamcinolone Injection for Nail Lichen Planus

Nicolau syndrome (Embolia cutis medicamentosa) is a rare complication following parenteral administration of a drug. It has been reported in association with intramuscular, subcutaneous, intravenous and intra-articular injections. However, Nicolau syndrome following intramatricial injection has not been described to the best of our knowledge. We report the case of an 18-year-old male who developed this complication following 7^th session of intramatricial injection. The patient was started on broad spectrum antibiotic coverage, vasodilator therapy, analgesics, and daily dressing. On day 21, the symptoms completely resolved with return of normal color of the digit. The case is being reported to make dermatologists aware of the possibility of Nicolau syndrome following intramatricial injection of triamcinolone acetonide.

Carpal tunnel syndrome and associated nail changes: Review and examples from the author's practice

Carpal tunnel syndrome (CTS) is commonly seen by general practitioners and often presents with neurologic symptoms of nocturnal pain and paresthesia along the median nerve distribution. Approximately 20% of patients also present with cutaneous findings (ulcerations, blistering, sclerodactyly, nail dystrophy) characterizing a severe form called necrotic CTS. Necrotic CTS can also be associated with bone changes (acro-osteolysis). In the author's practice, combined nail and skin findings are not an uncommon presentation of CTS, although this form remains overlooked and underreported in the dermatological textbooks and studies. This manuscript aims to review the literature on CTS cases, with a specific focus on using associated nail findings as diagnostic clues. The literature review along with a few additional recent cases from the author's practice demonstrate that CTS is frequently accompanied by a variety of nail changes including koilonychia, longitudinal fissuring, Beau's lines, onychomadesis, melanonychia, nail thickening, hyperkeratosis, and ischemic ulcerations with paronychia. Furthermore, when these changes are limited to the second and third fingernails, they should prompt the diagnosis of CTS. Once suspected, diagnostic evaluation is not difficult and surgical management can resolve cutaneous findings and prevent irreversible changes such as acro-osteolysis.

Dyskeratosis congenita presenting with dysphagia

Dyskeratosiscongenita (DKC) is a genetically heterogeneous disease of defective telomere maintenance that may demonstrate different patterns of inheritance. It is characterized by thetriad of dystrophy of the nails, leukokeratosis of the oral mucosa, and extensive net-like pigmentation of the skin. We report a case ofDKC who presented with a chief complaint of dysphagia.

The change of causative pathogens in toenail onychomycosis

BACKGROUND

Toenail dystrophies are among the most common diseases in adulthood. Onychomycosis is one of the most frequently observed infectious diseases of the nail.

AIM

The aim of this study was to determine the prevalence of fungal agents in the etiology of nail dystrophies such as discoloration, thickening, subungual hyperkeratosis, and onycholysis in toenails and to emphasize the importance of diagnosis by other laboratory confirmation tests since various nail diseases may mimic onychomycosis.

SUBJECTS AND METHODS

Nail samples taken from 53 patients who were admitted to the dermatology clinic with the complaint of toenail disorders were examined by using potassium hydroxide mount, fungal culture, and matrix-assisted laser desorption/ionization time-of-flight mass spectrometry methods. Each nail was photographed, and descriptive analysis of the data was performed.

RESULTS

Of 53 patients included in the study, 39 were female (73.6%) and 14 were male (26.4%). The ages of the patients ranged from 14 to 70 years, and the mean age was 37.8 years. No fungi could be isolated in 17 (32%) patients with nail dystrophy, while fungal pathogens were observed in 36 (68%) patients on potassium hydroxide mount, culture, and matrix-assisted laser desorption/ionization time-of-flight mass spectrometry examinations. Among nondermatophyte molds, Aspergillus species (52.7%) were identified as the most common fungal pathogen causing onychomycosis.

CONCLUSION

Although fungal pathogenic agents are mostly detected among the diseases causing color changes and deformities in the nails, it should be kept in mind that nail findings of systemic or other skin diseases may mimic onychomycosis and the diagnosis should be confirmed by laboratory tests in addition to clinical manifestations for accurate treatment.

STUDY LIMITATIONS

Other systemic diseases causing nail dystrophy were not questioned in the study.

Pachyonychia Congenita Type 1: Case Report and Review of the Literature

The case of an 8-year-old boy is hereby reported, who presented with nail dystrophy, subungual hyperkeratosis, oral leukokeratosis, and numerous follicular papules all over the body. The features were consistent with a diagnosis of pachyonychia congenita type 1. The case is being reported for its rarity. We also discuss in a nutshell, the literature till date.

Keratin 17 Mutations in Four Families from India with Pachyonychia Congenita

Pachyonychia congenita (PC) is a rare autosomal dominant genetic skin disorder due to a mutation in any one of the five keratin genes, KRT6A, KRT6B, KRT6C, KRT16, or KRT17. The main features are palmoplantar keratoderma, plantar pain, and nail dystrophy. Cysts of various types, follicular hyperkeratosis, oral leukokeratosis, hyperhidrosis, and natal teeth may also be present. Four unrelated Indian families presented with a clinical diagnosis of PC. This was confirmed by genetic testing; mutations in KRT17 were identified in all affected individuals.

Diverse Pathological Findings of Interstitial Lung Disease in a Patient with Dyskeratosis Congenita

A 42-year-old man with a history of surgery for tongue cancer was referred to our hospital due to an abnormal chest shadow. High-resolution computed tomography showed lower lobe reticulation. A physical examination revealed nail dystrophy, oral leukoplakia, and reticulated hypopigmentation. Lung biopsy revealed subpleural and perilobular fibrosis, suggestive of usual interstitial pneumonia. However, multiple pathological findings, including homogenous fibrosis and cell infiltration in the centrilobular region, which were compatible with nonspecific interstitial pneumonia, and bronchiolitis were also seen. Genetic testing showed a hemizygous missense mutation in the DKC1 gene, and the patient was diagnosed with dyskeratosis congenita. Although anti-fibrotic therapy was initiated, the patient's respiratory function has continued to decrease.

First case of pachyonychia congenita in the Czech Republic

Pachyonychia congenita (PC) is a rare autosomal dominant skin disorder characterized predominantly by hypertrophic nail dystrophy, oral leukokeratosis, and painful palmoplantar keratoderma. It is associated with a mutation in one of five keratin genes, KRT6A, KRT6B, KRT6C, KRT16, or KRT17. The International PC Research Registry (IPCRR) confirms that as of January 2014 there have been 547 cases of PC genetically confirmed. It is estimated that there are between 2000 and 10,000 cases of PC in the world. However, the exact prevalence of PC is not yet established. We report a case of PC-K6a, p.Arg164Pro, in a 40-year-old man. Initially he was diagnosed with onychomycosis and was treated with systemic antifungals. This is the first genetically confirmed case of PC in the Czech Republic.

What do we learn from dystrophic epidermolysis bullosa, nails only? Idiopathic nail dystrophy may harbor a COL7A1 mutation as the underlying cause

Dystrophic epidermolysis bullosa (DEB) is a genodermatosis caused by mutations in the COL7A1 gene. DEB, nails only (DEB-na), is a rare type of DEB. Patients with DEB-na can be overlooked, and genetic testing is helpful to determine the correct diagnosis. We collected two families with DEB-na. Clinical information was analyzed. Ultrastructural analysis of the skin tissue was performed. Blood samples were obtained. Next-generation sequencing was performed and the results were confirmed by Sanger sequencing. A genetic study revealed two novel heterozygous mutations: COL7A1:c.6742G>A (p.G2248R) in patient 1 and c.7181C>G (p.P2394R) in patient 2. Precise diagnosis was made for every patient based on clinical findings and genetic studies. We summarized the phenotype and COL7A1 mutations related to DEB-na. We report a new phenotype of DEB-na and two novel mutations in COL7A1. In addition, we emphasize the importance of careful clinical examination and genetic testing in the diagnosis of DEB-na.

Onychodystrophy as the only sign of congenital candidiasis

Congenital candidiasis infection often presents as a skin rash with variable involvement of nails and mucous membranes. Isolated nail involvement is rare, may present late, and can often be managed with topical antifungal medication. We report a case of congenital candidiasis limited to the fingernails that resolved completely within 3 months with topical treatment.

Dyskeratosis congenita in a Nigerian boy

Dyskeratosis congenita is a rare hereditary disease. It mainly affects males and manifest between 5 years and 12 years. Its classic manifestation consists of skin pigmentary changes, nail dystrophy, oral leukoplakia, bone marrow failure and predisposition to malignany. We report the case of a 9-year-old boy who presented with hyperpigmentation of the skin, palms and soles, leukoplakia of the tongue, dystrophy of the nails, epiphoria and recurrent epistaxis with gum bleeding. Full blood count showed pancytopenia and bone marrow biopsy showed hypocellular marrow with no abnormal cells. He was transfused with pack red blood cells, platelets concentrate and was commenced on co-trimoxazole prophylaxis and anabolic steroid. He is currently on follow-up in the paediatric clinic.

Treatment of idiopathic onychodystrophy with a 1064 nm picosecond neodymium-doped:yttrium aluminum garnet laser: A retrospective study

BACKGROUND

Laser treatment has emerged as a novel treatment modality for onychodystrophy. Only a few small series have assessed the efficacy of laser treatment in onychodystrophy, most of which were case reports. The therapeutic effect of the 1064 nm neodymium-doped:yttrium aluminum garnet (Nd:YAG) laser for onychodystrophy has been demonstrated. Recently, the picosecond Nd:YAG (PSNY) laser has been introduced to improve various skin disorders.

AIMS

The aim of this study was to verify the efficacy of a 1064 nm PSNY in management of idiopathic onychodystrophy.

METHODS

We present a case series of dystrophic nails treated with a PSNY for onychodystrophy improvement. Planimetry using ImageJ software was used to calculate lesion reduction and proximal clear nail growth. Clinical improvement was assessed using a 5-point Global Assessment Scale (GAS). Adverse events were also assessed.

RESULTS

Twenty-five patients (11 males and 14 females) with a total of 128 nails (94 finger nails and 34 toe nails) were treated. The mean treatment number was 8.7 ± 6.2, and the mean total duration of treatment was 33.4 ± 34.6 weeks. The average proportion of the lesion area decreased significantly (from 65.9% to 46.6%) after PSNY treatment (P < .001). The mean GAS (3.16 ± 1.18) exhibited fair improvement, and there were no serious adverse events.

CONCLUSION

The 1064 nm PSNY laser can provide fair improvement for onychodystrophy with a good prognosis at least during the follow-up period and optimal cosmetic results in Asian patients.

Onychopathy Induced by Nivolumab: A Targeted Immunotherapy

Nivolumab is a human immunoglobulin G4 (IgG4) monoclonal antibody that binds to the PD-1 receptor on T-cells and blocks its interaction with PD-L1 and PD-L2, releasing the PD-1 pathway-mediated inhibition of the immune response, including the anti-tumor immune response, resulting in decreased tumor growth. Here, we present a case of a 56-year-old lady with a diagnosis of squamous cell carcinoma (SCC) of the lip who presented with dystrophy of 20 nails, distal onycholysis, yellow-black discoloration of nail plates, painful paronychia with superimposed bacterial infection of big toes of both feet for three months. Few warty growths were also appreciated on big toes of both feet. She had undergone for her SCC 33 sessions of radiotherapy and 43 cycles of nivolumab 140mg for 60 minutes every two weeks. Following discontinuing this drug, the peri-ungual and nail bed inflammation improved, however nail plate dystrophy persisted. To our knowledge, the occurrence of nail dystrophy with nivolumab has never been reported before but it has been described with other targeted therapies.

Atypical Presentation of Pemphigus Vulgaris: Nail Involvement in a 20-Year-Old Male

Pemphigus vulgaris (PV) mainly causes blistering of the skin and mucous membranes, with nail unit involvement being rare. Nail involvement may serve as an indicator of disease severity. We present a case of a 20-year-old male with PV who had both cutaneous and nail findings, with nail changes corresponding with disease severity. The patient with biopsy-confirmed PV, on prednisone and mycophenolate, presented to the emergency department with an acute flare of PV and severe mandibular pain and lymphadenopathy. At follow-up in our outpatient department, the physical examination was significant for onychomadesis and onycholysis of the fingernails. Prednisone and mycophenolate dosages were increased, and rituximab infusions were initiated. Bullae and mucosal lesions resolved on the follow-up, and nail changes improved. This case appends an unusual perspective to the limited literature on PV-associated nail changes, especially in younger patients. It advocates for meticulous history taking and physical examination and supports a correlation between nail symptoms and PV disease severity.

Risk Factors and Treatment Trends for Onychomycosis: A Case-Control Study of Onychomycosis Patients in the All of Us Research Program

Introda significant: Onychomycosis is the most common nail disorder seen in clinical practice, and it may have significant impact on patient quality of life. Understanding risk factors for onychomycosis may help to devise screening and treatment guidelines for populations that are more susceptible to this infection. Using a national database, we aimed to explore associations between onychomycosis and age, sex, and underlying medical conditions, as well as to examine current onychomycosis treatment trends. Materials and Methods: We performed a nested, matched, case-control study of patients in the All of Us database aged ≥ 18 years (6 May 2018-1 January 2022). Onychomycosis cases were identified using International Classification of Diseases (ICD) and Systematized Nomenclature of Medicine (SNOMED) diagnostic codes (ICD-9 110.1, ICD-10 B35.1, SNOMED 414941008). Demographic information (i.e., age, sex, and race), treatments, and co-diagnoses for onychomycosis patients and case-controls were recorded. Wald's test applied to multivariate logistic regression was used to calculate odds ratios and p-values between onychomycosis and co-diagnoses. Additionally, 95% confidence intervals were calculated with a proportion test. Results: We included 15,760 onychomycosis patients and 47,280 matched controls. The mean age of onychomycosis patients was 64.9 years, with 54.2% female, 52.8% Non-Hispanic White, 23.0% Black, 17.8% Hispanic, and 6.3% other, which was similar to controls. Patients with onychomycosis vs. controls were more likely to have a co-diagnosis of obesity (46.4%, OR 2.59 [2.49-2.69]), tinea pedis (21.5%, OR 10.9 [10.1-11.6]), peripheral vascular disease (PVD) (14.4%, OR 3.04 [2.86-3.24]), venous insufficiency (13.4%, OR 3.38 [3.15-3.59]), venous varices (5.6%, OR 2.71 [2.47-2.97]), diabetes mellitus (5.6%, OR 3.28 [2.98-3.61]), and human immunodeficiency virus (HIV) (3.5%, OR 1.8 [1.61-2.00]) (p < 0.05, all). The most frequently prescribed oral and topical medications were terbinafine (20.9%) and ciclopirox (12.4%), respectively. The most common therapeutic procedure performed was debridement (19.3%). Over the study period, ciclopirox prescriptions (Spearman correlation 0.182, p = 0.0361) and fluconazole prescriptions increased (Spearman correlation 0.665, p = 2.44 × 10^-4), and griseofulvin (Spearman correlation -0.557, p = 0.0131) and itraconazole prescriptions decreased (Spearman correlation -0.681, p = 3.32 × 10^-6). Conclusions: Our study demonstrated that age, obesity, tinea pedis, PVD, venous insufficiency, diabetes mellitus, and HIV were significant risk factors for onychomycosis. In addition, the most frequent oral and topical onychomycosis medications prescribed were terbinafine and ciclopirox, likely reflective of efficacy and cost considerations. Identifying and managing these risk factors is essential to preventing onychomycosis' primary infections and recurrences and improving treatment efficacy.

Successful Treatment of Dystrophic Nails Caused by Onychotillomania Using Pulsed Dye Laser 595 nm: A Case Report

Onychotillomania is characterized by an irresistible urge to pick or pull at one's nails, resulting in significant damage to the nail and surrounding tissue. In severe cases, it can cause onychodystrophy, which leads to abnormal changes in nail shape, color, texture, and growth. Managing onychotillomania can be challenging due to the lack of standard treatment and concurrent behavioral disorders. Pharmacotherapy and behavioral therapy have shown some positive outcomes from reported cases. The treatment for onychodystrophy varies depending on the underlying cause and may entail the application of topical, systemic, or laser therapies. Nevertheless, there is currently no consensus on the most effective treatment approach. This report presents a case of onychodystrophy caused by onychotillomania successfully treated using a pulsed dye laser 595 nm. The treatment was administered four times, with a two-week interval between sessions. Significant improvement was seen within four weeks of starting the treatment, and by the end of the eight-week program, the dystrophic thumbnails had almost completely resolved. After a thorough ten-month follow-up, it has been determined that the dystrophic nails have not reappeared. Moreover, there has been a significant decrease in the patient's tendency to pull her nails.