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A Cross-Sectional Descriptive Study of Dermoscopy in Various Nail10.5005/Jp-Journals-10061-0003 Diseases at a Tertiary Care Center Original Article

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A Cross-Sectional Descriptive Study of Dermoscopy in Various Nail10.5005/Jp-Journals-10061-0003 Diseases at a Tertiary Care Center Original Article IJDY A Cross-sectional Descriptive Study of Dermoscopy in various Nail10.5005/jp-journals-10061-0003 Diseases at a Tertiary Care Center ORIGINAL ARTICLE A Cross-sectional Descriptive Study of Dermoscopy in various Nail Diseases at a Tertiary Care Center 1Dipali Rathod, 2Meena Bhaskar Makhecha, 3Manas Chatterjee, 4Tishya Singh, 5Shekhar Neema ABSTRACT Clinical significance: Dermoscopy is a noninvasive comple- mentary tool which aids in diagnosis of nail diseases more Introduction: Nail diseases may often possess a challenge for quickly and can also be used for monitoring the evolution, the treating dermatologist, as they may primarily be affected therapeutic response, and prognosis of these diseases. without any skin involvement and sometimes may present with subtle changes which can be easily missed by the naked Keywords: Alopecia areata, Lichen planus, Melanonychia, eye. The macroscopic nail changes can be assessed very Nail dermoscopy, Nail psoriasis, Onychomycosis, Pitted kera- well with a naked eye, however, the important minutiae may tolysis, Scleroderma, Trachyonychia. be assessed with a dermoscope. How to cite this article: Rathod D, Makhecha MB, Chatterjee Aim: To study the characteristic dermoscopic findings in M, Singh T, Neema S. A Cross-sectional Descriptive Study of various nail diseases. Dermoscopy in various Nail Diseases at a Tertiary Care Center. Materials and methods: A total of 250 patients (males-130, Int J Dermoscop 2017;1(1):11-19. females-120) with clinically evident nail diseases were enrolled Source of support: Nil in this cross-sectional descriptive study. After a thorough clinical examination, patients were subjected to dermoscopic Conflict of interest: None examination of all 20 nails. Chi-square test or Fisher’s exact test (in a very few patients of nail diseases) were used for INTRODUCTION statistical analysis, with a significance threshold of p < 0.05. Nails may be involved primarily or secondarily due to Results: Nail psoriasis (n = 45) was the commonest nail disease found in which the most common dermoscopic feature underlying systemic diseases and their examination may was circular punctate depressions (64.5%). Onychomycosis provide clues to establish the diagnosis and guidance (n = 40) was the next common disease in which yellowish regarding the management of these nail diseases. Several discoloration (100%) was commonly seen in all patients and skin, hair, and nail diseases may result in severe nail rough scaly surface (100%) in the total dystrophic type. In pitted keratolysis (n = 19) transverse brown bands (57.9%) were most abnormalities, which if not addressed, may cause func- commonly seen as was the case in eczemas. Lichen planus tional interference and permanent dystrophy. Diseases of (n = 14) was associated with longitudinal fissuring (64.3%) most nail comprise approximately 10% of all the dermatological commonly. Trachyonychia (n = 5) was associated with longitu- conditions.1,2 Clinicopathologic tools are time-consuming dinal fissuring (100%) in all cases. The most common dermo- and give false negative results in up to 35% of patients. scopic feature of alopecia areata (n = 4) was circular punctate depressions (75%). Systemic scleroderma (n = 4) typically Although, the naked eye can appreciate majority of the showed giant capillaries (75%) as the most common feature. macroscopic details of the nail unit apparatus, dermo- Conclusion: A meticulous search with the dermoscope, fur- scope furnishes details which may be easily missed. This nishes minuscule details of the nail unit that can be diagnostic of article provides the diagnostic importance of dermoscope several nail diseases at an early stage before dystrophy sets in. in the evaluation of various nail diseases. However, further studies are required to validate these findings. However, before we move onto the main topic, let us see the difference between nail and skin dermoscopy. Nail dermoscopy is technically difficult owing to 1,2,5 3 4 Assistant Professor, Senior Advisor and Head, Resident nail size, shape, convexity, and hardness. The entire nail 1,3Department of Dermatology, INHS, Asvini, RC Church, Colaba cannot be visualized as a whole at one particular time, Mumbai, Maharashtra, India therefore, cannot be easily interpreted and it is cumber- 2,4Department of Dermatology, Hinduhrudaysamrat Balasaheb some to take pictures of this area. Nail plate surface Thackeray Medical College & Dr. Rustam Narsi Cooper Municipal changes can be appreciated with dry dermoscopy, General Hospital, Juhu, Vile Parle (West), Mumbai, Maharashtra India whereas color abnormalities can be appreciated with large quantities of interface medium (linkage fluid gel) or by 5Department of Dermatology, Command Hospital (EC), Kolkata West Bengal, India use of polarized dermoscopy. Corresponding Author: Dipali Rathod, Assistant Professor Normal Nail Unit under the Dermoscope Department of Dermatology, INHS, Asvini, RC Church, Colaba Mumbai, Maharashtra, India, Phone: +918655638949, e-mail: The nail plate appears pale pink in color with smooth [email protected] and shiny surface. Nail bed below the transparent plate International Journal of Dermoscopy, May-August 2017;1(1):11-19 11 Dipali Rathod et al appears pale pink too. The epithelium of proximal A total of 250 out of 42,105 patients attending der- nailfold (PNF) has a smooth surface with pale pink to matology OPD were enrolled, that accounted for an brown color. Cuticle is easily visible as a transparent trans- incidence of 0.60% during this study period. verse band that seals the nail plate to PNF. Hyponychial The mean age was 37.8 years. The highest number epithelium shows digital creases and capillaries of the (49) of patients belonged to the age group 31 to 40 years dermis appear as red dots (40× magnification). (19.6%) and the lowest number of patients (6) belonged to the age group >70 years (2.4%). The youngest patient AIM was 3-year-old and the oldest was 72-year-old. Our aim was to study the characteristic dermoscopic Among 250 patients, 130 (52%) were males and 120 findings in various nail diseases. (48%) were females and M : F ratio was 1.09 : 1. Right hand fingernails were most commonly involved MATERIALS AND METHODS in 192 patients (78.6%) followed by left hand fingernails After obtaining the approval of institutional ethics com- in 171 patients (68.4%), right foot toenails in 109 (43.6%) mittee, a total of 250 consecutive patients were enrolled and left foot toenails in 102 (40.8%). The finger nails were in the study after written informed consent. Ours was a significantly more commonly involved as compared with cross-sectional descriptive study conducted over a period the toe nails (p = 0.000). of 8 months (October 2014 - May 2015). A total of 140 patients (56%) presented with onset Patients with clinically detectable nail unit involve- of disease ranging from 1 month to 1 year. However, ment and belonging to all age groups of both sexes were the shortest duration observed was 1 week and longest included whereas those already on treatment for the duration was 20 years. primary cause and those not wilfully giving consent were The most common occupations observed were excluded. The diagnosis was established by two senior housewives 77 (30.8%) followed by students 58 (23.2%), consultants, based predominantly on the clinical features. domestic helps 40 (16%), and laborers 29 (11.6%). Each patient was subjected to a detailed history regard- Among 80 patients (32%) with systemic diseases, ing demographic profile, onset and evolution of the nail the most commonly observed conditions were diabetes changes, history pertaining to associated skin, and systemic mellitus in 30 patients (34.5%) followed by hyperten- complaints. This was followed by a complete general physi- sion in 29 patients (33.3%) and ischemic heart disease in cal examination and cutaneous and systemic examination. 5 patients (5.7%). Both, underlying dermatological disease Later, dermoscopic evaluation of all the nails was done (Table 1) and nail changes (Table 2) were encountered using a handheld polarized Heine’s Delta 20 dermoscope in 181 patients (72.4%), while nail disease alone was whereas digital dermoscopic images were taken with a observed in 69 patients (27.6%). Canon 1200D DSLR camera. Ultrasound gel was used as the Statistically significant dermoscopic nail findings of linkage fluid between the contact plate and the nail plate. the common nail diseases observed in our study were Statistical Methods used for Analysis as follows: After data collection, it was entered in Microsoft Excel and Nail Psoriasis (n = 45) analyzed using STATA version 13. The quantitative data was presented with the help of mean, standard deviation, More common - circular punctate depressions (64.5 vs median, and interquartile range and the qualitative data 5.9%, p = 0.000) (wherein 64.5% stands for percentage was presented with the help of frequency and percent- of this dermoscopic manifestation seen in nail psoriasis age tables. and 5.9%, that of this manifestation seen in other nail We calculated the means and standard deviations diseases), reddish pink border (62.3 vs 1%, p = 0.000), for the linear variables and proportions for the categori- brown-purple streaks (48.9 vs 21.5%, p = 0.000), white cal variables. The proportions across various categories color (35.6 vs 2%, p = 0.000), nail free edge nonruinous were compared using the Chi-square test or the Fisher’s aspect (35.6 vs 3.5%, p = 0.000), irregular edge (33.4 vs exact test (in those conditions where a very few patients 2%, p = 0.000), dilated capillaries (31.2 vs 1%, p = 0.000), were there in the sample). A p-value of less than 0.05 was linear edge (17.8 vs 5.4%, p = 0.010), proximal nail scaling considered to be statistically significant. (17.8 vs 2%, p = 0.000), and orange pink spot (11.2 vs 0%, p = 0.000). RESULTS Less common - brown color (4.5 vs 25.9%, p = 0.001), After enrolling the patients, the data were collected, tabu- gray black color (2.3 vs 19.6%, p = 0.003), and rough scaly lated, analyzd, and the results obtained were as follows: surface (2.3 vs 11.8%, p = 0.057%).
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