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Nail Disorders in Dark Skin 34 Moetaz El-Domyati and Noha H

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Nail Disorders in Dark Skin 34 Moetaz El-Domyati and Noha H Nail Disorders in Dark Skin 34 Moetaz El-Domyati and Noha H. Moftah The nail unit is a skin appendage produced by the skin. Its painful paronychia result, occasionally, with pus-filled small major function is mechanical protection of the distal digit, abscesses. Chronic paronychia may be painful and show peri- also representing a part of the overall cosmetic appearance of odic flare-ups in labor workers, after exposure to chemicals the body. Genetic disorders, infections, various dermatoses, and other irritants, etc. Treatment is by warm soaks with senility, tumors, etc. may result in a series of changes of the water, liquid antibacterial soaps, and topical antibiotics; in nail showing alterations of growth, color, thickness, and con- severe cases oral antibiotics may be required. If a paronychial tour of the nail plate. Thus, examination of the digits and abscess is diagnosed, surgical drainage is indicated [2]. nails often provides diagnostic clues for underlying cutane- ous or systemic disease. Alterations and deformities of the nails may be characteristic and helpful for the physician to 34.1.2 Fungal Infections support his diagnosis; others are not specific but still provide valuable clues for targeted medical investigation. Major dif- Infection of the nails with dermatophytes, Tinea (T.) ferences of nail pathology between Caucasians and dark- unguium is common both in white Caucasians and in pop- skinned ethnic populations are not known or prominent; ulations with darkly pigmented skin. The average preva- however, environmental exposure and socioeconomic cir- lence in fair skin populations in Europe and North America cumstances in populations living in hot climate zones differ is approximately 4% [3, 4] and up to 5.5–10% in popula- and cause differences in the clinical presentation and medi- tions with dark skin [5]. The prevalence of onychomycosis cal assistance. In addition, pigment lability in dark skin eas- is clearly higher (>10%) in patients with diabetes, distur- ily causes diffuse or striate melanonychia [1]. bances of blood circulation, peripheral neuropathies, immunocompromised individuals, and the elderly. In pop- ulations with dark skin, onychomycosis represents 20–40% 34.1 Infections of the Nail of all onychopathies and about 30% of cutaneous fungal infections [5]. Tinea unguium represents 7.7% of all der- 34.1.1 Bacterial and Viral Infections matophyte infections [6], whereby T. interdigitale, T. rubrum, and T. verrucosum are the most common agents Nail infections are usually due to bacteria that invade dam- [7]. Rarely, T. soudanense may be detected. aged nails through the seal between the nail plate and the sur- The clinical picture includes: rounding tissue and enter and cause inflammation in the hyponychium and swelling of the surrounding nail folds (par- (a) Distal and lateral subungual onychomycosis (DLSO) onychia). The most common causative agents are which is the commonest pattern of fungal nail infection Staphylococcus spp., followed by pseudomonas and some in most populations (Fig. 34.1a) streptococci; in rare cases herpes viruses may be the causative (b) White superficial onychomycosis (WSO) seen primarily agent. In advanced cases discoloration of the nail plate and on the toes, in which fungi invade the nail plate surface, with formation of small, well-delineated, opaque, white, powder-like, transverse coalescing islands (c) Proximal subungual onychomycosis (PSO) which is the M. El-Domyati (*) • N. H. Moftah Department of Dermatology, STDs and Andrology, least common pattern, could be considered as the pre- Minia University, Al-Minya, Egypt senting sign of acquired immunodeficiency syndrome © Springer International Publishing AG, part of Springer Nature 2018 369 C. E. Orfanos et al. (eds.), Pigmented Ethnic Skin and Imported Dermatoses, https://doi.org/10.1007/978-3-319-69422-1_34 370 M. El-Domyati and N. H. Moftah Fig. 34.1 (a) Distal subungual onychomycosis a with distal onycholysis and subungual hyperkeratosis. (b) Total dystrophic onychomycosis with thickened, rough, friable, and hyperkeratotic nail plates. (c) Candidal onychomycosis with swollen proximal nail folds, loss of cuticle, patent proximal nail groove, and total dystrophic nails b c (d) Total dystrophic onychomycosis (TDO) occurs as the known as Beau’s lines. In candidal onychomycosis, there is result of progression of any of the three previous forms no subungual hyperkeratosis, and the nail does not crumble of onychomycosis with nail matrix involvement with away as in TDO [5, 8] (Fig. 34.1c). rough, friable, hyperkeratotic, and crumbling nails Infections with non-dermatophytic molds account for (Fig. 34.1b) 1.5–6% of all onychomycoses that fall into two categories, causative agents which are isolated from affected nails, in Infections with Candida spp. commonly occur in hot cli- particular Scytalidium dimidiatum and Scytalidium hyali- mate zones and fingernails of females due to frequent han- num, or opportunistic fungi that may be isolated as contami- dling of water and soap during household work leading to nants, e.g., Scopulariopsis brevicaulis and Aspergillus rough, irregular, convex, and dystrophic nails with loss of sydowii [8]. In tropical zones with moist environment, cuticle and proximal nail groove. Candida albicans can Scytalidium is often detected. infect the nail as a primary or secondary pathogen (18–20%); Diagnosis of onychomycosis is primarily based upon however, secondary appearance is more common, especially direct microscopy after scraping of hyperkeratotic nail bed after nail onycholysis and candidal paronychia. Nail matrix and mounting in 10–30% KOH with warming to emulsify infection results in transverse depressions in the nail plate lipids or adding 36% dimethyl sulfoxide instead of heating. 34 Nail Disorders in Dark Skin 371 Table 34.1 Commonly prescribed medications for onychomycosis Dosing Cure rate (%) Treatment Indications Active agent schedule Clinical Mycotic Organism Adverse effects Comments Topical – WSO Ciclopirox 8% Daily for 6–9 29–36 (77% DF, NDM, – Periungual – Patients should not – Mild DLSO lacquer 48 weeks with yeasts erythema bathe for 8 h when – <50% of nail debridement) applied surface Amorolfine 5% Weekly for 1 16 DF, NDM, – Periungual – Damaged nail – <3 fingers lacquer 48 weeks yeasts erythema should be removed – No matrix – Discoloration using scissors or nail involvement Terbinafine Daily for 1 16 DF, NDM, clippers solution 48 weeks yeasts – Application to nail plate, nail bed, and Efinaconazole Daily for 16–17 53–55 DF, NDM, – Local reaction hyponychium 10% solution 48 weeks yeasts Tavaborole 5% Daily for 7–9 31–36 DF, NDM, solution 48 weeks yeasts Systemic – PSO Terbinafine 250 mg 1×/ 66 76 DF, NDM – GIT – Liver and renal – >50% of nail day disturbances function tests are surface – Asymptomatic required – >3 fingers liver enzyme elevation Itraconazole Pulse: 70 63 DF, NDM, – GIT – Liver function 200 mg 2×/ yeasts disturbances tests are required day for – Hypokalemia especially with 1 week/month – Elevated preexisting hepatic Continuous: 70 69 transaminase and dysfunction 200 mg 1×/ triglycerides – Contraindicated day in patients with ventricular dysfunction or congestive heart failure Fluconazole 150–300 mg 41 48 Candida, – GIT – Liver function 1×/week limited in disturbances tests and potassium DF levels are required – Not FDA-approved in onychomycosis Surgical Partial in: 0 – Infection debride- – Lateral nail – Distal nail ment involvement embedding – Onycholytic pocket on nail undersurface WSO white superficial onychomycosis, DLSO distal lateral subungual onychomycosis, PSO proximal superficial onychomycosis; DF dermatophytes; NDM non-dermatophytic molds; GIT gastrointestinal; FDA Food and Drug Administration Drug interactions: Terbinafine: antiarrhythmic agents, beta-blockers, SSRIs, tricyclic antidepressants, and warfarin; Itraconazole: benzodiazepines, calcium channel blockers, proton pump inhibitors, statins, and warfarin; Fluconazole: benzodiazepines, calcium channel blockers, statins, and terfenadine The nail is examined for fungal hyphae, arthrospores, or Treatment of fungal nail infections varies depending on the yeast forms; however, direct microscopy cannot always iden- responsible organism and the severity of the infection. Topical tify the specific fungus. Cultures from nail bed or nail plate antifungal treatment is difficult to perform and often remains debris are performed for confirming diagnosis and ascertain- unsuccessful, while systemic treatment is effective but may be ing the exact etiologic fungus. Different media are used, associated with side effects. The usual duration of treatment with including primary medium containing cycloheximide, which oral antifungals is 6–8 weeks for fingernail involvement and is directed against most NDM and bacteria, e.g., DTM myco- 12 weeks or longer for toenail involvement (Table 34.1). Despite sel (BBL), mycobiotic (DIFCO), and cycloheximide-free the number of available antifungal drugs, not all patients with secondary media, but with addition of antibiotics to elimi- onychomycosis are cured because of nonadherence to treatment, nate bacterial contamination, e.g., Sabouraud glucose agar, incorrect diagnosis, or advanced disease. Moreover, there are Littman Oxgall medium, and potato dextrose agar [5]. long-term recurrence rates, ranging from 10 to 53% [9]. 372 M. El-Domyati and N. H. Moftah 34.2 Nail Abnormalities in Dermatoses are indicated in management-resistant nail psoriasis, with or without cutaneous and psoriatic
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