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Subungual osteochondroma is a relatively uncommon benign bone tumor affecting mostly children and young adults, and is a major source of pain and nail deformity. Treatment consists of marginal excision and meticulous wound closure. In this report, we present three cases of subungual osteochondroma arising from the dorsal aspect of distal phalanx of the great toe, which were managed by marginal excision with preservation of nail apparatus under digital block anesthesia with the use of a ring tourniquet. We emphasize on the use of ring tourniquet made by glove's finger and the technique of preserving the nail apparatus to prevent nail deformity. At final follow-up, there is no evidence of recurrence or nail deformity with good functional and cosmetic result.

Onychomycosis, a fungal infection caused by dermatophyte fungi such as T. rubrum and non-dermatophyte fungi which affect about 2-8% of people worldwide. Treatment of onychomycosis is hampered owing to poor systemic circulation into the nail apparatus and highly compact structure of nail plate that limits the topical delivery of drugs. Basically, two types of therapies are discussed in this review article, which are traditional and device based therapies. Traditional therapy includes surgical, topical and systemic treatments of onychomycosis. Device-based therapy is a non-invasive treatment which includes Iontophoresis, Ultrasound, Photodynamic, and Laser treatments.

Background Lichen planus (LP) is a common skin disorder of unknown aetiology that affects the skin, mucous membranes and nails. Although metal allergies have been implicated in the development of oral LP (OLP), the contribution of these allergies to nail LP (NLP) has yet to be studied in detail. Objective To elucidate the link between metal allergy and NLP. Methods We retrospectively analysed 115 LP patients with respect to the contribution of metals to either NLP or OLP. We also attempted to detect the specific metals involved in these nail lesions. Results Of the 79 patients that received a metal patch test (PT), 24 (30%) were positive for at least one of the metal compounds tested. Notably, the prevalence of positive reactions to metals in the NLP patients was significantly higher as compared with the OLP patients (59% vs. 27%, P

Onychomycosis is a fungal infection of the nail apparatus that affects 10 - 30% of the global population. Current therapeutic options for onychomycosis have a low to moderate efficacy and result in a 20 - 25% rate of relapse and reinfection. New therapeutic options are needed to broaden the spectrum of treatment options and improve the efficacy of treatment.This review discusses the emerging pharmacotherapeutics; including topical reformulations of terbinafine, new azole molecules for systemic and topical administration, topical benzoxaboroles and topical polymer barriers. The paper also discusses device-based options, which may be designed to activate a drug or to improve drug delivery, such as photodynamic therapy and iontophoresis; laser device systems have also begun to receive regulatory approval for onychomycosis.Device-based therapeutic options for onychomycosis are expanding more rapidly than pharmacotherapy. Systemic azoles are the only class of pharmacotherapy that has shown a comparable efficacy to systemic terbinafine; however terbinafine remains the gold standard. The most notable new topical drugs are tavaborole, efinaconazole and luliconazole, which belong to the benzoxaborole and azole classes of drugs. Photodynamic therapy, iontophoresis and laser therapy have shown positive initial results, but randomized controlled trials are necessary to determine the long-term success of these devices.

The classification of onychomycosis, infection of the nail apparatus caused by fungi, has changed over time with the recognition of new pathways of nail infection, new organisms, and new variations in the appearance of diseased infected nail. Taking into account published descriptions of nail morphology in fungal infection, the following forms of onychomycosis are recognized: distal and lateral subungual, superficial, endonyx, proximal subungual, mixed, totally dystrophic, and secondary onychomycosis. These can be subdivided, where appropriate, by color and pattern of nail plate change. The purpose of the revised classification is to provide a framework to assist selection of treatment, estimate prognosis, and evaluate new diagnostic methods.

Nail apparatus deformities associated with burn injuries can cause significant functional and aesthetic concerns. The majority of perionychial deformities result from eponychial retraction and scarring, whereas a minority are due to direct damage to the regenerative part of the nail complex. A variety of different techniques have been described for reconstruction including the use of local flaps, skin/composite grafts, and microvascular transfer. The authors review the different strategies available in the current burns literature and present an algorithm for the management of perionychial burn deformities.

Fingertip amputations are a common injury in both adults and children. Replantation with revascularisation provides the gold standard result but is not always possible due to lack of expertise, degree of injury or patient factors. Perionychial grafts harvested from the amputated digit tip, anatomically restored and supported by a local flap are already known to be an effective option in the treatment of adult fingertip amputations. Such procedures can be performed by surgeons familiar with local flap techniques, can result in nail apparatus survival even with greater degrees of tissue injury and do not require prolonged protection or immobilisation. We present a consecutive series of four adults and four children who underwent perionychial grafts with flap support, to report the range of nail apparatus outcomes and to demonstrate this technique's relative utility in children.

Case Reports; Journal Article; Review; Superficial Acral Fibromyxoma is a rare tumor of soft tissues. It is a relatively new entity described in 2001 by Fetsch et al. It probably represents a fibrohistiocytic tumor with less than 170 described cases. We bring a new case of SAF on the 5th toe of the right foot, in a 43-year-old woman. After surgical excision with safety margins which included the nail apparatus, it has not recurred (22 months of follow up). We carried out a review of the location of all SAF published up to the present day. Yes

Longitudinal melanonychia presents in various conditions including neoplastic and reactive disorders. It is much more frequently seen in non-Caucasians than Caucasians. While most cases of nail apparatus melanoma start as longitudinal melanonychia, melanocytic nevi of the nail apparatus also typically accompany longitudinal melanonychia. Identifying the suspicious longitudinal melanonychia is therefore an important task for dermatologists. Dermoscopy provides useful information for making this decision. The most suspicious dermoscopic feature of early nail apparatus melanoma is irregular lines on a brown background. Evaluation of the irregularity may be rather subjective, but through experience, dermatologists can improve their diagnostic skills of longitudinal melanonychia, including benign conditions showing regular lines. Other important dermoscopic features of early nail apparatus melanoma are micro-Hutchinson's sign, a wide pigmented band, and triangular pigmentation on the nail plate. Although there is as yet no solid evidence concerning the frequency of dermoscopic follow up, we recommend checking the suspicious longitudinal melanonychia every 6 months. Moreover, patients with longitudinal melanonychia should be asked to return to the clinic quickly if the lesion shows obvious changes. Diagnosis of amelanotic or hypomelanotic melanoma affecting the nail apparatus is also challenging, but melanoma should be highly suspected if remnants of melanin granules are detected dermoscopically.

Subungual melanoma represents approximately 1 - 3 % ofall cutaneous melanomas in light-skinned people, while in dark-skinnedpeople (phototype V and VI) it is one of the most common melanomasubtypes. Since differentiation to benign nail lesions can be difficult,diagnosis is often made at an advanced tumor stage. Prognosis considerablydepends on tumor thickness and is rather poor compared to othermelanoma subtypes. Micrographic surgery allows a complete excisionwith functionally and cosmetically acceptable results making anamputation nowadays mostly dispensable.

Background: Onychomycosis is a very common disease and accounts for upto 50% of the diseases affecting the nail apparatus. Diagnosis of onychomycosis is usually confirmed with the help of a potassium hydroxide (KOH) mount and fungal culture. Onychoscopy can be a handy and additional tool for the diagnosis. Aims and Objectives: To determine the dermoscopic findings in distal lateral subungual onychomycosis (DLSO). Materials and Methods: A prospective study of 60 nails with a clinical and mycological diagnosis (KOH with Chicago sky blue positive) of DLSO. Dermoscopic examination was performed using a Heine delta 20 plus dermatoscope and the features were recorded. Results: Longitudinal striae and jagged proximal edges seen in all 60 (100%) patients. Intermittent spiked pattern was seen in 47 nails (78.3%). Chromonychia and distal irregular termination were noticed in 23 (38.3%) and 7 (11.7%) nails, respectively. Conclusions: Onychoscopy can be used as an important diagnostic tool while evaluating nail disease, especially in DLSO. Limitations: Small study sample and lack of comparison with other nail diseases that manifests with distal onycholysis.

PURPOSE To provide the practitioner with current information on the most common nail disorders. TARGET AUDIENCE This continuing education activity is intended for physicians and nurses with an interest in wound care and related disorders. OBJECTIVES After reading this article and taking this test, the reader should be able to: 1. Describe the structures that compose the nail apparatus. 2. Identify the most common nail disorders, including etiology and treatment.

an asymptomaric subungual nodule should always be biopsied

The fingernail serves many functions during everyday use of the hand that are often taken for granted. The perionychium is a multifaceted structure, the anatomic details and physiologic function complexities of which must be firmly grasped by those surgeons wishing to effectively treat injuries to the fingertip. The nail itself serves to protect the fingertip, regulate peripheral circulation, and enhance the tactile sensibilities that allow humans to perform very fine motor functions. Injuries to the nail apparatus cause functional deficits and cosmetic deformities. Because of the relative prominence of the nail on the fingertip, the perionychium is the most frequently injured part of the hand.

The nail apparatus contains tissues of various echogenicities and is thus well suited for ultrasound examination. Furthermore, ultrasonography is widely available and non-invasive and may therefore be used for longitudinal studies of tissues and diseases. Characteristic ultrasound pictures can be seen in psoriasis, cysts, vascular abnormalities,and other nail diseases. Ultrasound examination can visualize and quantify morphologic and functional aspects of nail biology.

Background Although nail apparatus melanoma has been widely evaluated, only limited data are available concerning its clinical features, which depend on its initial clinical morphology, broadly defined as a melanonychia or nonmelanonychia lesion. Objective We sought to determine heterogeneity on the basis of the initial clinical morphology of nail apparatus melanoma. Methods We searched the Asan Medical Center database for cases of nail apparatus melanoma that were confirmed by skin biopsy specimen. Patients were classified with either nail apparatus melanoma that began as melanonychia (group A) or nail apparatus melanoma that began as nonmelanonychia lesions (group B). Results We identified 49 patients with nail apparatus melanoma. Of these, 29 and 20 patients were included in groups A or B, respectively. The prediagnosis duration was significantly longer in group A. At the time of diagnosis, advanced stage and deeper Breslow thickness were noted in group B. The median overall survival period of the whole cohort was 93.0 months, and the 5-year overall survival was 67%. Patients in group A demonstrated better survival outcomes. Limitations This study is a retrospective, single-center design. Conclusion Nail apparatus melanoma demonstrates different clinical features and survival outcomes depending on whether the lesion begins as melanonychia or nonmelanonychia.

Item does not contain fulltext Hair and nails are often stated to have much in common in relation to their origin, anatomical structures, and common involvement in many diseases. Hair and nails are predominantly epithelial structures derived from primitive epidermis and made up of keratinous fibrils embedded in a sulfur-rich matrix. It was first noted early in the 20th century that the nail unit was comparable in several respects to a hair follicle sectioned longitudinally and laid on on its side. The epithelial components of hair follicle and nail apparatus are differentiated epidermal structures that may be involved jointly in several ways as congenital and hereditary anomalies and acquired conditions such as alopecia areata, lichen planus, iatrogenic causes, and fungal infection. Multielemental characterization of human hair and nails shows that even after sample washing, many elements are enriched in the surface of the nails.

O melanoma do aparelho ungueal é apresentação relativamente rara dessa neoplasia, muitas vezes diagnosticada como nevo juncional, hematoma subungueal ou mesmo onicomicose. Esse fato leva a um atraso no diagnóstico e, conseqüentemente, na instituição da terapêutica específica, contribuindo para agravar o prognóstico de uma doença que por si só já é muito agressiva. Os autores relatam um caso de melanoma no primeiro quirodáctilo esquerdo de uma paciente negra com evolução de um ano, ressaltando a importância de avaliar certos critérios clínicos para obter o diagnóstico em fases mais precoces da doença. Nail apparatus melanoma is a rare presentation of melanoma and may be misdiagnosed as junctional nevus, subungual hematoma or onychomycosis. This fact often leads initially to inappropriate treatment and significant delays in appropriately managing such an aggressive disease. The authors report a case of melanoma on the left thumb of a black patient evolving for a year. Emphasis was placed on the importance of assessing certain clinical characteristics in order to reach an early diagnosis.

Fingertip injuries can be treated in different ways, including shortening with primary closure, skin grafts, and local or distant flaps. Nail bed involvement complicates fingertip reconstruction and may influence the choice of treatment. Local flaps can usually replace the pulp and provide a satisfactory functional and aesthetic result, whereas reconstruction of the fingernail apparatus is more difficult. In the period between 1998 and 2001, 12 fingertip injuries with nail bed involvement were treated with a combination of local flaps (Tranquilli-Leali and Venkataswami flaps) and the eponychial flap. The eponychial flap described by Bakhach is a backward cutaneous translation flap that lengthens the nail plate and restores a good appearance of the nail apparatus. This technique is simple to use and can be used with different flaps for pulp reconstruction.

Psoriasis of the nail greatly affects quality of life because of the difficulty in achieving long-lasting remission. Pustular psoriasis of the nail apparatus is characterized by the formation of sterile pustules, starting on one or two fingers or less often on the toes, and spontaneous improvement has rarely been observed. This case presents a girl with refractory nail psoriasis accompanied by periodic pustular eruption that responded well to topical treatment with indigo naturalis oil extract drops, achieving a remission of longer than 1 year.

We report the first case of subungual perineurioma presenting as clubbing of one finger, an unusual clinical feature. Histological study showed a myxoid tumour but with, unexpectedly, a diffuse expression of CD34. Differential diagnoses between perineurioma and myxoid soft tissue tumours expressing CD34 are discussed.

Congenital nail apparatus nevi often show substantial enlarge -ment and wide involvement and greatly concern parents of a child as well as dermatologists. The differential diagnosis from melanoma is critical. The biopsy of the nail matrix is very traumatic and a fearful experience for a child. Therefore, a longterm careful follow-up with digital monitoring is very important and should be the first choice of management.Ronger et al. [1] reported that only three cases of mel-anoma showed micro-Hutchinson’s sign in 148 cases of melanonychia. However, similar findings are also observed in congenital nevus of the nail apparatus. We report three cases of congenital or early-onset nevus of the nail appara-tus with minute periungual regular pigmentation found on dermoscopy.We used the terms, “Hutchinson’s sign” and “pseudo-Hutchinson’s sign” based on the original descriptions [2, 3]. Baran and Kechijian [3] originally defined the term, pseudo-Hutchinson’s sign, for three conditions, including 1) benign pigmentation of the nailfolds, 2) pigmentation of the nailfolds due to malignant but non-melanoma tumors, 3) pigmentation seen through translucent nailfolds.

The nail plate is the permanent product of the nail unit. Consequently, any aggression of any structure of the nail apparatus will be transmitted as alterations to the nail plate and/or surrounding tissues. In occupational contact dermatitis, common sensitizers, plants or flowers, produce nail modifications. Cosmetic sensitizers are a special type of allergen in the nail region.

Biopsy of the nail unit is often undertaken for the evaluation of irregular pigmentation, especially longitudinal melanonychia (pigmented bands). There are a variety of barriers to arriving at a diagnostic conclusion, however. The nail plate covers the source of the pigmentation. Clinical cues can thus be misleading. There may be a lack of familiarity with nail anatomy and biopsy techniques on the part of the clinician. Suboptimal specimens may thus result. Many pathologists also lack familiarity with normal nail unit histology and pathology, and many pathology laboratories lack experience with respect to handling of these specimens, which often contain both delicate tissue and a hard nail plate, leading to technical shortcomings.

Rhinosporidiosis is an uncommon chronic granulomatous disease caused by Rhinosporidium seeberi. It primarily affects the nasal mucosa and the nasopharynx. The disease may disseminate to the skin, larynx, trachea, genitalia, bones and even the internal organs. Although simultaneous onset of nasal and disseminated lesions has been reported, dissemination usually occurs several years after the onset of nasal lesions. We report a rare case of disseminated rhinosporidiosis involving both nares, the nasal mucosa, nasopharynx, oral cavity and oropharynx, as well as widespread cutaneous lesions over the trunk and the limbs with nail involvement. This last feature has not, to our knowledge, been previously reported.

Epidermoid carcinoma of the nail apparatus (ECNA) has attracted increasing interest for the following reasons: greater awareness of its frequency, variability in its clinical presentation, potential involvement of several digits, discovery of the involvement of human papillomavirus (HPV) types 16, 34, and 35 as possible causative factors, and its similarity to epidermoid carcinoma of the anogenital areas. We describe a man with an in situ epidermoid carcinoma of the fourth fingernail presenting as a longitudinal melanonychia (LM), in which HPV-16 DNA was detected.

Nail abnormalities can arise in conjunction with or as a result of systematic pathologies. These pathologies include single-organ diseases, multisystemic diseases, and drug-induced insults. Clinical signs associated with these conditions include dyschromias, vascular alterations, periungual tissue changes, textural dystrophies, contour alterations, and growth-rate alterations. The associated systemic pathologies may affect any part of the nail apparatus, including the nail matrix, the nail plate, the nail bed, the underlying vasculature, and the periungual tissues. The anatomical location and extent of damage determine the clinically manifested anomaly.

Item does not contain fulltext Bowen's disease or squamous cell carcinoma in situ is a malignancy of the skin confined to the epidermis that unusually involves the nail apparatus. The ideal treatment should complete clear the tumor, with preservation of the cosmetics and the function of the finger, which can be very difficult to achieve depending on tumor's location and the extension. The high cure rates for Bowen's disease and the principles of photodynamic therapy, suggest that this technique may be a great option in the management of this kind of lesion. Therefore, this is a case report of a 47-years-old man with diabetes and HIV+ serology who presented a patch of Bowen's disease at the distal phalange of the finger treated with photodynamic therapy in order to avoid surgical complications, a more aggressive treatment or even mutilation. An excellent response was reached, preserving all the structures of the nail, with clinical and histopathological cure and complete remission after two years of follow up. 01 december 2013

Introduction Anatomically, nail is a hard protective covering over the terminal phalynx, and this helps to avoid any injury, as well as enhances the sensory perception over the pulp of digits. The nail apparatus consists of nail plate, nail folds, nail bed, and hyponychium. Various Diseases may affect the nail, eg infections, papulosquamous disorder, habitual dosrde and tumorers. Patients and methods We included 250 patients aged more than 18 years presenting to our out patients department (OPD) primarily with nail complaints. A detailed history of the disease was taken, and all the 20 nails were examined. Relevant investigations (KOH scraping, pus culture sensitivity, or biopsy) were performed. Results The age of the patients varied between 18 and 85 years, with a mean value of 35.37±15.16 years. Male to female ratio was 1:1.06. About 24 patients belonged to the geriatric age group. In all, 50 (20%) patients had their disease directly related to their profession. The most common presenting complain was discoloration followed by deformity. Finger nails were more commonly involved. The most common diagnosis was onychomycosis (55.6%), followed by traumatic nail (6.4%), chronic paronychia (4.4%), acute paronychia (3.6%), lichen planus (3.6%), onychocryptosis (3.6%), and eczematous nail changes (1.6%). Conclusion Onychomycosis is the most common primary nail apparatus abnormality responsible for discoloration of nail presenting to dermatology OPD, followed by nail trauma, paronychia, lichen planus, and onychocryptosis.

Malignant Melanoma is a high mortality neoplasm. The involvement of the nail apparatus is rare, with only 2 out of 3 patients seeking medical attention as the result of recent nail melanocytic lesions. This results in late diagnosis and a prognosis worse than cutaneous melanoma. We report a female, presenting with ulcerative lesions with clinical and laboratory features compatible with leishmaniasis. On return after treatment initiation a longitudinal melanonychia was observed on her first right finger. Biopsy of the nail matrix was performed. Histopathology was compatible with melanoma in situ. Longitudinal melanonychia is not a specific sign for melanoma and it is important that the dermatologist should identify the suspect lesions correctly. The incidental diagnosis of nail melanoma in situ in our case significantly impacted the patient's survival.

The nail unit is constructed by distinctly regulated components. The nail isthmus is a lately proposed region as a transitional zone between the most distal part of the nail bed and the hyponychium. It is difficult to recognize the nail isthmus in the normal nail, but it is easy to identify the region in nail disorders such as pterygium inversum unguis and ectopic nail. We describe structure and putative function of the nail isthmus via histopathologic features of pterygium inversum unguis and ectopic nail.

The paper summarizes the data available in the literature on the prevalence of onychomycoses worldwide, their etiology, clinical presentation, and treatment and the authors’ clinical experience. It presents criteria for the systemic and local therapy of onychomycoses and describes nail plate removal methods (indications, contraindications, and complications) in the view of a dermatologist and a surgeon. The current concept of onychomycosis treatment with the local antimycotic naftifine and nail apparatus removal is given.

Summary We report two cases of acquired fibrokeratoma which present new clinical and histological features specific to the nail apparatus. There are three histological characteristics, (i) A deep epithelial invagination which develops from the proximal nail fold and is orientated in the same direction as, but is more proximal than, the normal matrix, (ii) The postero-inferior aspect of the cul-de-sac produced by the invagination acts as an accessory matrix, giving rise to a pseudo-nail plate. The granular layer is reduced or absent, (iii) This accessory nail apparatus lies on a conical dermal tumour, sharply demarcated from the surrounding dermis, with a wide base narrowing towards the tip. The finger shaped structure is reminiscent of Kint's type I acquired fibrokeratoma.

We report a patient who developed a subungual radiodermatitis 25 years following radiotherapy for a verruca of the lateral nail fold. The different stages and the treatment of chronic radiodermatitis of the nail apparatus are described. We want to emphasize the late onset of such lesions and the prime importance of the anamnesis.

Background: New targeted therapies have been developed for inflammatory and neoplastic diseases. Main observation: We report on a 73-year-old woman who developed multiple eruptive periungual and subungual pyogenic granulomas. Because of severe rheumatoid arthritis the patient was treated with monoclonal anti-CD20 antibodies. Eruptive granuloma pyogenicum developed after the second antibody application and remained more than 8 weeks after targeted therapy was over. New lesions, however, did not appear. Conclusion: Eruptive granuloma pyogenicum of the nail apparatus is a possible new rare adverse effect of targeted therapies. To the best of our knowledge this is the first case in association with anti-CD20 antibody treatment. ____________________________________________________ Wollina U. Multiple eruptive periungual pyogenic granulomas during anti-CD20 monoclonal antibody therapy for rheumatoid arthritis. J Dermatol Case Rep. 2010; 4(3): 44-46.

The indications for retinoids in diseases involving the nails fall into 3 groups: proven use (with sometimes controversial reports); possible use; and suggested use. The complications of the retinoids on the nail apparatus are reviewed and their mechanisms explained.