BEYOND ONYCHOMYCOSIS: OTHER NAIL DYSTROPHIES

Tracey C. Vlahovic, DPM FFPM RCPS (Glasg) Clinical Professor, J Stanley and Pearl Landau Faculty Fellow Temple University School of Podiatric Medicine, Phila, PA CONFLICTS OF INTEREST: ORTHO DERM, BAKO EVALUATION AND TREATMENT ALGORITHM

OSI severe: orals (multiple courses), with/without OSI adjunctive topical treatment Onychomycosis Comorbid Conditions? OSI moderate: orals and/or topical OSI mild: Abnormal topical monotherapy Nail

Not Differential Appropriate Treatment Onychomycosis Diagnosis

OSI, onychomycosis severity index. HOW TO COLLECT NAIL SPECIMEN

• Dermatophytes in DSO invade the nail bed rather than the nail plate, the specimen MUST BE OBTAINED from the NAIL BED, which is the greatest concentration of viable fungi • First, Wipe the area with an alcohol pad • Second, debride the nail as usual • Third, take specimen from the nail bed as proximally to the cuticle as possible with a small curette or a #15 scalpel • “If debris is insufficient, material should be obtained from the nail bed. Material should also be obtained from the underside of the nail plate, with emphasis placed on sampling from the advancing infected edge most proximal to the cuticle. This is the area most likely to contain viable hyphae and least likely to contain contaminants”

Elewski B E. Clinical pearl: diagnosis of onychomycosis. J Am Acad Dermatol. 1995;32:500–501 NAIL DYSTROPHY

• Generalized term • Roughness, Beau’s lines, onychorrhexis, ridging • Acrocyanosis • Alopecia areata • Congenital • Lichen planus • Occupational • Psoriatic • Onychomycosis IS IT DYSTROPHY OR ONYCHOMYCOSIS?

• Following antifungal therapy, some dystrophy may remain, or you may not be dealing with a fungal infection Treatment options: • Urea nail preparations • Genadur (hydroxypropyl chitosan) (Medimetriks) • Nuvail (poly-ureaurethane 16%) (EPI Health) • KeryFlex (Podiatree Company) for cosmesis WHERE IS THE PATHOLOGY?

Follow the Follow shape shape of of the PNF: the Lunula: Exogenous conditions internal; systemic

Zaiac & Daniel: Dermatol Therapy 2002, 15 (2) FIFTH TOENAIL DYSTROPHY FROM BIOMECHANICS/ SHOEGEAR, NOT CAUSED BY ONYCHOMYCOSIS PSORIASIS VS ONYCHOMYCOSIS

Dogra A, Arora AK. Nail psoriasis: The journey so far. Indian J Dermatol 2014;59:319-33 MYCOSIS OR PSORIASIS? Pustular Psoriasis, KOH/culture neg, Dermoscopy: onycholysis with discolored border MYCOSIS OR PSORIASIS? SECONDARY ONYCHOMYCOSIS

Both, KOH/culture pos, with corynebacterial erythrasma and psoriatic patches MYCOSIS OR PSORIASIS? PSORIASIS, KOH/CULTURE NEG, DERMOSCOPY POSITIVE AT ONYCHOLYSIS Differential diagnosis Signs (in order of frequency)

• Pitting • Salmon patches/oil drop sign/discoloration • Onycholysis • Onycholysis • Onychomycosis • Subungual hyperkeratosis • Lichen planus • Trachyonychia • Splinter hemorrhages • Beau’s lines/onychorrhexis

• Koebner phenonmenon!!!!!! NAIL FOLD PSORIASIS

• Paronychia • Psoriatic patches on proximal nail fold NAIL MATRIX PSORIASIS

• Red lunula • Pitting • Beau’s lines • Onychorrhexis • Trachonychia • Leukonychia

Jiaravuthisan MM et al. JAAD, Volume 57, Issue 1, July 2007, Pages 1-27 NAIL BED PSORIASIS

• Oil drop sign/salmon patches • Onycholysis • Splinter hemorrhages • Subungual hyperkeratosis KOEBNERIZATION DIAGNOSIS • Look for the obvious and ASK!!! • KOH/Culture; PAS; PCR • Radiographs to look for arthritic changes in DIPJ • Biopsy of suspected psoriatic patch • Nail punch biopsy

• Even with secondary onychomycosis, parakeratosis is more pronounced in psoriasis WHERE TO PUNCH BIOPSY A NAIL

Dogra A, Arora AK. Nail psoriasis: The journey so far. Indian J Dermatol 2014;59:319-33 HISTOPATHOLOGY OF PSORIATIC NAIL

Dogra A, Arora AK. Nail psoriasis: The journey so far. Indian J Dermatol 2014;59:319-33 TREATMENT • Topical corticosteroid • Injected steroid • Topical calcipotriol or calcipotriene • Topical 5-fluorouracil • Topical tazarotene • Oral cyclosporine • Oral methotrexate • Pulsed dye laser • Oral Acitretin • Chinese Flower/Herb extract (Psoothe) *Scher Cutis 2001; 68(5) LIFESTYLE CHANGES

• Keep nails short • Wear gloves if on fingernails; have shoe size done properly to minimize biomechanical trauma in appropriate patients • Nail prostheses such as keryflex, gel nails, acrylic nails • Treat mycosis, then psoriasis LICHEN PLANUS ALOPECIA AREATA ECZEMA FAILED TWO ROUNDS OF ORAL TERBINAFINE INJECTING THE PROXIMAL NAIL FOLD WITH TRIAMCINOLONE 10%

INJECTING THE NAIL FOLD FOR LATERAL NAIL FOLD INFLAMMATION TEENAGER WITH MULTIPLE NAIL AVULSIONS, NAIL RECENTLY “FELL” OFF DISAPPEARING NAIL BED

• Coined in 2005 by Dr Daniel • A shortened or narrowed nail bed that is the result of long standing onycholysis • 20% shorter than the bilateral nail • Long standing onycholysis can cause epithelialization to occur and dermatoglyphics to appear; distal nail ingrowth • May occur on fingernails (onychophagia) or toenails (hallux most common)

Cutis 2005;76:325–327 OYSTER SHELL IN APPEARANCE RECENTLY DIAGNOSED WITH PARKINSON’S, AND NAIL APPEARANCE IS BOTHERSOME BENIGN TUMOR: ONYCHOMATRICOMA • Rare tumor of the nail matrix, painless • Misdiagnosed as Onychomycosis • “worm holes”, longitudinal thickening/ridging

• J Am Acad Dermatol. 2017 Feb;76(2S1):S19- S21. • J Foot Ankle Surg. 2017 May 27

Am J Dermatopathol 2010;32:1–8 THANK YOU!!! [email protected]