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.

Patient-reported care domains that enhance the experience of "being known" in an ambulatory cancer care centre

Purpose

This study explored patients' perceptions of "being known" in an ambulatory chemotherapy unit.

Methods

Using a qualitative descriptive design, 10 participants with various cancer diagnoses were recruited from a large cancer centre in Montreal, Quebec. Audiotaped individual interviews were transcribed verbatim. Textual data were coded and analyzed thematically.

Findings

Participants spoke of their need to have the staff approach them as individuals first and then as persons with cancer. They further underscored the importance of: (1) feeling truly welcome in the cancer care environment, (2) being provided with person- and situation-responsive care, and (3) considering occupational and social roles that go beyond the "sick role". Mutual patient-nurse disclosure also contributed to perceptions of a personalized care approach.

Implications for nursing

In addition to key elements construed as crucial for enhancing perceptions of being known, future studies should further document how the interplay among demographic, physical/psychological, and cultural factors affect these perceptions.

Medication education program for Indian children with asthma: A feasibility stud

OBJECTIVE

It is postulated that children with asthma who receive an interactive, comprehensive, culturally relevant education program would improve their asthma knowledge (AK), asthma control, and adherence compared with children receiving usual care. The aim of this study was to develop, implement, and evaluate the efficacy of a culturally relevant asthma education intervention for children with asthma and their parents in India.

METHODS

Children with asthma (7-12 years) and their parents were recruited from an outpatient clinic in a Chest Diseases Hospital in New Delhi, and were randomly assigned to either an intervention or usual care group. At baseline, outcome data collected included pediatric asthma caregiver quality of life (PACQL, primary outcome), AK, asthma control, adherence, inhaler technique, action plan ownership, and goal achievement. These data were collected again at 1 and 6 months after baseline. Outcomes were compared within and between groups using ANOVA techniques.

RESULTS

Forty parent-child pairs were recruited. Of these, 24 pairs of children with asthma and their parents received the educational intervention. The PACQL significantly improved from baseline to 6 months in the intervention (5.87 ± 0.94-7.00 ± 0.03) versus the usual care group (5.90 ± 0.52-6.34 ± 0.56) (P < 0.001). Other outcomes such as the parents' and child's AK, child's asthma control and inhaler technique were significantly improved in the intervention group across the study. All the participants possessed a written asthma action plan at the end of the intervention. Eighty-five goals were set by children with asthma across all the visits and were achieved by completion.

CONCLUSION

An asthma educator delivered interactive program simultaneously involving children with asthma and their parents, improved quality of life, empowered and promoted better self-management skills.

Role of nail bed methotrexate injections in isolated nail psoriasis: conventional drug via an unconventional route

Nail psoriasis can be a debilitating condition; however, in patients with isolated nail involvement, the use of toxic systemic therapies such as methotrexate may not be justified. We report on 4 patients (30 involved nails between them), who were treated with injections of methotrexate (0.1 mL of a 25 mg/mL solution) into the nail bed at 3-weekly intervals. Mean baseline Nail Psoriasis Severity Index (NAPSI) was 4.77 (range 2-8, cumulative score 143; n = 30); dropping successively at each visit to 2.43 (range 0-4, cumulative score 73; n = 30) at 15 weeks. The decline in mean NAPSI from 4.87 to 2.17 was statistically significant (P < 0.001; Friedman analysis). Reported adverse effects were pain, injection site pigmentation and nail bed haemorrhage. Administration of specific targeted therapy to the nail bed may help manage nail psoriasis effectively.

An uncommon cause of scleroderma

The human immunodeficiency virus (HIV) pandemic is nearly 20 years old. HIV infection is characterized by profound immunodeficiency resulting in an increased incidence of opportunistic infections and neoplasms. However, the greatest paradox is the occurrence of certain autoimmune disorders in the setting of HIV. These include diffuse interstitial lymphocytosis syndrome (DILS), reactive arthritis, systemic lupus erythematosus (SLE), and rheumatoid arthritis (RA). It has also been seen that even in the absence of these well-defined diseases, various rheumatological manifestations such as arthralgias, arthritis, myopathy, vasculitis, and sicca syndrome are commonly associated with HIV. To the best of our knowledge, the association of HIV with scleroderma has not previously been reported.

Combination of surgical avulsion and topical therapy for single nail onychomycosis: a randomized controlled trial

BACKGROUND

Conventional therapy of onychomycosis is prolonged and often frustrating, which is why combination therapy involving topical, oral and surgical measures has been advocated as the treatment of choice. There are no controlled studies evaluating the efficacy of nail avulsion followed by topical antifungal therapy.

OBJECTIVES

To evaluate the efficacy of combined surgical and topical therapy for onychomycosis.

METHODS

Forty patients with single nail onychomycosis [28 with distal and lateral subungual onychomycosis, seven with total dystrophic onychomycosis (TDO) and five with proximal subungual onychomycosis] were randomly assigned to four treatment groups. Each group received avulsion of the involved nail, followed by ketoconazole 2% cream without (group I) or with occlusion (group II), or oxiconazole 1% cream without (group III) or with occlusion (group IV). Topical therapies were applied twice daily. The patients were reviewed monthly and treatment was continued until the regrowth of completely normal nail (mycologically negative). In cured cases, further monthly review was carried out for at least 6 months, without any form of therapy. At each visit direct microscopic examination was repeated.

RESULTS

There was a high dropout rate, with seven patients (group I), six patients (group II), six patients (group III) and eight patients (group IV) completing the treatment protocol. Out of these, mycological cure was achieved in three (43%) patients in group I, four (67%) in group II, two (33%) in group III and six (75%) in group IV. All the cases of TDO failed to respond to this therapy. Overall, 15 of 27 (56%) patients were cured with this approach. On further follow up, recurrence of onychomycosis was recorded in two patients in group I. No side-effects or long-term complications of the nail avulsion were encountered. Important limitations encountered in the present study included a small sample size, a high dropout rate (32%) and poor patient compliance.

CONCLUSIONS

Contrary to earlier reports, surgical nail avulsion with topical antifungal agents was not found to be a very encouraging modality for the treatment of onychomycosis. Both oxiconazole and ketoconazole delivered comparable results. Occlusion improved the treatment outcome, although the difference was not statistically significant. As a subtype, TDO showed poorest response. Surgical nail avulsion followed by topical antifungal therapy cannot be generally recommended for the treatment of onychomycosis.

Diagnosis of nail psoriasis: importance of biopsy and histopathology

BACKGROUND

Involvement of the nail is quite common in psoriasis and at times may be the sole diagnostic clue. However, the histopathology of nail psoriasis has not been adequately evaluated. A confirmation of the diagnosis is required in cases suspected to have nail psoriasis in order to plan long-term therapy.

OBJECTIVES

To assess the diagnostic significance and safety profile of nail biopsy in cases with nail psoriasis.

METHODS

Clinical and mycological features were studied in 42 patients with nail psoriasis. Of these, 22 patients gave consent for nail biopsies to be taken and the histopathological changes were assessed.

RESULTS

Males were affected more commonly (57%) with a peak incidence in the age group of 10-20 years (29%). Distal onycholysis, discoloration of nail plate, subungual hyperkeratosis and fine nail pitting were the predominant clinical features. In the 22 biopsies done, hyperkeratosis with parakeratosis (91%) was found to be the most common and hypergranulosis was the least common histological finding (36%). Clinicohistological correlation was possible only in 55% cases. Periodic acid-Schiff (PAS) staining was done for all biopsies.

CONCLUSIONS

Histopathological examination of nails is a valuable diagnostic aid, especially in the absence of skin lesions. Examination of the PAS-stained sections is necessary before making a histological diagnosis of nail psoriasis because onychomycosis and psoriasis may show similar histology.

The therapeutic value of glycolic acid peels in dermatology

Chemical peeling or chemexfoliation has become increasingly popular in recent years for treatment of a number of cosmetic skin problems. Topical glycolic acid in the concentration of 10-30% for 3-5 minutes at fortnightly intervals was investigated as a therapeutic peeling agent in 41 patients having acne (39%), melasma (36.5%), post inflammatory hyperpigmentation (12%) and superficial scarring of varied etiology (12%). A final evaluation done at 16 weeks revealed that this modality is useful especially in superficial scarring and melasma, moderately successful in acne patients with no response in dermal pigmentation. No significant untoward effects were seen.

Parakeratosis pustulosa--a distinct but less familiar disease

Parakeratosis pustulosa (PP) is a distinct but less commonly known skin disease, which is frequently seen, in young girls. We describe the clinical and histological features of PP in a 7 month old female baby. Further, it is stressed that unless carefully looked for, this entity may be easily misdiagnosed as chronic paronychia, acrodermatitis of Hallopeau, pustular psoriasis, atopic dermatitis, tinea pedis or dry fissured eczematoid dermatitis and mistreated subsequently.

PCR-mediated recombination in amplification products derived from polyploid cotton

PCR recombination describes a process of in vitro chimera formation from non-identical templates. The key requirement of this process is the inclusion of two partially homologous templates in one reaction, a condition met when amplifying any locus from polyploid organisms and members of multigene families from diploid organisms. Because polyploids possess two or more divergent genomes ("homoeologues") in a common nucleus, intergenic chimeras can form during the PCR amplification of any gene. Here we report a high frequency of PCR-induced recombination for four low-copy genes from allotetraploid cotton ( Gossypium hirsutum). Amplification products from these genes ( Myb3, Myb5, G1262 and CesA1) range in length from 860 to 4,050 bp. Intergenomic recombinants were formed frequently, accounting for 23 of the 74 (31.1%) amplicons evaluated, with the frequency of recombination in individual reactions ranging from 0% to approximately 89%. Inspection of the putative recombination zones failed to reveal sequence-specific attributes that promote recombination. The high levels of observed in vitro recombination indicate that the tacit assumption of exclusive amplification of target templates may often be violated, particularly from polyploid genomes. This conclusion has profound implications for population and evolutionary genetic studies, where unrecognized artifactually recombinant molecules may bias results or alter interpretations.

Measurement of femtosecond Polarization Mode Dispersion (PMD) using biased p-shifted low-coherence interferometry

Conventional low-coherence interferometry (LCI) can be employed in the measurement of polarization mode dispersion (PMD) of fiber-optic components and fibers. However, the smallest PMD, which can be measured using this technique, is limited by the coherence length of the source. We propose a biased p-shifted Michelson interferometer where a birefringent crystal is inserted in front of the interferometer to introduce a bias differential group delay (DGD) larger than the coherence time of the source. In this way, the limitation imposed by the source coherence time has been overcome and PMDs much smaller than the source coherence time, in the order of several femtoseconds, can be measured. Experimental results for the PMD have been shown and compared with Jones matrix eigen-analysis. The theoretical model confirms the experimental observations.

Perceiving tongue position

Two experiments on perceiving the tongue position were conducted in which naive human subjects pointed to gingival targets, or to extensions of their fingertip, with their tongue. The aim in experiment 1 was to inquire about the existence and accuracy of the perception of the horizontal position of the tongue inside and outside the mouth, and whether kinesthetic elements other than the skin might contribute to perceiving tongue position. Vertical positioning and the calibration of the sensory map that can be presumed to underlie position sense in the tongue were examined in experiment 2. It was found that position sense is equally good in the presence and absence of anesthesia of the mucosa, suggesting that the muscles, tendons, and corollary discharge contribute to position sense in the tongue. Perception of the tongue position both inside and outside the mouth is accurate, with the error in tongue positioning being about 2 degrees. Feedback improved naive subjects' accuracy very little.

The effect of loading on position sense in the tongue

The position sense of the tongue and aftereffects on the position sense subsequent to loading were directly investigated. Nine subjects judged the straightahead with the tongue before and after straining laterally with the tongue against the horizontal force induced by a 29.5-g weight. Two of these subjects also participated in the experiment after the surface of the tongue had been anesthetized. Prior loading of the tongue biased the subjects' subsequent judgment of the straight-ahead; following loading, the tongue was placed farther in the direction of the previous effort. The results are discussed with reference to postcontraction effects from experiments on loading the limb and eye.