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Importance: Congenital malalignment of the great toenail (CMGT) is an idiopathic deviation of the nail apparatus. CMGT predisposes patients to recurrent stress forces, microtrauma, and secondary complications. The purpose of this study was to review the current published photographs to determine the relationship between variants of CMGT and the disappearing nail bed (DNB). Observations: A search in PubMed and Google using the terms congenital malalignment of the great toenail, disappearing nail bed, and lateral nail deviation was performed. Of the 53 photographs found in a total of 35 articles, 23 were disqualified due to low picture resolution or poor angle. The remaining 30 photographs were evaluated. Pure nail malalignment with associated dystrophy and DNB was found in 22 of 30 photographs. Four of 30 cases demonstrated pure deviation of the distal phalanx, with nail dystrophy but minimal DNB. The remaining 4 cases demonstrated a combination of toe deviation and nail unit deviation with varying degrees of DNB. Conclusions and Relevance: DNB was associated with all forms of pure CMGT. Moreover, a variant of malalignment of the distal phalanx was noted in 8 photographs. This has potential implications for further studies and treatment to correct secondary complications.

BACKGROUND Dermatologists specialize in treating conditions of the skin, hair, and nails; however, it is our experience that the field of nail diseases is the least discussed facet of dermatology. Even less acknowledged is the complexity of nail procedures and how best to accurately code for these procedures. OBJECTIVE To convene a panel of experts in nail disease to reach consensus on the most accurate and appropriate Current Procedural Terminology (CPT) codes associated with the most commonly performed nail procedures. METHODS A questionnaire including 9 of the most commonly performed nail procedures and potential CPT codes was sent to experts in the treatment of nail disease, defined as those clinicians running a nail subspecialty clinic and performing nail procedures with regularity. A conference call was convened to discuss survey results. RESULTS Unanimous consensus was reached on the appropriate CPT codes associated with all discussed procedures. LIMITATIONS Although this article details the most commonly performed nail procedures, many were excluded and billing for these procedures continues to be largely subjective. This article is meant to serve as a guide for clinicians but should not be impervious to interpretation in specific clinical situations. CONCLUSION Billing of nail procedures remains a practice gap within our field. The authors hope that the expert consensus on the most appropriate CPT codes associated with commonly performed nail procedures will aid clinicians as they diagnose and treat disorders of the nail unit and encourage accurate and complete billing practices.

Background Tinea capitis is a common fungal infection in Israel, most commonly caused by the dermatophyte Trichophyton tonsurans. Objectives To investigate the effectiveness of oral antifungal monotherapy in producing clinical or complete cure. We also evaluated the impact of topical therapy (bifonazole 1% shampoo and/or betamethasone valerate 0.1% solution), prior to oral treatment, on patients' likelihood of clinical or complete cure. Methods A retrospective chart review was conducted. Patients with mycologically confirmed tinea capitis were treated with one of four regimens: (1) terbinafine (greater than 40 kg: 250 mg/day, 20 to 40 kg: 125 mg/day, less than 20 kg: 62.5 mg/day), (2) itraconazole 5 mg/kg daily, (3) fluconazole 6 mg/kg daily, or (4) griseofulvin 20 mg/kg daily. We used generalized linear models (GLM) to determine whether there was a significant association between the odds of cure and choice of treatment. Results The causative species was Trichophyton tonsurans in all but 6 cases that grew T violaceum. For pediatric patients, the odds of having complete or clinical cure within 6 weeks was greater if they used terbinafine compared to itraconazole, fluconazole, or griseofulvin (odds ratio [OR] = 9.06, P = .047). The likelihood of complete or clinical cure within 8 weeks of oral therapy was lower if topical steroids were previously used compared to if topical antifungals were used prior to systemic treatment (OR = 0.29, P = .046). Conclusions Our findings substantiate prior literature demonstrating that terbinafine is non-inferior to griseofulvin, itraconazole, and fluconazole in the therapy of pediatric tinea capitis caused by T tonsurans.

Nail manifestations are 1 of the several extrapulmonary findings associated with COVID-19 caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Nail changes, however, have been largely ignored and not yet summarized. This article is intended to increase awareness of nail manifestations of SARS-CoV-2, which occur weeks to months after acute infection and the periungual pernio-like changes may occur concomitantly with infection. An electronic search was carried out in PubMed (Medline), Science Direct, and Scopus databases. The following keywords and all of their possible combinations were used to identify studies: “SARS-CoV-2,” “COVID-19,” “Coronavirus,” “2019-ncov,” “nail,” and “nails.” Six case reports were included in this study. Manifestations identified included red half-moon sign, transverse orange nail lesions, Mees’ lines, and Beau’s lines. Though largely nonspecific, these findings can be recognized with the onset of symptom onset or as late as 16 weeks following the disease. Some of these findings are shared with other conditions associated with a proinflammatory state. Nail changes offer unique insight into the pathophysiologic basis for SARS-CoV-2 and they may serve as diagnostic clues.

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., SCOPUS: re.j, info:eu-repo/semantics/published

Nail plate brittleness (or fragility) is a common complaint affecting up to 20% of the population, especially women over 50 years of age, with fingernail fragility being more prevalent than toenail fragility. Nail brittleness is characterized by nails that split, flake and crumble, become soft and lose elasticity. The main clinical presentations are: onychoschizia, onychorrhexis, superficial granulation of keratin and worn-down nails. According to causative factors, we can distinguish 2 forms of nail fragility (NF): a primary “idiopathic or brittle nail syndrome” form and NF secondary to different causes such as inflammatory nail disorders, infections, systemic diseases and general conditions, traumas and alteration of the nail hydration. Optimal management requires treatment of the primary cause of brittle nails, when possible. In idiopathic NF oral supplementation, vitamins (especially biotin, also known as vitamin B7), trace elements and amino acids (especially cysteine) have been reported to be useful. In addition, several products, such as topical moisturizers and lacquers could be considered to restructure the affected nail plate and to reduce psychological impacts of this common problem., SCOPUS: re.j, info:eu-repo/semantics/published

Although dermatophytes are considered the predominant causative organisms in onychomycosis, non-dermatophyte mold (NDM) infections may be more prevalent than originally thought and may be more difficult to treat. There are limited data of oral antifungal efficacy in treating NDM onychomycosis.A retrospective chart review (2009-2016) was conducted in patients receiving continuous oral terbinafine or pulse itraconazole for toenail onychomycosis due to NDMs. Mycology results and percent nail affected were recorded with patient characteristics including demographics and concurrent diseases. Complete, clinical, and mycological cure were tabulated.Data from 176 patients were collected. Mycological and complete cure rates for terbinafine (69.8% and 17%) and itraconazole (67.5% and 22%) were not significantly different from each other. Regardless of oral treatment, age (Continuous terbinafine and pulse itraconazole were similar in efficacy for curing NDM onychomycosis. Age was the most consistent prognostic factor affecting likelihood of cure, with factors that may influence drug reaching the site of infection also decreasing likelihood of mycological cure.

Previous studies have suggested the applicability of cold atmospheric pressure plasma for the treatment of onychomycosis. Whether delivering cold plasma in sub-atmospheric pressure would be beneficial for this purpose is yet to be established. The current study aimed to evaluate efficacy of cold sub-atmospheric and atmospheric pressure plasma in Trichophyton rubrum growth inhibition. Bovine nails infected with T. rubrum were treated by a cold air plasma device, which enables utilizing plasma in sub-atmospheric pressures (Low = 100 millibar; High = 300 millibar) or atmospheric pressure. The infected foci were exposed to the plasma source directly or indirectly. Treatment with high sub-atmospheric pressure setting achieved T. rubrum growth reduction of 94.0% and 73.0%, for direct and indirect exposure to the plasma source, respectively (P < .001). Low sub-atmospheric pressure setting achieved similar T. rubrum growth reduction of 86.2% for direct exposure to the plasma source (P < .001), but only marginally significant 58.8% reduction rate for indirect exposure to the plasma source (P = .056). None statistically significant fungal growth reduction was attained with the use of atmospheric pressure setting. Cold plasma was shown to effectively inhibit T. rubrum nail growth, with sub-atmospheric pressure setting achieving better outcome than atmospheric pressure.

Background Candida onychomycosis mostly involves fingernails. Yet, in contrast to dermatophytes, Candida isolation from dystrophic fingernails does not prove casualty, as sample contamination and non-pathogenic Candida growth occur. Characterising treatment outcome of Candida-positive dystrophic nails is crucial to avoid unnecessary treatment. Objective To investigate predicators associated with treatment outcome among Candida-positive dystrophic fingernails. Patients and methods A retrospective cohort study was carried out among 108 adults with Candida-positive dystrophic fingernails not cured with adequate systemic anti-fungal course. Diagnosis was based on a single mycological culture. Patients with treatment failure (n = 85; 78.7% of the cases) were compared to patients with partial response (mild to almost cure; n = 23; 21.3% of the cases) at 9 to 12 months following treatment initiation. Results Treatment failure was significantly associated with primary onycholysis (odds ratio [OR] 2.8; 95% confidence interval [CI] 1.1-7.4) and prolonged dystrophy (12.8 vs. 3.7 years in average), compared to partial treatment response. Non-responders had lower odds to present with distal lateral subungual onychomycosis, compared to partial responders (OR 0.3; 95% CI 0.1-0.7). Demographic and mycological characteristics, as well as number of nails affected, co-presence of paronychia, and treatment regime were not found to be associated with treatment response. Conclusion Candida-positive primary onycholysis was shown to be non-responsive to systemic anti-fungal treatment, suggesting that anti-fungal treatment is not indicated. For other clinical scenarios, high proportions of treatment non-response suggest that determining causality of Candida should not be based on a single positive mycological culture.

Introduction: Onychomycosis is a chronic nail fungal infection resulting in nail damage and a decreased quality of life. Chemical avulsion of the nail with urea and bifonazole ­removes fungally infected debris, increasing antifungal treatment efficacy and penetration. Previous clinical ob­servations describe patients who applied their urea and ­bifonazole ointment less frequently, achieving earlier nail removal. In this study, we analyzed the relationship between duration of urea and bifonazole application and time to nail avulsion. Methods: χ2 tests, multiple regression analysis, and ANOVA were performed to analyze the similarities between treatment regimens (daily, every 3 days, or once a week), association of regimens or patient characteristics to nail removal, and compare time to nail removal between each regimen, respectively. Results: Daily application of ointment and sealing resulted in an average length of time (±SD) to nail removal of 18.7 days (±6.8 days); once every 3 days resulted in nail removal at 12.7 days (±6.2 days) and once per week at 11 days (±4.46 days) (p < 0.001). Age was the only patient factor that affected duration to nail removal. Conclusion: Once weekly application of ointment with sealing for a 1-week duration is associated with a decrease in time to complete chemical avulsion of the nail by approximately 1 week.

Unfortunately, the co-author name was incorrectly published as “Jose L. López-Esterbaranz” instead of ‘Jose L. López-Estebaranz” in the original article. The correct version of author name is updated here. The original article has been corrected., SCOPUS: er.j, info:eu-repo/semantics/published

Background: Onychomycosis is a difficult-to-treat fungal infection of the nails. The efficacy of monotherapy is not ideal, and combination therapies provide an alternative that may increase treatment efficacy. Method: A retrospective analysis of data from 91 patients was undertaken. Treatment for toenail onychomycosis occurred between 2014 and 2016 and consisted of combination therapy with oral terbinafine (250 mg/day for 12 weeks) or itraconazole (3 pulses, 400 mg/day for 7 days) + K101 nail solution daily, or K101 nail solution monotherapy. Efficacy outcomes at 12 and 15 months were analyzed. Results: At 12 months, the clinical cure rate for combination of terbinafine + K101 solution was significantly higher than that for K101 monotherapy (p = 0.008). Patients receiving this combination also showed significant improvement in percent of affected nail at 3 months (p = 0.029), while patients receiving itraconazole + K101 solution demonstrated improvement in percent of affected nail at 6 months (p = 0.037). At 15 months, there was no significant difference between treatments for complete, clinical, and mycological cure. Conclusion: Combination therapy with oral terbinafine or itraconazole and K101 nail solution results in clearance of infected nail earlier than that with topical K101 alone. These combinations may encourage compliance and be effective for patients with moderate onychomycosis.

Wide differences in the cure rates of onychomycosis in various clinical studies can be avoided if we bear in mind some insights that will help us make study results more consistent. We suggest less rigid criteria in defining the cure rate, the inclusion of all toenails in studies, and the exclusion of nails with a history of trauma. Rather than address patients as a homogenous group, regardless of age, we suggest dividing them into age groups. Researchers should not forget inflammatory diseases that can imply changes on the nails and should take into account the duration of onychomycosis, nail changes caused by asymmetry, and the possibility of dermatophytoma.

Onychomycosis is a common disorder that is difficult to cure. Prevalence is lower in children (0.7%), but athletes are 2.5-fold more likely to develop the disease, with infections of the toenails seven times more prevalent than those of the fingernails. This is a concern for athletes as it can interfere with their performance. The risk of developing onychomycosis is increased by the warm environment of many sports activities; the use of occlusive footwear; the warm, moist environment associated with socks and sweating; shared, close quarters among athletes; and trauma to the foot and toenail. Once infected, onychomycosis treatment requires a long duration of treatment with strict compliance, a potential problem for younger patients. Treatment carries the risk of significant side effects, and recurrence rates remain high. Avoiding infection can be a potent first line of defense and may circumvent the need for treatment. Preventive recommendations such as keeping toenails short and proper washing of laundry, to name a few, can be effective and are discussed here. Technological improvements such as synthetic, moisture-wicking socks and well-ventilated, mesh shoes have also been shown to reduce moisture and injury. Education about preventing fungal spread and improving hygiene in the locker room, gym, and pool are of critical importance. This overview of onychomycosis focuses primarily on the preventive measures and innovative changes in athletic gear. It also provides a compact step-by-step guide to prevention intended to be useful for both the general public and the professional. It can be reproduced to use as a handout for athletes, trainers, and coaches.

Topical steroids for the treatment of retronychia.

Nail involvement in psoriasis is common, and the severity of it does not always parallel the intensity of cutaneous disease. We created a consensus group, of which the aim was to provide practical recommendations for the treatment of nail psoriasis in patients without skin psoriasis or with mild skin lesions with no indication for a systemic treatment. This collaborative process was conducted by an international panel of dermatologists with special expertise in nail disorders, using formal consensus methods. During this process, the panel strived to establish an agreement regarding the definition of nail psoriasis, the severity of nail psoriasis, and treatment response. Treatment recommendations are provided regarding nail psoriasis severity and matrix or bed involvement. Few-nail disease was considered as nail psoriasis affecting ≤3 nails. In the case of matrix involvement only, intralesional steroid injections were considered the treatment of choice. Topical steroids alone or in combination with topical vitamin D analogues were suggested for nail psoriasis limited to the nail bed. For the systemic treatment of nail psoriasis acitretin, methotrexate, cyclosporine, small molecules, and biologics may be employed., SCOPUS: re.j, info:eu-repo/semantics/published

Onychomycosis is the most common nail disease and affects large parts of the population. Psoriasis is a frequently encountered skin disorder with nail involvement being found in up to 80% of the patients at some time of the course of the disease. It has been postulated that onychomycosis occurs more frequently in patients with nail psoriasis, but the results of studies in the literature are controversial. Moreover, onychomycosis could exacerbate psoriasis through Koebner phenomenon and the treatment of psoriasis could predispose to onychomycosis. Finally, the differential diagnosis could be a real challenge due to many same clinical signs, the high prevalence and the possible coexistence of the two diseases. This article attempts to enlighten all these different aspects of a very close relationship.

Background: The nail bed may epithelialize and develop dermatoglyphics after long-standing onycholysis. We have called this phenomenon the disappearing nail bed (DNB). DNB may present as a shortened or narrow nail bed. Methods: Examination of all 20 nails was performed in each patient enrolled to the study. DNB was defined as the presence of a nail which is at least 20% shorter and/or narrower than the identical nail on the opposite hand or foot. Age, sex, and nail history were recorded. Fungal studies were done on all patients with DNB if that nail exhibited clinical signs of onychomycosis. Results: Of 540 patients, 71 (13.15%) showed DNB. Sixty patients had only the toenails involved, and 10 patients had only the fingernails involved. One patient had both toenails and fingernails involved. The average age for fingernail DNB was 67.2 years and 69.6 years for toenails DNB. Nail history was remarkable for biting in 8 patients, nail trauma in 11 patients, and surgery in 12 patients. With respect to the toenails, onychomycosis was found in 22 patients of the DNB group. Conclusions: Our study suggests that DNB is a common phenomenon, which is more likely to appear in advancing age and is associated with onychomycosis.

Paronychia refers to the inflammation and/or infection of the nail folds. It occurs in to forms commonly: acute paronychia and chronic paronychia. Both forms are caused by a disruption of the normal seals of the nail apparatus. The disruption of the seals in the nail apparatus is commonly caused by irritants, contactants, as wells as repetitive trauma from manicures. Acute paronychia often demonstrates a distinct collection of pus or abscess formation within a nail fold. The most common cause of acute paronychia is Staphylococcus aureus. It may also be caused by other organisms including methicillin resistant Staphylococcus aureus. Chronic paronychia refers to paronychia that lasts more than 6 weeks. The treatments for acute and chronic paronychia are distinct. Chronic paronychia is considered to be an inflammatory process, although there can be secondary colonization by Candida and hypersensitivity to Candida may play a role in persistence and exacerbation of the process.

Onycholysis refers to separation, most commonly distal, of the nail plate from the underlying nail structures. If it is distal, there is separation from the nail bed. It is less commonly proximal. The term onychomadesis refers to proximal separation of the nail plate from the nail matrix area. Simple onycholysis of the fingernails most commonly presents to the practitioner. Of topical antifungal medications, solutions are best, then lotions are next best. Most patients are troubled by the appearance of the nails, and usually the condition has been present for weeks to months before patients will seek medical advice. For onycholysis to occur, there must be a disruption of the adherence of the various components of the nail unit to each other. To establish the diagnosis of simple onycholysis, other primary dermatoses affecting the nail unit, such as nail unit psoriasis or nail unit lichen planus must be excluded. The role of Candida in onycholysis is controversial, and Candida can commonly be found on culturing nails with onycholysis. Treatment consists of a multifaceted approach. The most important aspect is an irritant avoidance regimen. The nails should be clipped back to the point of attachment at the nail bed to avoid additional trauma. Avoidance of nail cosmetics is important to help improve the onycholysis. Use of nail cosmetics may be resumed 1 month after the affected nails have returned to normal. Aside from the behavioral changes described above, topical antifungal medications can be helpful in hastening the resolution of onycholysis. Oral fluconazole may be of benefit in recalcitrant cases, especially when Candida has been cultured and/or pseudohyphae are found. For cases not responding to therapy, biopsy should be employed. The biopsy may show signs of a primary inflammatory dermatosis of the nail unit, or in the case of recalcitrant onycholysis of a single nail, may identify a tumor of the nail bed as the ultimate cause of the onycholysis. Long standing onycholysis may result in the disappearing nail bed.

Objective We evaluated the efficacy of griseofulvin and fluconazole in reducing the potential for person-to-person transmission of tinea capitis (TC) in children. Methods Children with TC with positive fungal cultures were treated with griseofulvin 25 mg/kg/day (group A) or fluconazole 6 mg/kg/day (group B) for at least 21 days and up to 12 weeks until cure was achieved. Clinical and mycologic examinations occurred before treatment and on days 3, 7, 10, 14, and 21 of treatment. During each visit, mycologic examination was performed from scalp lesions of children and fingertips of medical staff and parents after a brief touch of the patient's scalp lesions. Results Ninety patients were enrolled: 48 treated with griseofulvin and 42 with fluconazole. The predominant species were Trichophyton violaceum (n = 44) and Microsporum canis (n = 41), followed by Trichophyton mentagrophytes (n = 3) and Trichophyton rubrum (n = 2). Ten days after treatment more than 75% of patients from both treatment groups were noncontagious. At day 21, all patients from group A were noncontagious and two (7%) with positive culture of M. canis from group B were still contagious. Conclusions No statistically significant differences were found between treatment groups. Griseofulvin and fluconazole reduced the potential for disease transmission in children with TC, with griseofulvin being more effective for M. canis infections, although children with TC may be potentially contagious even after up to 3 weeks of treatment. These data should be considered regarding school attendance of children with TC.

Onychomadesis occurs when the proximal nail plate becomes unattached to the underlying structures. When only one or a few nails are involved, the cause is usually physical trauma. A 23-year-old female presented with a 4-year history of recurrent onychomadesis involving her bilateral great toes that occurred during the springtime. While recurrent trauma from winter shoes or athletic activities may be a contributing factor, our patient was convinced that wearing tight-fitting socks during winter nights was the primary pathophysiologic process. By wearing socks only during the days and decreasing the amount of time the nails spent traumatized due to pressure, the patient's recurrent condition was eliminated.

Recurrence rates are high for onychomycosis, with prophylactic topical antifungal use proposed to counter recurrence. Although this is a reasonable action for many clinicians, few studies have been conducted on the efficacy of topical prophylaxis. A retrospective chart review (2010-2015) was conducted in patients receiving oral terbinafine or itraconazole for toenail onychomycosis. Following complete cure, a topical antifungal (amorolfine, bifonazole, ciclopirox olamine, or terbinafine spray) was used weekly as prophylaxis. Recurrence was recorded along with patient characteristics including demographics and concomitant medical conditions. Data from 320 patients were collected. Recurrence was significantly lower in patients receiving topical antifungal prophylaxis than in no prophylactic treatment following oral terbinafine (p < .001), but not itraconazole (p = .185). Regardless of oral treatment, the use of topical antifungals as prophylaxis (p < .001) decreased, and the number of affected toenails (p = .048) and family history of fungal infections (p < .001) increased the likelihood that recurrence would occur. This study supports the use of topical antifungal medications as prophylactic treatment to help prevent recurrence of toenail onychomycosis and suggests that those with a family history of fungal infections should be closely monitored.

Melanonychia may occur in all age groups. Melanonychia is more common in adults than in children. The peak age of incidence of nail unit melanoma is 50–70 years. Nail unit melanocytic nevus with longitudinal melanonychia is more frequent in children than in adults. African–Americans present a higher incidence of longitudinal melanonychia. Nail unit melanoma is more common in dark-skinned subjects. Nail melanoma in children is rare.

Beau lines, onychomadesis, and retronychia are nail dystrophies with distinctive clinical findings. Trauma has been reported as the initiating factor in each of these entities. Infections, severe medical illnesses, major surgery/anesthesia, medication side effects, and autoimmune disease can produce Beau lines and onychomadesis. This article illustrates the common underlying pathophysiological mechanism that produces each of these nail dystrophies.

Drugs, chemicals, and biological substances accumulate and are stored in hair and nails where they can be detected and measured. Advantages of analyzing hair and nail samples also include their easy and non-invasive collection, the small sample size required for analysis, and their easy storage at room temperature. We report 3 examples of heavy metal poisoning diagnosed because of the hair or nail symptoms. Drugs and toxins that can be detected in hair and nails are reviewed and the application of hair/nail analysis in general and in forensic medicine is discussed.

The severity of tinea pedis infection determines the course of treatment required. Mild infections may be resolved using a topical agent. More severe presentations (eg, dermatophytosis complex) may require treatment that eliminates the bacterial and fungal infection. Some topical monotherapies may exhibit both antifungal and antibacterial activity. In other instances, it may be necessary to combine an antifungal agent with an antibacterial agent. If inflammation is present, an agent with known anti-inflammatory action may need to be used. The chronic presentation of tinea pedis (dry type) sometimes does not respond well to topical therapy. In such instances, systemic antifungal therapy is required to ensure that adequate concentrations of the therapeutic agent are present at the site of infection.

Clinical diagnosis of nail disorders is often difficult since different diseases produce nail signs that are quite similar. Most available books on nails describe the different nail disorders but are difficult to consult for doctors who are not specifically interested on nails. The purpose of this book is to provide the differential diagnosis of nail disease starting from the clinical evaluation, this will permit to doctors who are approaching nails for the first time to see all the nail diseases that can cause that particular sign and to know which exams are important to reach the final diagnosis. Therapy for each disorder is provided. This book is designed to provide all dermatologists with the tools to diagnose nail disorders by clinical signs. Certain important nail signs will be illustrated by clinical pictures and in some cases schematics. Then with this information the clinician will be on his/her way to obtaining the proper diagnosis. With the correct diagnosis, it is easier to give the best therapy. This book will offer dermatologists a simple and quick approach to the diagnosis and management of nail disorders.

AAD Ad Hoc Task Force on Bioterrorism: This algorithm for cutaneous anthrax is intended to offer physicians the Task Force’s current recommendations for treating this disease. It is not intended to establish a legal standard of care. Adherence to these guidelines will not ensure successful treatment in every situation. Furthermore, these guidelines should not be deemed inclusive of all proper methods of care or exclusive of other methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding the propriety of any specific therapy must be made by the physician and the patient in light of all the circumstances presented by the individual patient. These recommendations are subject to regular revision as updated information becomes available.

Nail plate and nail unit abnormalities may be helpful as diagnostic tools or as a part of the puzzle for confirmation of systemic disease. There are specific and nonspecific nail signs, which can be seen involving one or more nails, that occur simultaneously or secondary to systemic disease. Occasionally these clues can be diagnostic, while most are nonspecific reaction patterns. Nail changes occur in the nail plate as a result of nail matrix abnormalities caused by systemic disease and other systemic insults such as reactions to medications. In this article we review some of the more common nail signs that can be used to help diagnose systemic disease.

Background: Atopic dermatitis/eczema (AD/E) is a common disease. Few studies have attempted to quantify the cost to third-party payers. Objective: Our purpose was to identify the annual cost of medical services and prescription drugs for the treatment of AD/E to private insurance and Medicaid payers in the United States. Methods: We used a retrospective study design employing claims data from 1997 and 1998 from a private insurer and a state Medicaid program to analyze costs incurred. Beneficiaries were considered to have AD/E if they had at least one claim in 1997 with a primary or secondary listing of 1 of 3 diagnosis codes: 691.8, other atopic dermatitis and related conditions; 692.9, contact dermatitis and other eczema when no cause is specified; or 373.3, noninfectious dermatoses of eyelid. Patients who did not meet the diagnosis criteria served as a control group in each payer for comparisons of expenditures with the AD/E group. Results: Disease prevalence was 2.4% (private insurer) to 2.6% (Medicaid) of all eligible beneficiaries, and 3.5% to 4.1% of patients submitted at least one health care claim during the study period. Medicaid-insured patients used outpatient hospital visits and hospitalizations at a greater rate than did privately insured patients; neither used emergency departments extensively. The third-party payer cost of illness for AD/E ranged from $0.9 billion to $3.8 billion when projected across the total number of persons younger than 65 years insured by private insurers and Medicaid in the United States. More than one fourth of all health care costs for patients with AD/E may be attributed to AD/E and co-morbid conditions. Conclusions: Annual costs of AD/E are similar to those of other diseases such as emphysema, psoriasis, and epilepsy. Patients incur significant costs associated with AD/E and co-morbid conditions. (J Am Acad Dermatol 2002;46:361-70.)

O nychomycosis is a common disorder and makes up approximately half of the nail disorders and 30% of the dermatophytoses we see as dermatologists. In older individuals the prevalence is high and likely approaches 60% or more in those older than 70 years. During the 1990s, onychomycosis was ‘‘hot,’’ not in any small part because of the onychomycosis treatment battles between orally administered terbinafine and itraconazole. Since 1996, however, no new Food and Drug Administrationeapproved systemic drugs for onychomycosis have come to market. During this time, the use of griseofulvin for tinea unguium has greatly diminished because of the greater efficacy of terbinafine and itraconazole. Topical ciclopirox lacquer is the latest onychomycosis drug to be approved in the United States, but its efficacy in providing a complete cure as a monotherapy is unacceptably low. This situation is compounded as longterm follow-up of patients treated for tinea unguium has been lacking. Indeed, the article by Piraccini et al is a welcome addition to the literature. This was a 7-year prospective study limited to patients who had achieved a complete (clinical and mycological) cure with either terbinafine or itraconazole. Of 73 patients, 41 also used topical amorolfine after achieving cure. ‘‘The administration of systemic terbinafine to treat the first episode of onychomycosis seemed to provide better long-term success in those patients with a complete response. . ..’’ The statistical value was difficult to access because 59 patients were treated with terbinafine and only 14 with itraconazole.

Background: Onychomycosis is the most frequent cause of nail disease and represents 30% of all mycotic infections of the skin. Objective: Our purpose was to compare the effectiveness and tolerability of intermittent dosing of itraconazole ("pulse therapy") with placebo in fingernail onychomycosis. Methods: Seventy-three patients with clinically and mycologically diagnosed fingernailonychomycosis were randomly selected to receive itraconazole, 200 mg twice daily, or placebo for the first week of each month for 2 consecutive months; patients were observed for 19 weeks. Seventy-one patients received the study medication and were included in the safety analysis. Efficacy of treatment was evaluated in 46 patients. Results: A significantly greater proportion of itraconazole-treated patients than placebo-treated patients achieved clinical success (77% vs 0%), mycologic success (73% vs 13%), and overall success (68% vs 0%). No itraconazole-treated patient had a clinical or mycologic relapse during the follow-up period. Ten itraconazole-treated patients (28%) and nine placebo-treated patients (26%) had adverse events. Three patients discontinued treatment for safety reasons. Conclusion: Pulse therapy with itraconazole for 2 consecutive months produces significantly greater clinical, mycologic, and overall success than placebo. Short-term itraconazole pulse therapy for fingernail onychomycosis is effective and well tolerated. (J Am Acad Dermatol 1997;36:231-5.)

The traditional management of onychomycosis includes mechanical, chemical, and surgical approaches, as well as topical and oral antifungal medications. Topical preparations have been consistently disappointing, and the tendency in later years has been to rely on two systemic agents-griseofulvin and ketoconazole-for management of more severe or recalcitrant infections. However, both drugs require a long duration of therapy (4 to 6 months for fingernails, 10 to 18 months for toenails). Even with such prolonged treatment, the overall success rate is only about 15% to 30% for toenail infections and 50% to 70% for fingernail infections. Furthermore, both griseofulvin and ketoconazole have numerous potential side effects and drug/drug interactions. Therefore, laboratory monitoring should be performed during the course of treatment with these agents and they should be used only after evaluation of the patient's current medical status and a review of concomitant medications.

There are no known pathognomonic nail signs of human immunodeficiency virus (HIV) infection. However, several presentations should increase the index of suspicion. (1) Proximal white subungual onychomycosis or superficial white onychomycosis, especially of the fingernails, is present. Trichophyton rubrum appears to cause both most commonly in HIV-infected patients. Periungual dermatophyte involvement and involvement of all 10 fingernails is unusual in non-HIV-infected persons. (2) Candida is a primary pathogen of the nail bed and nail plate especially if many nails are involved. (3) A destructive, almost granulomatous-like psoriatic involvement of the nails is present. (4) Squamous cell carcinoma of the nail bed in a young adult. There are no clinical trials to confirm the efficacy of therapy mentioned in this article. The treatment suggestions are empirical and are the personal views of the authors.

Nail lichen planus is an uncommon inflammatory disorder of unknown etiology that may present as an isolated finding or maybe associated with mucosal or cutaneous lichen planus. Diagnosis is not always easy as nail lichen planus may have different presentation depending on whether the inflammation involves the nail matrix, nail bed, or both. Onychoscopy may be helpful, but a nail biopsy is always suggested to confirm the clinical suspect. Nail lichen planus has the peculiar characteristic to have a potential scarring outcome; therefore, prompt diagnosis and treatment are mandatory. The choice of therapy is difficult, as there aren’t guidelines for treatment and the published literature is limited to case series and expert opinions. The gold standard treatment of nail lichen planus is based on steroids, which can be either injected intralesionally, if one up to three nails are involved, or prescribed systemically. Treatment should last 4–5 months and then be tapered off. Fingernails respond quicker than toenails. The prognosis of lichen planus is variable: 1/3 of the patients in fact do not respond to therapy, and recurrences are common.

Paronychia is an inflammatory disorder affecting the proximal and lateral nail folds, which normally protect the nail matrix from the environment. It is a very common fingernail affection, three times more common in women than in men and occurring at any age.

International audience; Background: Selected lactic acid bacteria were reported to prevent atopic dermatitis and experimental asthma but the mechanisms of their immunomodulatory effects are not fully elucidated. In this study, the signaling pathways triggered by Lactobacillus plantarum NCIMB8826 were investigated and the potential use of this strain producing a variant of the mite allergen Der p 1 as live vaccine vehicle was evaluated.Methods: Mouse bone marrow-derived dendritic cells were stimulated with wild-type or a L. plantarum teichoic acid mutant to evaluate the secretion of cytokines. A recombinant L. plantarum expressing Der p 1 was engineered, its in vitro immunomodulatory properties were characterized and its prophylactic potential was evaluated in a Der p 1-sensitization murine model.Results: Mouse dendritic cells stimulated by L. plantarum triggered the release of interleukin-10 (IL-10), IL-12 p40, IL-12 p70 and tumor necrosis factor-alpha (TNF-α). IL-12 p40 secretion was dependent on nuclear factor-κB (NF-κB), mitogen-activated protein (MAP) kinases, Toll-like receptor 2 (TLR2), TLR9 and on the bacterial teichoic acid composition. Recombinant L. plantarum producing Der p 1 exhibited similar immunostimulatory properties as wild-type. Prophylactic intranasal pretreatment of mice with this recombinant strain prevented the development of the typical Th2-biased allergic response by a drastic reduction of specific IgE and the induction of protective allergen-specific IgG2a antibodies. Moreover, both wild-type or recombinant L. plantarum reduced airway eosinophilia following aerosolized allergen exposure and IL-5 secretion upon allergen restimulation.Conclusion: By combining both Th1-type immunostimulatory properties and an efficient allergen delivery capacity, recombinant L. plantarum producing Der p 1 represents a promising vaccine against house dust mite allergy.