Nail lichen planus: A review of clinical presentation, diagnosis and therapy

Lichen planus is a multifaceted disease of complex etiopathogenesis. Nails are involved in up to 10% of patients with lichen planus. Although most cases are mild, serious consequences may occur due to rapid progression of the disease, the high risk of scarring, and the resulting irreversible damage to the nail structure. Permanent damage of at least one nail occurs in approximately 4-12% of patients with nail lichen planus. In this narrative review, we emphasize the pathophysiology of nail lichen planus, the emergent nature of the disease, and the spectrum of different clinical manifestations. Diagnosis of nail disease in general, and of nail lichen planus in particular, is rapidly evolving. This review provides a comprehensive account of the non-invasive and invasive diagnostic techniques and treatment options reported in the literature, with emphasis on the efficacy and safety of the drugs used, the associated evidence, and the factors to be taken into account in planning and providing adequate treatment. The role of aesthetic and camouflage options is also summarized.

Photoonycholysis: new findings

First described in 1961, photoonycholysis (PO) is a rare nail alteration that may result from drug intake, from topical aminolevulinate photodynamic therapy or from photosensitive conditions such as porphyria or pseudoporphyria. Spontaneous PO is rare. This review updates the numerous causes of PO and highlights some new ways producing this condition. Four different types of PO are clearly recognized without relationship with the responsible drug. An updated list of potential inducing drug is provided. Some practical points on PO have been raised. The inability to reproduce photoonycholysis experimentally should be emphasized, and the pathogenesis of PO still needs to be clarified.

Influence of the nature and environment of manganese in Mn-BEA zeolites on NO conversion in selective catalytic reduction with ammonia

Manganese-containing BEA zeolites, Mn_xSiBEA (x = 1-4 wt%) and Mn_(I.E.)AlBEA, were prepared by a two-step post-synthesis method and a conventional wet ion-exchange, respectively, and applied as catalysts in the selective catalytic reduction of NO with ammonia (NH₃-SCR). The physicochemical analysis of zeolite properties by high-energy-resolution fluorescence-detected XANES (HERFD-XANES) and X-ray emission spectroscopy (XES) uncovered that the coordination, geometry and oxidation state of Mn species are strongly related to the preparation method. Additionally, the study of catalyst acidity by FTIR spectroscopy with CO and pyridine probe molecules provided important insight into the number and type of acidic centres present on the catalyst surface. The catalytic results revealed that NO conversion depended on the state and content of Mn. The zeolites obtained by the two-step post-synthesis method and with a low Mn content were very active in the medium temperature range (NO conversion ∼100%) with simultaneous high selectivity to N₂ due to the presence of isolated, framework Mn(iii) and Mn(ii) species. The N₂O formation was especially high in the case of catalysts containing extra-framework polynuclear Mn species and negligible in the case of Mn_(I.E.)AlBEA containing predominantly isolated, extra-framework Mn(ii) species.

Incorporation of Mn into the vacant T-atom sites of a BEA zeolite as isolated, mononuclear Mn: FTIR, XPS, EPR and DR UV-Vis studies

A MnSiBEA zeolite has been prepared via a two-step postsynthesis procedure which consisted, in the first step, of the treatment of a tetraethylammonium BEA zeolite with nitric acid for the formation of vacant T-atom sites and then, in the second step, of the incorporation of Mn ions into the framework, resulting in a SiBEA zeolite, through their reaction with the silanol group of the vacant T-atom sites. The incorporation of Mn ions into the framework of the SiBEA zeolite has been evidenced using XRD. The formation of isolated mononuclear Mn(ii) and Mn(iii) in a MnSiBEA zeolite has been shown using FTIR, diffuse reflectance UV-Vis, EPR and XPS. The acidic properties of the mononuclear manganese species have been investigated via FTIR spectroscopy using pyridine as the probe molecule. The changes in the oxidation state of the Mn species under various treatments have been proven using EPR.

[Scabies of the nail unit in an infant]

BACKGROUND

There are no guidelines regarding the management of scabies in infants and recurrence is common at this age. We report the case of an infant with subungual hyperkeratosis and ungual lesions subsequent to classic scabies.

PATIENTS AND METHODS

A 7-month-girl, treated 6 weeks earlier with esdepallethrin for scabies, consulted for acquired lesions on 3 toe nails. These nails were thickened and displayed subungual hyperkeratosis. Physical examination of the skin, the finger nails and mucous membranes was otherwise normal. Fungal analyses were negative, but direct microscopic examination revealed numerous larvae of Sarcoptes scabiei as well as ovular debris. The child was treated with urea 40% to obtain chemical avulsion of the nails, and with topical esdepallethrin and a quarter tablet of ivermectin orally; there was no follow-up of the child.

DISCUSSION

Ungual scabies has already been reported in crusted scabies and very rarely in classic scabies. Subungual and ungual locations of S. scabiei may constitute a source of reinfestation with scabies in infants. Treatment is not well defined and currently involves chemical avulsion of the nails and the application of topical antiscabies treatment.

Koilonychia: an update on pathophysiology, differential diagnosis and clinical relevance

Koilonychia, a concave nail dystrophy, has multiple aetiologies and may be hereditary, acquired or idiopathic. Within dermatology, koilonychia is often a manifestation of an inflammatory dermatosis such as psoriasis or lichen planus, or a sign of onychomycosis. Other disease associations include iron store abnormalities, Plummer-Vinson Syndrome, nutritional deficiencies and occupational or traumatic aetiologies. In young children, koilonychia of the toenails is commonly transient and idiopathic, although familial and syndromic cases are reported. The dermatologist must be aware of the potential cutaneous and systemic associations with koilonychia in order to guide appropriate workup, treatment and/or referral. An algorithm for evaluation of koilonychia is presented along with discussion of common causes of koilonychia and a comprehensive list of all known associations.

[Cosmetic nail products]

Cosmetic embellishment of fingernails involves the use of substance that harden either after the evaporation of solvents (varnishes) or after polymerisation (artificial acrylic nails, gel tips, glue-on artificial nails). Pathological reactions to cosmetics usually occur at a remote site for varnishes, and, most commonly, in situ with polymerising substances. Unvarnished artificial nails do not affect pulse oximetry readings, and in theory, patients are not required to remove them. However, a real problem of contamination via artificial nails exists. Increased carriage of pathological Gram-negative organisms and of Staphylococcus aureus and yeasts has been noted among nursing staff wearing artificial nails, both before and after fingernail cleaning. Fingernail fragility manifests itself through a number of different physical signs such as soft, breaking nails, with longitudinal or transverse fissures, showing distal doubling or friability. In some subjects, excessive manicuring with metal instruments or manicure sticks results in rolled onycholysis, of evocative appearance, or transverse onycholysis.

Abundance of Cottus poecilopus is influenced by O2 saturation, food density and Salmo trutta in three tributaries of the Rožnovská Bečva River, Czech Republic

The distribution patterns of alpine bullhead Cottus poecilopus in three tributary streams of the Rožnovská Bečva River (Danube basin) were studied with respect to temperature, oxygen concentration and saturation, shading, current, conductivity, total organic carbon (TOC), nitrates and phosphates, biochemical oxygen demand (BOD₅ ), pH, redox potential, bottom grain structure, density of macroinvertebrates and the abundance of brown trout Salmo trutta. Sites with lower abundance per hectare of C. poecilopus differed significantly in dissolved oxygen saturation, density of macroinvertebrates during the autumn period (positive correlation with C. poecilopus) and in abundance per hectare of S. trutta (negative correlation). These results indicate that these factors significantly influence the distribution of this endangered species in the studied catchment and that stocking of S. trutta will impair its recovery.

Acroosteolysis presenting with brachyonychia following exposure to cold

BACKGROUND

A vast number of conditions ranging from simple trauma to hereditary and collagen vascular disease had been described in association with acroosteolysis.

OBJECTIVE

To demonstrate that severe cold exposure not mounting to frostbite may be associated with acroosteolysis.

METHODS

A 16-year-old girl with acroosteolysis presenting with brachyonychia was fully investigated for possible cause of her nail and bone deformity.

RESULTS

Lab investigations including Parathormone levels, Anti Scl 70, ANA, Anti-CCP and RF levels were all normal. X-ray imaging revealed resorption of the tufts of the terminal phalanges bilaterally. Disruption of nail fold capillaries with sluggish flow in capillary loops was evident on capillaroscopy.

CONCLUSION

It had been repeatedly reported that frostbite, Raynaud's disease and diseases associated with repeated chilblains may be associated with secondary cold-induced acroosteolysis. Here, we present a case of acroosteolysis associated with brachyonychia following exposure to severe cold not mounting to frostbite.

The prevalence of onychomycosis in the global population: a literature study

BACKGROUND

Onychomycosis is a common disorder, and high prevalence figures are commonly cited in the literature.

OBJECTIVES

Evaluate the prevalence of onychomycosis based on published studies.

METHODS

Relevant studies were identified in Medline by using specific search criteria.

RESULTS

Eleven population-based and 21 hospital-based studies were identified. The mean prevalence in Europe and North America was 4.3% [95% Confidence Interval (CI): 1.9-6.8] in the population-based studies, but it was 8.9% (95% CI: 4.3-13.6) for the hospital-based studies. Both population-based and hospital-based studies showed that onychomycosis is more common in toenails and is seen more frequently in males. The main causative agent was a dermatophyte in 65.0% (95% CI: 51.9-78.1) of the cases. Trichophyton rubrum was the single most common fungus and was cultured on average in 44.9% of the cases (95% CI: 33.8-56.0). Moulds were found on average in 13.3% (95% CI: 4.6-22.1) and yeasts in 21.1% (95% CI: 11.0-31.3).

LIMITATIONS

We may not have been able to locate all studies.

CONCLUSIONS

Onychomycosis is a common disorder, but it may not be as common as cited in the literature, because hospital-based studies might overestimate the prevalence of onychomycosis. It is more frequent in males, and toenails are more commonly affected. Dermatophytes, particularly T. rubrum, are the main causative agents.

[Nerve sheath myxoma of the hyponychium]

BACKGROUND

Nerve sheath myxoma is a rare benign tumour of the extremities that was long confounded with neurothekeoma. Herein, we describe a rare case of interest because of its site on the hyponychium.

PATIENTS AND METHODS

A 31-year-old woman presented with a painless distal tumour on the right ring finger that had been present for 3 to 4 years. It consisted of a firm, round nodule under the nail and spreading to the fingertip. Complete excision was carried out after cutting away the distal nail plate. Histological examination revealed a myxoid tumour comprising very clearly delineated lobules containing pale fusiform cells with small nuclear inclusions. These cells expressed S100 protein but no CD34 or epithelial membrane antigen (EMA). Complete excision was performed and a full recovery was made.

DISCUSSION

This type of tumour is characteristic of nerve sheath myxoma, and is almost certainly of Schwannian origin, although distinct from Schwannoma. It is rare, occurs after the age of 35 years and is preferentially located in the extremities of the limbs. There has only been one other description of its occurrence under the fingernail, in which it was described as neurothekeoma. However, neurothekeoma is entirely different, being more cellular, with no expression of protein S100, and marked by the NKIC3 antibody; it occurs in children or young adults, and is frequently found on the face. These two tumours were confused for some time, but today they must be completely distinguished from one another. These myxomas must be completely excised because of the risk of relapse. Finally, they should be distinguished from other myxoid tumours of the digits, certain of which can be malignant.

Bronchoscopy as an indicator of tracheobronchial fungal infection in non-neutropenic intensive-care unit patients

We aimed to establish that a bronchoscopic view can be as reliable as microbiology, and support an empirical tracheobronchial fungal infection (TBFI) treatment decision. We retrospectively studied 95 respiratory failure patients with suspected TBFI admitted to the intensive-care unit (ICU) in 2008 with sticky secretions, hyperaemic mucosa, and whitish plaques on bronchoscopic view. Patients not suspected of having TBFI were chosen as a control group (n = 151). Broncheoalveolar lavage (BAL) fluid was cultured, and biopsy samples were taken from the lesions. Biopsy samples positive for fungi were defined as 'proven', only BAL-positive (+ fungi) cases were 'probable TBFI', and BAL-negative (- fungi) cases were 'possible TBFI'. BAL (+ fungi) and BAL (- fungi) in the control group were defined as 'colonization' and 'no TBFI', respectively. The sensitivity, specificity and positive and negative predictive values of BAL (+ fungi) were 85.1% (63/74), 81.4% (140/172), 66.3% (63/95), and 92.7% (140/151), respectively. Biopsies were performed in 78 of 95 patients, and 28 were proven TBFI with fungal elements, and 100% were BAL (+ fungi). Probable TBFI was seen in 30 of 95 patients with BAL (+ fungi), and possible TBFI (BAL(- fungi)) in 25 of 95. Among the 95 patients, microbiology revealed fungi (90.5% Candida species; 9.5% Aspergillus) in 63 (66.3%). In the controls, the colonization and no TBFI rates were 11 of 151 and 140 of 151, respectively. Observing sticky secretions, hyperaemic mucosa and whitish plaques by bronchoscopy is faster than and may be as reliable as microbiology for diagnosing TBFI. These findings are relevant for empirical antifungal therapy in suspected TBFI patients in the ICU.

Finger retronychias detected early by 3D ultrasound examination

BACKGROUND

A new pattern of ingrown nail, called retronychia is involved in the posterior translation of the whole nail unit producing paronychia.

OBJECTIVE

To demonstrate an unusual case of paronychia that affected three of the fingers on the right hand.

METHODS

We used 3D ultrasound to study the whole nail unit in the fingers of both the affected (right) and non affected (left) hand.

RESULTS

Backward motion of the nail unit with decreased distance between the origin of the nail plates and the distal interphalangeal joint was clearly demonstrated by 3D ultrasound in the affected fingers.

CONCLUSION

3D ultrasound provides non invasive and more understandable information about the physiopathological changes in retronychia.

Nail biology and nail science

The nail plate is the permanent product of the nail matrix. Its normal appearance and growth depend on the integrity of several components: the surrounding tissues or perionychium and the bony phalanx that are contributing to the nail apparatus or nail unit. The nail is inserted proximally in an invagination practically parallel to the upper surface of the skin and laterally in the lateral nail grooves. This pocket-like invagination has a roof, the proximal nail fold and a floor, the matrix from which the nail is derived. The germinal matrix forms the bulk of the nail plate. The proximal element forms the superficial third of the nail whereas the distal element provides its inferior two-thirds. The ventral surface of the proximal nail fold adheres closely to the nail for a short distance and forms a gradually desquamating tissue, the cuticle, made of the stratum corneum of both the dorsal and the ventral side of the proximal nail fold. The cuticle seals and therefore protects the ungual cul-de-sac. The nail plate is bordered by the proximal nail fold which is continuous with the similarly structured lateral nail fold on each side. The nail bed extends from the lunula to the hyponychium. It presents with parallel longitudinal rete ridges. This area, by contrast to the matrix has a firm attachment to the nail plate and nail avulsion produces a denudation of the nail bed. Colourless, but translucent, the highly vascular connective tissue containing glomus organs transmits a pink colour through the nail. Among its multiple functions, the nail provides counterpressure to the pulp that is essential to the tactile sensation involving the fingers and to the prevention of the hypertrophy of the distal wall tissue, produced after nail loss of the great toe nail.

Development and validation of nail psoriasis quality of life scale (NPQ10)

BACKGROUND

The chronic and treatment-resistant nature of nail psoriasis affects patients' lives not only physically but also psychologically. Although there are scoring systems available for disease severity, there is as yet no scale to evaluate the impact of this condition upon the patients' quality of life.

OBJECTIVES

This study aims to develop and validate a quality of life scale specifically for nail psoriasis.

METHODS

A questionnaire was developed during a study conducted in France between 2004 and 2005. With the cooperation of l'Association Pour la Lutte Contre le Psoriasis, the questionnaire was sent to a random sample of 4000 of its 17,000 members.

RESULTS

The response rate was 33%. Of the 1309 questionnaires returned, 795 showed the presence of nail psoriasis and these were eligible. The scale score is obtained by adding together the responses to the 10 questionnaire items and the result is expressed as a percentage. The value of the score obtained is proportional to the functional difficulty experienced. The determination of Cronbach's a coefficient and a Principal Component Factor Analysis show, respectively, very good internal consistency and the unidimensional nature of the scale. Test-retest results on 15 patients showed good reproducibility. Results were validated with reference to the Dermatology Life Quality Index. In this study, the NPQ10 score is significantly influenced by gender (women have a higher score) and by the duration of psoriasis (recent onset implies greater functional difficulty). Finally, the score is much higher when the nail psoriasis affects both the hands and the feet.

CONCLUSION

This study confirms a change in the quality of life of patients who have nail psoriasis. The NPQ10 scale, specific to this condition, is simple to use and has the attributes needed in a quality of life scale. The scale must now be tested in longitudinal studies (such as clinical trials) to confirm its ability to measure a change in status.

Chemical avulsion with urea nail lacquer

BACKGROUND

Among the therapeutic possibilities for onychomycosis, chemicalnail avulsion is a logical approach to the eradication of the pathogen.

METHODS

A new formulation was used as a nail lacquer containing 40% urea in a film-forming solution in 10 patients presenting with onychomycosis. The urea nail lacquer was applied with a brush twice a day for 1 week by the patient and for a further week in two patients presenting total dystrophic onychomycosis.

RESULTS

This transungual delivery system weakens the nail plate/nail bed attachment in the diseased area.

CONCLUSION

The urea nail lacquer is comfortable for the patient and allows easy removal of the affected part of the fungal nail plate.

Three cases of intrathoracic gossypiboma with varying morbidities depending on the time of detection

An intrathoracic gossypiboma (surgical sponge retained within the thoracic cavity during surgery) is rare but causes serious surgical complications and presents with difficulties in the differential diagnosis. In this article, we describe three cases of intrathoracic gossypiboma identified with the help of exploratory surgery 22, 10 and 3 years after they had been retained after surgery. The radiological findings varied in these cases and were insufficient for an accurate preoperative diagnosis. Marked deterioration in the neighboring lung tissue was observed over time, and the patients who had gossypibomas for 22, 10 and 3 years required pneumonectomy, lobectomy and partial decortication, respectively.

Combination of fluconazole and urea in a nail lacquer for treating onychomycosis

BACKGROUND

METHODS

Altogether, 13 patients with onychomycosis, aged 25-78 years, most with involvement of the matrix region, were treated. A solution of 1% fluconazole and 20% urea in a mixture of ethanol and water was applied once daily, at bedtime.

RESULTS

In four patients there was complete resolution of the condition; four patients who had involvement of one nail only demonstrated a 90% improvement. Of the four patients who had presented with involvement of both big toenails, two showed 50% improvement bilaterally and in the remaining two patients there was a 90% improvement in one nail and a 50% improvement in the other. One patient with proximal white subungual onychomycosis of the finger nail, who grew Alternaria, relapsed during treatment after an initial positive response.

CONCLUSION

Generally, a favourable response to local treatment may be anticipated only if the distal two-thirds of the nail is affected. In view of this, and despite the fact that most of the patients were severely affected with involvement of the proximal third of the nail, the response to local therapy was appreciable.

Endoscopic removal of a chondromatous hamartoma by bronchoscopic electrosurgical snare and argon plasma coagulation

A 31-year-old woman presented with a cough, pain on the left side on deep inspiration, dyspnea, and fever. A chest x-ray showed pneumonic infiltration of the left middle and lower lung and decreased left hemithorax volume. A computed tomography (CT) revealed an occlusion of the left main bronchus by an intraluminal tumour. Bronchoscopic biopsy specimens suggested an endobronchial hamartoma. Therefore, we resected the tumour endobronchially using a bronchoscopic electrosurgical snare and argon plasma coagulation.

A multicentre, randomized, controlled study of the efficacy, safety and cost-effectiveness of a combination therapy with amorolfine nail lacquer and oral terbinafine compared with oral terbinafine alone for the treatment of onychomycosis with matrix involvement

BACKGROUND

Onychomycosis is common, accounting for up to 50% of all nail disorders. Toenail onychomycosis can cause nail deformity, embarrassment, pain and walking difficulties. Some populations, such as individuals with diabetes, are at higher risk for developing secondary complications such as infections. Treatment takes many months and therapeutic choices can increase clinical effectiveness, lower toxicity and minimize healthcare costs.

OBJECTIVES

Based on the results of a previous pilot study, the objective of the present study was to show, in a larger population, the enhanced efficacy of a combination of amorolfine nail lacquer and oral terbinafine in the treatment of onychomycosis with matrix involvement. In addition, a cost-effectiveness analysis was performed.

METHODS

In this multicentre, randomized, open-label, parallel group study, patients were randomized to receive either a combination of amorolfine hydrochloride 5% nail lacquer once weekly for 12 months plus terbinafine 250 mg once daily for 3 months (AT group) or terbinafine alone once daily for 3 months (T group). The study duration was 18 months including a 6-month treatment-free phase following the 12-month active treatment phase for the AT group and a 15-month treatment-free phase following the 3-month active treatment phase for the T group. The primary efficacy criterion was overall response, dichotomized into success or failure, success being the combination of clinical cure and negative mycology at month 18. This criterion was used as the effectiveness measure in the pharmacoeconomic analysis, conducted from a payer perspective.

RESULTS

In total, 249 patients were included into the study: 120 in the AT group and 129 in the T group. A significantly higher success rate was observed for patients in the AT group relative to those in the T group at 18 months (59.2% vs. 45.0%; P = 0.03). Both treatment regimens were safe and well tolerated. Treatment cost per cured patient was lower for the combination than for terbinafine alone in all countries.

CONCLUSIONS

Study results confirmed that, in the treatment of dermatophytic toenail onychomycosis with matrix involvement, amorolfine nail lacquer in combination with oral terbinafine enhances clinical efficacy and is more cost-effective than terbinafine alone.

An effective surgical treatment for nail thickening in Darier's disease

BACKGROUND

Nail thickening of idiopathic or hereditary aetiology originating in the matrix is difficult to treat. OBJECTIVE; The purpose is to describe an easy surgical technique to reduce the thickness of the nail.

METHODS AND RESULTS

The result is achieved by shortening the matrix with an excellent cosmetic appearance in the newly formed nail plate.

CONCLUSION

Nail thickening in Darier's disease originating in the matrix, and other similar hereditary or idiopathic conditions, may benefit from this surgical approach.