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A Dissertation on a CLINICAL STUDY of NAIL CHANGES in PAPULOSQUAMOUS DISORDER

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A Dissertation on a CLINICAL STUDY of NAIL CHANGES in PAPULOSQUAMOUS DISORDER A Dissertation on A CLINICAL STUDY OF NAIL CHANGES IN PAPULOSQUAMOUS DISORDER Dissertation Submitted to THE TAMILNADU Dr.M.G.R. MEDICAL UNIVERSITY CHENNAI - 600 032 With partial fulfillment of the regulations for the award of M.D. DEGREE IN DERMATOLOGY , VENEREOLOGY AND LEPROLOGY (BRANCH – XII) COIMBATORE MEDICAL COLLEGE, COIMBATORE MAY 2018 DECLARATION I Dr. A. AMUTHA solemnly declare that the dissertation entitled “A CLINICALSTUDY OF NAIL CHANGES IN PAPULOSQUAMOUS DISORDER ” is a bonafide work done by me at Coimbatore Medical College Hospital during the year JUNE 2016- JUNE 2017 under the guidance & supervision of Dr.M .REVATHY M.D.,D.D., Professor & Head of Department, Department of Dermatology, Coimbatore Medical College & Hospital. The dissertation is submitted to Dr.MGR Medical University toward partial fulfilment of requirement for the award of MD degree branch XII Dermatology, Venereology and Leprology. PLACE: Dr A. AMUTHA DATE : COPYRIGHT DECLARATION BY THE CANDIDATE I hereby declare that The Tamilnadu Dr. M.G.R Medical University, Chennai shall have the rights to preserve, use and disseminate thisdissertation / thesis in print or electronic format for academic / researchpurpose. PLACE: COIMBATORE Dr.A.AMUTHA DATE: CERTIFICATE This is to certify that the dissertation entitled “A CLINICAL STUDY OF NAIL CHANGES IN PAPULOSQUAMOUS DISORDER” is a bonafide original work done by Dr. A. AMUTHA post graduate student in the Department of Dermatology, Venereology and Leprology, Coimbatore Medical College Hospital during the year JUNE 2016- JUNE 2017 under the guidance & supervision of Dr.M.REVATHYM.D (Derm)., Professor & Head of Department, Department of Dermatology, Coimbatore Medical College & Hospital. The dissertation is submitted to Dr.MGR Medical University toward partial fulfilment of requirement for the award of MD degree branch XII Dermatology, Venereology and Leprology. Date: GUIDE Dr. M. REVATHY, M.D (Derm)., Professor & HOD, Department of Dermatology, Coimbatore Medical College & Hospital. Date: Dr. M. REVATHY, M.D (Derm)., Professor & HOD, Department of Dermatology, Coimbatore Medical College & Hospital. Date: Dr.B. ASOKAN, M.S., Mch., DEAN, Coimbatore Medical College & Hospital Coimbatore. ACKNOWLEDGEMENT I solicit my humble thanks to the Dean Dr. B. ASOKAN, M.S., Mch., Coimbatore Medical College Hospital, for allowing me to conduct the studyin this hospital. I am also immensely thankful to my guide Prof. M. REVATHY, M.D (Derm)., Professor Head of the Department, Dermatology and Leprology for her invaluable guidance, motivation and help throughout the study. I would like to express my gratitude and indebtness to our Prof. Dr.P.P.RAMASAMY, M.D., for his constant support and encouragement. I express my earnest gratitude to all the Assistant Professors, Department of Dermatology., Dr.B.Eswaramoorth M.D., Dr.R.Madhavan, M.D, Dr.S.Bharathi, M.D., Dr. S. Swarnalakshmi, M.D., Dr. R. Ranjaniand, Dr.Prathibawithout their help and guidance this work would not have been possible. I owe great debt of gratitude toDr P. Mohan, MD., DV., for his kind support and encouragement. I owe a lot to my Parents, my husband and my children ,who have always stood by as my pillar of strength . My sincere thanks to all my post graduate colleagues Dr.M.S KrishnaMeera, Dr S.Divya, Dr.N.Dinesh, Dr.Vijaylakshmi, Dr.Manivannan, Dr.Neikhrele, Dr.Meghana M J and Dr.R.Vithya and who have been of immense help throughout the study period. I am very grateful to all patients for their co-operation and participation in the study Dr A. AMUTHA TABLE OF CONTENTS S.NO CONTENTS PAGE 1 INTRODUCTION 1 2 AIM OF STUDY 2 3 REVIEW OF LITERATURE 3 4 MATERIALS AND METHODS 35 5 OBSERVATION AND RESULT 38 6 DISCUSSION 67 8 SUMMARY 76 9 CONCLUSION 79 10 BIBLIOGRAPHY 81 11 ANNEXURES PROFORMA 91 CONSENT FORM 94 KEY TO MASTER CHART 96 MASTER CHART LIST OF TABLES SL PAGE TABLES NO. No 1 Nail changes in childhood and old age 19 2 Classification of papulosquamous disorder 21 3 Age distribution in papulosquamous disorder 3 4 frequency of various papulosquamous disorder 40 5 Characteristics of nail change in papulosquamous 42 disorders 6 Frequency and distribution of nail changes in upper 43 limb and lower limb 7 KOH mount 44 8 Co morbid conditions 45 9 Age distribution in psoriasis 46 10 Pattern of nail involvement in psoriasis and the 48 common nail involved 11 Age sex distribution table in lichen planus 50 12 Frequency of nail changes in lichen planus and 52 common nail involved 13 Age , gender and nail changes in prp 55 14 Age , gender and nail changes in lichen nitidus 56 15 Age , gender and nail changes in lichen striatus 58 SL PAGE TABLES NO. No 16 Age , gender and nail changes in parapsoriasis 58 17 Age , gender and nail changes in plc 59 18 Comparing my study with three major studies 68 19 Pattern of nail involvement in lichen planus 70 LIST OF FIGURES SL FIGURE PAGE NO No. 1 Embryological development of nail apparatus 4 2 Gross and microscopic anatomy of nail 5 Differentiation and movement of cells within nail 3 6 apparatus 4 HPE of nail 12 5 Nail glossary 17 6 Clinical signs of nail psoriasis 24 7 Nail changes in lichen planus 28 8 Way of numbering of digits 37 LIST OF CHARTS S.No CHARTS PAGE NO. 1 Gender Distribution of Papulosquamous 39 Disorder 2 Age And Sex Distribution Of Patients With Nail 41 Changes : 3 Co morbidities - Pie chart 45 4 Gender Distribution Chart 47 5 Frequency of nail changes in upper limb and 49 lower limb 6 Age Sex Distribution Chart 51 7 Frequency of nail changes in upper limb and 53 lower limb in Lichen Planus COLOUR PLATES S.No Colour Plate PAGE NO. 1 Fig. 1 Psoriasis nail changes 60 2 Fig. 1 Psoriasis nail changes 60 3 Fig. 3 Psoriasis joint involvement 61 4 Fig.4 Psoriasis 61 5 Fig. 5 Lichen planus nail changes 62 6 Fig. 6 Lichen planus nail changes 62 7 Fig. 7 Trachyonychia 63 8 Fig. 8 Trachyonychia 63 9 Fig.9 Lichen nitidus 64 10 Fig.10 Lichen Striatus 64 11 Fig. 11 PRP with nail changes 65 LIST OF ABBREVIATION LP - Lichen Planus PRP - Pityriasis rubra pilaris LN - Lichen nitidus LS - Lichen Striatus : PR - Pityriasis Rosea PLC - Pityriasis lichenoides PLEVA - Pityriasis Lichenoides Et Varioliformis Acuta Eg - Example CBC - Complete blood count RFT - Renal function test LFT - Liver function test KOH - Potassium hydroxide HIV - Human immune deficiency Virus DM - Diabetes Mellitus- INTRODUCTION As face is the index of the mind, so is nail the index to health. Nail is one of the epidermal derivatives that produce the hardest epithelial structure know in mammalian biology. Nails not only provide aesthetic beauty to hand and feet but also aid in providing protection, tactile sensation and social communication. During the 5th century Hippocrates described clubbing as a significant sign to the myriad of systemic manifestations. Since then many nail findings are identified in association with various diseases. Hence forth, nails examination should be an essential component of a complete dermatological examination. Furthermore at times, various nail abnormalities can be a presenting features before other signs of the disease become apparent. Nail disorders comprise of 10 % all dermatological disorders, the main contributors being papulosquamous disorder. The increasing aesthetic concern among general public has made even the mildest nail alteration as an important issue for the patient. Abnormal nails are of paramount clinical importance, particularly when they an exclusive feature devoid of other obvious symptom of a disease. 1 AIM & OBJECTIVE OF THE STUDY AIM: To describe clinical patterns of fingernail alterations in patients with papulosquamous disorder. Objectives a) To evaluate the pattern, clinical characteristics and severity of nail involvement in individual papulosquamous disorders b) To assess the association of nail changes with various papulosquamous disorders individually. 2 REVIEW OF LITERATURE A CLINICAL STUDY OF NAIL CHANGES IN PAPULOSQUAMOUS DISORDER EMBRYOLOGY1 OF NAIL The finger nail development commences at 8–9 weeks of gestation. Initially there is development of an uninterrupted groove by invagination of the primitive epidermis, termed as the nail field. A group of cells from the proximal area of the nail fold then grows on the digit which halts about 1 mm from phalanx, this gives rise to the matrix primordium. This site will further contribute to the development of epithelium of the proximal nail fold, the distal and intermediate matrix epithelium. At 13 weeks gestation: the proximal nail fold is formed and the signs of growth of nail plate is noticed from the lunula. At this stage, the stratum corneum and stratum granulosum start to appear, from the nail field epithelium commencing distally. At 18 week : The granular layer recedes and disappears 3 At 20 weeks gestation: the process of maturation and cellular differentiation in the matrix occurs which is similar to that of adults. At 32 weeks of gestation : nearly all the parts of the nail can be seen. In the toe nail the developmental process starts about 4 weeks later than the finger nail 1 Fig 1 : Embryological development of nail apparatus 4 Fig 2 : Gross and Microscopic Anatomy of Nail Nail matrix Nail plate Nail bed Nail fold Cuticle Lunula NAIL MATRIX Matrix is a specialized epithelial structure that lies above the mid portion of the distal phalanx. It is wedge- shaped on longitudinal sections and can be subdivided into 5 Dorsal (the ventral aspect of the proximal nail fold), Intermediate ( germinal matrix or matrix) Ventral ( nail bed ) sections Fig 3 Differentiation and movement of cells within nail apparatus Cells of the proximal half of the matrix produce nearly 80% of the nail plate, whereas <1% of nail plate is contributed by nail bed.2 HPE : The matrix, at the nail base is composed of germinative epithelium without a granular layer.
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