Acta Derm Venereol (Stockh) 1999; 79: 81^95 LETTERS TO THE EDITOR Proximal White Subungual Onychomycosis in the Immunocompetent Patient: Report of Two Cases and Review of the Literature Sir, ture was performed and grew T. rubrum; a nail specimen sent for PAS Proximal white subungual onychomycosis (PWSO) is the rar- staining was positive for the presence of hyphae. The patient started est subtype of onychomycosis (1). In PWSO, the infection pulse therapy with itraconazole 200 mg bid for 1 week each month. begins with fungal invasion of the stratum corneum of the At a return visit after two pulses of itraconazole, the patient was noted proximal nail fold, followed by infection of the deeper portions to have moderately improved. of the nail plate. This presentation of onychomycosis is most commonly caused by T. rubrum; other common causative agents include T. megninii, T. schoenleinii, T. tonsurans, T. DISCUSSION mentagrophytes,andE. £occosum (1, 2). The majority of initial cases of PWSO reported were patients The two cases we report, in addition to the others in the litera- with AIDS (1 ^ 3). In one study, 55 of 62 HIV-infected patients ture, indicate that there is a de¢nite subset of patients with with onychomycosis (83.7%) had PWSO (4). In more than PWSO who are immunocompetent. In patients with PWSO half of these patients (58%), T. rubrum was the etiologic with AIDS, toenail, rather than ¢ngernail, involvement has agent. PWSO has also been reported in patients with other been reported to be more common (1). In our cases, as well as immunode¢ciencies, including a renal transplant recipient on in some of the other immunocompetent patients, the ¢nger- immunosuppressive therapy (5), and a patient with systemic nails are prominent sites of involvement. This may be an lupus erythematosus on systemic steroids (6). In addition, important factor in helping to di¡erentiate groups of patients Baran (7) described a case of proximal subungual candida with proximal subungual disease. onychomycosis as a manifestation of chronic mucocutaneous We can draw the following conclusions about PWSO. When candidiasis. Recently, however, there have been several reports there is absence of paronychia, PWSO is usually caused by der- of immunocompetent patients developing PWSO (8 ^ 10). We matophytes and is seen mainly in immunocompromised now report two immunocompetent patients with proximal patients, especially when many nails are involved. If the patient white subungual disease, and review the other cases described, is not immunocompromised, a local cause of invasion, such as emphasizing that not all patients with this presentation are trauma, must be evaluated. PWSO with paronychia is usually a immunode¢cient. result of mold infection and occurs in both immunocompro- mised and immunocompetent patients. CASE REPORTS Case 1 A 47-year-old female physician without past medical history presented with a 2-month history of erythema and edema around the proximal nail fold a¡ecting the left index ¢nger, associated with nail changes. She noted that she had been handling spoiled food 1 week before the start of her symptoms, but denied a preexisting wound or trauma. Prior to presentation, she was treated with mupurocin ointment and oral dicloxacillin without improvement. Examination revealed mild erythema of the proximal nail fold; the nail plate showed a white dis- coloration involving the proximal region. The patient was in good health and noted that, on a recent life insurance work-up, an HIV test was negative. A complete blood count was within normal limits. Culture and culture mount with lactophenol cotton blue showed ¢ndings consistent with Fusarium species. She was treated with itraconazole 200 mg/daily for 4 weeks with clinical improvement. Case 2 A 32-year-old Hispanic woman with a history of seizure disorder presented with complaints of nail changes over the previous 4 months. She had no prior history of problems with her nails and no other systemic complaints. She denied recent nail trauma or manicure. On physical examination, there was proximal onycholysis, whitish discoloration, and subungual debris involving the thumbs, fourth ¢ngers, and great toes bilaterally, and the third left ¢nger (Fig. 1). A fungal culture was sent which grew Pseudomonas, but no fungi. An HIV test was performed, which was negative, and a chemistry panel and complete blood count, which were within normal limits. The patient returned for follow-up 3 weeks later. A repeat fungal cul- Fig. 1. Proximal subungual disease of the left third ¢ngernail. # 1999 Scandinavian University Press. ISSN 0001-5555 Acta Derm Venereol (Stockh) 79 82 Letters to the Editor REFERENCES sual manifestation of chronic mucocutaneous candidosis. Br J Der- matol 1997; 137: 286 ^ 288. 1. Elewski BE. Clinical pearl: proximal white subungual onychomy- 8. Piraccini BM, Morelli R, Stinchi C, Tosti A. Proximal subungual cosis in AIDS. J Am Acad Dermatol 1993; 29: 631 ^ 632. onychomycosis due to Microsporum canis. Br J Dermatol 1996; 2. Silver-Lizama E, Logemann H. Proximal white subungual onycho- 134: 175 ^ 177. mycosis in AIDS. Int J Dermatol 1996; 35: 290 ^ 291. 9. Baran R, Tosti A, Piraccini BM. Uncommon clinical patterns of 3. Noppakun NM, Head EE. Proximal white subungual onychomy- Fusarium nail infection: report of three cases. Br J Dermatol cosis in a patient with acquired immune de¢ciency syndrome. Int J 1997; 136: 424 ^ 427. Dermatol 1986; 25: 586 ^ 587. 10. Dordrain-Bigot ML, Baran R, Baixench MT, Bazex J. Fusarium 4. Dompmartin D, Dompmartin A, Deluol AM, Grosshans E, onychomycosis. Ann Dermatol Venereol 1996; 123: 191 ^ 193. Coulaud JP. Onychomycosis and AIDS. Int J Dermatol 1990; 29: 337 ^ 339. Accepted May 29, 1998. 5. Lee MM, Diven D, Smith EB, Pupo RA. Onychomycosis. Arch Dermatol 1990; 126: 402. 6. Rongioletti F, Persi A, Tripodi S, Rebora A. Proximal white sub- Je¡rey M. Weinberg1, Evelyn K. Koestenblatt1, Philip C. Don1, Soren ungual onychomycosis: a sign of immunode¢ciency. J Am Acad M. White1, Mark N. Stein1 and Mahrukh Bamji2 Dermatol 1994; 30: 129 ^ 130. Departments of 1Dermatology and 2Pediatrics, New York Medical 7. Baran R. Proximal subungual candida onychomycosis. An unu- College-Metropolitan Hospital Center, New York, NY 10029, U.S.A. Ring-induced Nail Pitting? Sir, Nail pitting is a common feature of abnormal texture in nail plates. Here we describe a 24-year-old male Caucasian patient who noticed abnormalities on the surface of the nail plate of his right fourth ¢nger after wearing a new silver ring. Dermatolo- gical examination disclosed small, shallow pits in a mainly lin- ear, single row arrangement extending from the lunular to the free margin of the nail plate (Fig. 1). Apart from the cosmetic aspect, the pits caused no apparent inconvenience. Similar lesions had occurred earlier on his left fourth ¢nger after wearing a new gold ring, which disappeared after removal of the ring. The medical history of the patient and extended family was completely unremarkable. Volker Grimm, Matthias MÎhrenschlager, Harald Bruckbauer, Lars D. KÎhler and Johannes Ring Department of Dermatology and Allergy Biederstein, Technical University of Munich, Biedersteiner Str. 29, D-80802 Munich, Germany. Fig. 1. Small, shallow pits presenting in a mostly linear, single row arrangement extending from the lunular to the free margin of the nail plate of the right fourth ¢nger while wearing a ring. Acta Derm Venereol (Stockh) 79 Letters to the Editor 83 Fox-Fordyce Disease: Two Cases in Patients with Turner Syndrome Sir, Fox-Fordyce disease (FFD) occurs as a chronic, itchy, papular skin eruption principally located in the apocrine gland-bearing areas (1, 2). Although it usually appears in a symmetrical distribution on the axillae and pubic area, it can also occasionally a¡ect the labia, perineum, mammary areolae, presternal area, umbilicus and the medial aspect of the upper thighs. Hair growth in the a¡ected regions is sparse or absent. Apocrine sweat is not produced at the ori¢ces of follicles of the a¡ected glands. Sometimes intense itching is present, apparently activated by intense sweating or by emo- tional excitation. More than 90% of reported cases have been observed in women between 13 and 35 years of age. The his- tologic picture is characterized by obstruction of the apocrine duct at its entrance into the follicular wall. The aims of this paper are to report two cases of FFD in two patients with Turner syndrome under treatment with growth hormone (GH) and to speculate as to whether these two conditions are correlated in any way. CASE REPORTS Case 1 A white 18-year-old girl was ¢rst seen in October 1992 for the evalua- tion of melanocytic naevi. The patient had been under observation since the age of 12 for short stature due to Turner syndrome. She had growth hormone (GH) de¢ciency and absence of ovaries; karyotype analysis was 45, X/46, Xi (Xq). The patient had been treated with GH 1 U/kg/week for 5 years in association with etinil-estradiol 100 Fig. 1. Fox-Fordyce disease in the axilla of patient 1. Note multiple, dis- ng/kg/day for the previous 3 years. In the previous 2 years, oxandro- crete, round, dome-shaped, follicular papules. Hair growth is sparse. lone 0.05 mg/kg/day had been added. At the time of our observation, the patient was still undergoing these 3 therapies and had a follicle-sti- area. Groin hair growth was normal and the patient did not complain mulating hormone value of 79.45 MIU/ml (normal value 3.7 ^ 10.5) of any symptoms. There was no family history of a similar disease, and and a luteinizing hormone value of 15.8 MIU/ml (normal value 1.6 ^ we decided not to treat the dermatosis. Histopathology showed mas- 10.0) as determined by £uoroimmunoassay kit (Eurogenetics).