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INSIDE Psoriasis Brittle nails Ingrown toenails

Longitudinal in a white-skinned Onycholysis with secondary pseudomonas infection. adult requires biopsy to exclude a melanoma. Tumours Yellow syndrome Nail procedures Case studies

the author

Ingrown toenail with hypertrophy of lateral lip and secondary infection. Haematoma

Dr Samantha Eisman is a consultant dermatologist at Sinclair Dermatology, East Melbourne. Ten important All images are property of Sinclair Dermatology.

Copyright © 2016 nail disorders Australian Doctor All rights reserved. No part Introduction of this publication may be reproduced, distributed, or transmitted in any form or by any THE nail and the nail appa- temic and local disease, and impaired functionality, but nail pathology and manage cover common nail disor- means without the prior written ratus are important indica- are significant in a person’s severe psychological distress appropriately are increas- ders and provide practical permission of the publisher. tors3906_bp_t of an individual’s hanks_ad_2 health. appearance. - Disease1 2016- not 01-and 14T16:social embarrassment. 08: 32+11: ingly 00 important in everyday approaches to treatment. For permission requests, email: [email protected] They can signify both sys- only causes discomfort and The ability to recognise practice. This article aims to cont’d next page

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Onycholysis

ONYCHOLYSIS refers to detach- nail bed disorders. (see table 1). If trauma. Trauma from footwear is ing reattachment of the nail bed to ment of the nail plate from the nail all nails are involved, then a drug often because of hyperextension the nail plate as soon as possible. It Treatment of onycholysis bed. It usually starts at the distal or systemic disease is likely and of the great toe during the propul- is imperative to identify the cause free edge of the nail and progresses fingernails may be more likely sive phase of gait and consequent in the first instance and initiate • Recognise and treat cause. proximally. affected than toenails. repeated hitting of the nail on the specific treatment if appropriate. • Protect nail from trauma and The detached nail appears Asymmetrical fingernail undersurface of the shoe front. General treatments are aimed at aggressive self-cleaning. smooth and white-yellow because involvement is more suggestive of Infection with fungi can lead to minimising trauma, avoiding irri- of air trapped in the subungual a local cause or cutaneous pathol- onychomycosis, and secondary tants and preventing complications space. It is usually asymptomatic ogy, such as psoriasis (see fig- infection with pseudomonas can (see box ‘Treatment of onycholy- • Cut nail short and straight, and but causes cosmetic concern. ure 1). The two main causes of cause green-brown discolouration sis’). If onycholysis is prolonged for clip fortnightly until regrowing nail Onycholysis may be idiopathic, onycholysis of the toenail, usually of the nail (see figure 2). more than six weeks, the resulting plate is attached to nail bed. related to trauma, or owing to the great toe, are infection and Treatment is aimed at promot- defect may be irreversible. • Avoid nail varnish and manicuring Table 1. Causes of onycholysis Figure 1. Onycholysis until resolution. due to psoriasis (note the Idiopathic red-brown onychodermal • Tape free edge of nail (with band just proximal to Trauma (manicuring, surgical tape) to encourage onycholysis indicative of adherence of nail plate to nail bed occupational, accidental, psoriasis) onychogryphosis) and to prevent progression of onycholysis. Environmental/ irritants Irritants: chemicals, paint, solvents, cosmetics Water • Avoid immersion in water, or wear Ultraviolet light (photo-onycholysis) cotton gloves under rubber gloves Cutaneous diseases Psoriasis and dry after soaking. Eczema (atopic, contact, irritant) Lichen planus • Properly fitted footwear. Blistering diseases Darier’s disease • Refer to podiatry for gait assessment and correction of Infections Fungal: dermatophyte, moulds, yeasts hyperextension of great toe by (candida) Figure 2. Onycholysis with providing orthotics for metatarsal secondary pseudomonas Bacterial (Pseudomonas spp) head support. infection. Viral (warts, herpes simplex, herpes zoster) Scabies • Apply topical antiseptics: 2-4% Drugs Retinoids, ACEIs, bleomycin, doxorubicin, thymol in chloroform twice daily. NSAIDs, beta blockers, oral contraceptives Photo-onycholysis: tetracyclines, psoralens, • If pseudomonas infection: sodium thiazides, quinine, cloxacillin hypochlorite solution 1 drop twice Metabolic/systemic daily or vinegar soaks. Systemic lupus erythematosus • Exclude secondary Endocrine: hyper- or hypothyroidism, diabetes onychomycosis. mellitus

Onychomycosis

ONYCHOMYCOSIS of the nails Table 2. Clinical presentations of onychomycosis Treatment is commonly due to infection Type of onychomycosis Clinical appearance Topical with dermatophytes. Trichophy- Onychomycosis is an infection and ton rubrum accounts for 90% Distal and lateral subungual Hyperkeratosis of undersurface of distal nail should always be treated. Indica- of cases. Less commonly, non- onychomycosis (figure 3) plate and bed tions for topical treatment include dermatophyte moulds and yeasts Onycholysis up to 50% involvement of the nail like Candida albicans can cause Dyschromias plate, lack of matrix involvement, onychomycosis. One hand-two foot syndrome three or four nails affected, and The mean prevalence of onycho- Tinea pedis often present superficial white onychomycosis. mycosis is 4.3%; however, figures Superficial white Crumbling white lesions on nail surface Other considerations include chil- are probably higher in Australia onychomycosis (figure 4) Most common in children dren, prophylaxis in those at risk because of the hot and humid cli- and when oral treatment is con- Proximal (white) subungual Infection in proximal nail fold and distal Figure 5. Deep linear yellow streaks/ mate, and sporting habits. onychomycosis portion normal spikes extending from the distal nail traindicated. Three topical prepara- Patients with AIDS (gross white plate proximally. These are bands of tions are commonly used in treating Presentation discoloration) yellow hyperkeratosis that progress onychomycosis (table 4). There is no Onychomycosis can involve a sin- data to support the use of any other Total dystrophic Complete destruction of nail plate from the distal margin proximally to gle nail, multiple nails and very topical agent as monotherapy. onychomycosis the matrix. The proximal yellow mass rarely all nails. Toenail infection is represents a dermatophytoma, a seven times more likely than fin- Figure 3. Distal mass of dividing fungus. Systemic gernail disease. The first and fifth and lateral Oral treatments are generally more toe are most likely affected, and subungual Diagnosis effective than topical therapies, but often accompanied by tinea pedis. onychomycosis Many disorders can mimic have potential adverse effects and Onychomycosis of the fingernail affecting all onychomycosis (see table 3). It is drug interactions (see table 5). These is uncommon without toenail dis- five toenails. therefore important to establish are indicated if topical treatment ease or tinea manuum. Fingernail microbiology confirmation prior has failed after six months, or if the disease alone is more likely to be to commencing treatment. Nails disease does not qualify for topical psoriasis, even in the absence of should be cleaned with an alcohol therapy as listed above. Both terbi- psoriatic skin disease. swab. Samples of nail clippings, nafine and itraconazole are consid- Onychomycosis has a variety of scrapings from subungual tissue ered first-line options for treatment. Figure 4. Early clinical presentations (see table 2). superficial or superficial nail plate, or biop- Fluconazole, although not licensed The clinical patterns depend on white sies of nail plate should be sent for for onychomycosis, is often used as the way and the extent that the onychomycosis microscopy and culture. Culture an alternative agent. Griseofulvin is fungus invades the nail, as well as prior to nail can identify the specific fungus, rarely used because of protracted the type of fungus and the indi- plate friability. but results can take 2–6 weeks treatment time and low cure rates. vidual host susceptibility. Clinical and false-negative rates are high Griseofulvin is, at present, the only features that are highly suggestive (30%). Nail plate can also be sent systemic therapy licensed in children of onychomycosis include friable for histopathology, with results aged under 18. However, there have nails and spikes (see figure 5 available in 3–5 days. been numerous safety studies look-

18 | Australian Doctor | 29 January 2016 www.australiandoctor.com.au ing at terbinafine and itraconazole and debridement (partial removal) gal mass and enhance penetration continued in addition to these treat- ous lasers have been approved, in children and, provided doses are can be useful in severe disease, non- of antifungal medication. Chemi- ments. including Nd:YAG short pulse, adjusted, these are currently used dermatophyte mould infection or cal avulsion can be performed with Q-switch 1064nm and the diode under specialist supervision. when dermatophytomas are present 40% urea ointment, while surgical Other 870, 930 and 980nm. Photodynamic (nidus of infection characterised avulsion involves separating the nail There are no randomised controlled treatment has been shown in a sin- Debridement/Avulsion by longitudinal streaks or spikes). plate from the nail bed using a nail trials as yet to recommend laser ther- gle-centre open trial to achieve cure Nail avulsion (complete removal) These treatments help reduce fun- elevator. Systemic treatment is often apy for onychomycosis but numer- rates of 44% at 12 months.

Table 3. Common differential diagnoses of onychomycosis Table 4. Topical agents for onychomycosis Condition Features Treatment Type For Dose Cure rates Psoriasis Pitting Amorolfine 5% Broad-spectrum No matrix disease 1-2 times a week CC: 12.7% Oil drop sign lacquer fungicidal and Maximum two nails involved File before application MC: 46.6% at 48 Red onychodermal band proximal to fungistatic Mild distal and lateral 6-12 months weeks onycholysis onychomycosis Lichen planus Nail plate thinned and ridged (longitudinal) Ciclopirox 8% Broad-spectrum No matrix disease Daily CC: 5.5-8.4% Dorsal pterygium: scarring at proximal lacquer fungicidal Mild distal and lateral 24 weeks for fingers MC: 29-36% aspect of the nail onychomycosis 48 weeks for toes Trauma Nail plate can appear abnormal 40% Urea with Bifonazole: Distal and lateral Urea CC: 54.8% Nail bed should be normal 1% bifonazole broad-spectrum onychomycosis (less 50%) Daily, for 2-3 weeks MC: 64.5% two Distal onycholysis antifungal Up to 3 nails Bifonazole weeks post Single nail affected Daily for four weeks but treatment Homogenous alteration of nail colour less than two months total Eczema Irregular buckled nails with ridging CC= complete cure rates; MC= mycological cure rates Lamellar onychoschizia (lamellar History of repeated soaking in water splitting) Usually distal portion of the nail Table 5. Systemic drug therapies for onychomycosis in adults Periungual squamous cell Single nail, warty changes of the nail fold, Treatment Dose Contraindications Blood monitoring carcinoma/Bowens disease ooze from edge of nail Itraconazole 200mg/day Liver disease LFT for continuous Malignant melanoma Black discolouration of the nail plate or the First-line Six weeks for fingernails Heart failure treatment only and nail bed therapy Twelve weeks for toenails Benzodiazepines, HMG-CoA reductase repeat every 4-6 weeks Pigment can extend onto the nail fold 400mg/day for one week a inhibitors, quinidines, pimozide Alopecia areata Pits, longitudinal ridging, brittleness, hair month (pulse) Pregnancy (category C) loss Two pulses fingernails Breastfeeding Three pulses toenails Terbinafine 250mg/day Liver disease LFT and FBC pre- First-line Six weeks for fingernails Breastfeeding treatment, then every therapy and 12-16 weeks for Pregnancy (category B) 4-6 weeks toenails Fluconazole 50mg/week Renal/hepatic impairment Baseline LFT and FBC Six months for fingernails Benzodiazepines/terfenadine/cisapride/ and 18 months for toenails astemizole/pimozide/ quinidine/erythromycin Pregnancy (category C) Breastfeeding Griseofulvin 500-1000mg/day Severe liver impairment Monitor LFT regularly 6-9 months for fingernails Porphyria if mild hepatic and 12-18 months toenail Lupus erythematosus impairment Pregnancy (category C) Longitudinal melanonychia in a white-skinned Men fathering a child for six months after adult requires biopsy to exclude a melanoma. therapy

Paronychia

PARONYCHIA is caused by Table 6. Treatment of Chronic Paronychia of the lateral and proximal nail folds. The cuticle is General Avoid wet work destroyed by chemical or mechani- Avoid trauma cal trauma. This causes inflam- Wear cotton gloves under rubber gloves mation that impairs nail fold Avoid excessive manicuring and nail cosmesis keratinisation and prevents the Active Treat cause if known formation of new cuticle, perpetu- Moderate to potent topical corticosteroid nocte ating the cycle of inflammation. Tacrolimus 0.1% ointment twice daily Infection, allergens or irritants In severe cases, use systemic corticosteroids or triamcinolone contribute to inflammation. acetonide 2.5mg/mL into nail fold monthly Systemic antifungals play no role in treatment Acute paronychia Recalcitrant cases: biopsy/radiology/culture, especially if one Acute paronychia usually follows digit involved minor trauma to the skin caused by manicuring, a splinter, thorn Disease is usually prolonged and erythematosis and systemic scle- prick, or subungual haematoma. self-limiting. Secondary infection rosis, and Raynaud’s disease may The infection presents with swell- Figure 6. Chronic paronychia in a chef with loss of cuticle, proximal nail fold is common with candida and pseu- all present with paronychia. Capil- erythema and nail plate ridging. ing, throbbing pain, heat and red- domonas. laroscopy can allow for examina- ness. Compression of the nail fold roform/alcohol twice daily). Com- there is prolonged contact with The causes of chronic paro- tion of the periungual capillaries in can produce pus. bination of topical antibiotics and soap, water and detergents, for nychia include irritant reactions, these conditions. Staphylococci and, less com- potent topical corticosteroids can example with chefs, hairdress- contact dermatitis, food hyper- Zinc deficiency and haematologi- monly, beta-haemolytic strepto- help reduce pain, inflammation ers and fishmongers. It is char- sensitivity, candida hypersensitiv- cal malignancies can present with cocci and gram-negative bacteria and swelling. If pseudomonas is acterised by inflammation of the ity and true candida paronychia. paronychia, albeit rarely. In diabe- are implicated in infection. Usually present, then sodium hypochlorite proximal nail fold with erythema, Drugs may be implicated includ- tes mellitus and peripheral vascular one nail is involved and occasion- solution (1 drop, twice daily) can oedema and absent cuticle (see fig- ing oral retinoids, cephalexin, pro- disease, presentation in the toenails ally can accompany an ingrown be applied around the nail. ure 6). One or several fingernails tease inhibitors, methotrexate and may occur and needs be excluded toenail. If episodes recur at the Systemic antibiotics (and antivi- are usually affected. cyclosporine. unless a diagnosis of ingrown toe- same site, suspicion of herpes sim- rals) are usually needed to prevent Chronic inflammation damages Cutaneous diseases implicated nails can confidently be made. plex virus should be considered. permanent nail dystrophy. the nail matrix and leads to nail include psoriasis, atopic derma- Treatment addresses prophy- Treatment involves drainage of plate abnormalities. The nail plate titis, autoimmune blistering dis- laxis, maintenance and active ther- an abscess, if present, and local Chronic paronychia may become friable and rough, orders and granuloma annulare. apy, and is listed in table 6. antiseptics (2-4% thymol in chlo- Chronic paronychia presents when with irregular transverse ridges. Dermatomyositis, systemic lupus cont’d next page

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Psoriasis

PSORIATIC nail changes can affect tinguishable from onychomycosis. A 50% of patients with psoriasis of the nail biopsy and nail clippings may be skin. Fewer than 5% of patients can needed to assist in the diagnosis. have nails affected as the only mani- Treatment of nail psoriasis depends festation of disease. Up to 85% of on the site and severity of disease in patients with psoriatic arthritis of the the individual, however the results hands and feet will have , can be disappointing. General princi- which can look unsightly and can ples include avoiding trauma to the cause distress. nail, keeping the nails short and reg- Depending on the site of nail appa- ular emollients. Taping the nails can ratus disease, the patient will present help prevent progression of onych- with different signs (see table 7). These olysis. Treatment options for nail bed signs may be seen together in the same or nail matrix disease include topical, nail. Irregular nail pitting (see figure intralesional, and systemic or biologi- Figure 9. Note loss of cuticle, 7), onycholysis with an erythematous cal therapies based on severity of nail nail ridging, and subungual border (see figure 8), and the oil drop disease and coexistent cutaneous or Figure 8. Onycholysis with irregular hyperkeratosis and non-specific sign are diagnostic of psoriasis. How- rheumatological manifestations of Figure 7. Deep irregular nail pitting of red-brown onychodermal band changes of cutaneous psoriasis ever, toenail psoriasis can be indis- psoriasis (see table 8). psoriasis. proximal to onycholysis. affecting the digits. Table 7. Psoriasis of the nails Table 8. Treatment options for nail psoriasis (elements in italics are diagnostic of fingernail psoriasis) Treatment Nail bed Nail matrix Site of disease Sign Description General Nail matrix Pitting (irregular) Pits are large, deep, white • keep short Yes Yes (figure 7) detachable scale • avoid trauma Yes Yes Ridging Transverse • use tape Yes Yes Yes Yes Thickening/crumbling Weakening of nail plate • emollients Beau’s lines Transverse groove due to Topicals (under occlusion daily) intermittent inflammation • clobetasol diproprionate 0.05% cream Yes Yes White nail plate — foci of • tazarotene 0.1% cream/ointment Yes parakeratosis in nail plate • calcipotriol/betamethasone ointment Yes Nail bed Salmon patches (‘oil Translucent yellow-orange Intralesional drop’ sign) discolouration triamcinolone acetonide 10mg/mL (0.1ml per digit, maximum four and monthly Yes (lateral fold) Yes (proximal fold) Onycholysis (with Nail plate separates from for six months, then every six weeks for six months, then two-monthly) erythematous border) nail bed Systemic (figure 8) Nail bed capillary damage • acitretin 0.3mg/kg/day Yes Yes Splinter haemorrhages Nail bed thickening • methotrexate 15mg/week Yes Subungual • cyclosporine 2.5mg/kg/day Yes hyperkeratosis (figure 9) Biologics Yes Yes

Brittle nails

BRITTLE or fragile nails are very ficial white onychomycosis, pso- and occupational activities. as may biotin 5-10mg per day for common and usually affect the fin- riasis, lichen planus, alopecia areata Treatment involves basic princi- 3-6 months. Iron supplementation gernails of women. They may be and eczema. ples of reducing trauma and reducing can be effective if serum ferritin idiopathic or be due to factors that Many systemic disorders can contact with water and detergents. levels are less than 10ng/mL. Zinc alter either nail plate production or affect the nail, and include vascular Nails should be kept short and cot- supplementation at 20mg/day may that damage the nail plate. diseases, endocrinopathies, chronic ton gloves should be worn under improve brittle nails and silica may Idiopathic nail brittleness is asso- infections and amyloidosis. rubber gloves during manual work. improve resistance of the nail plate. ciated with an intrinsic defect in Signs of nail brittleness include Nail cosmetics and manicuring Moisturisers containing urea the intercellular cement that holds splitting, softness, flaking, crum- should be avoided. Artificial nails and alpha-hydroxy acids applied together the nail plate keratinocytes. bling and (thinning, are commonly used to cover fragile to the hands and nails can increase Women have weaker intercellular longitudinal ridging and splitting). nails, but can compound fragility the water-binding capacity of the keratinocyte bridges than men, and In lamellar onychoschizia (see fig- because of materials used to apply nail plate. Lacquers containing these bridges weaken with old age Figure 10. Lamella onychoschizia: ure 10), the distal nail plate splits and remove these agents. hydroxypropyl chitosan or 16% and with environmental factors that distal nail plate splitting horizontally horizontally into multiple layers. Specific treatment involves poly-ureaurethane can decrease dehydrate the nail plate, including into multiple layers. This is common with frequent addressing the dermatological dis- lamellar splitting of the nail. wet work, manicuring and trauma. as can drugs (retinoids, iron, antiret- handwashing. ease or systemic condition impli- Some over-the-counter hardeners Nutritional deficiencies (vitamin rovirals, penicillamine). Brittle nails may be associated with cated. Oral supplementation with can, with prolonged use, make the A, E and H, zinc, selenium) and eat- Dermatological conditions may pain and unpleasant cosmetic appear- vitamins and amino acids, such as nail plate more rigid, and are therefore ing disorders can cause brittle nails, produce fragility, and include super- ance of the nails, and can impair daily cysteine, may improve nail strength, more prone to breaking and peeling.

Ingrown toenails Onychogryphosis

INGROWN toenails (onychocryp- trate into this distal wall and cause Granulation tissue can be pre- ONYCHOGRYPHOSIS affects tosis) are thought to arise from the discomfort. vented with both topical antibi- the elderly with thickening and imbalance between the widths of (trumpet nail) is otics and topical corticosteroids, hardening of the nail plate, usu- the nail plate and the nail bed, and characterised by over-curvature or with cryotherapy or chemical ally the hallux in a typical ram’s associated hypertrophy of the nail increasing the longitudinal axis of cautery. horn shape. It is associated with folds. The great toe is most com- the nail. The edges constrict the If conservative measures fail or chronic trauma, poor fitting foot- monly affected. nail bed tissue and dig into the lat- the disorder is severe, than surgery wear, neglect, impaired peripheral Juvenile ingrowing toenail is eral grooves, causing pain. Causes is indicated. circulation, and neuropathy. caused by improper trimming of the of pincer nails may be genetically If the nail is responsible for the Treatment addresses chemi- nail, with lateral spicules of the nail determined or due to foot deform- ingrown toenail, then definitive cal avulsion of the nail with 40% piercing the lateral soft tissue and ity or osteoarthritis. narrowing of the nail plate (nail urea ointment. The periungual producing inflammation from perfo- Treatment involves educating phenolisation) is preferred. If the skin is protected with tape, and, ration of the nail groove epithelium. Figure 11. Ingrown toenail with against prevention with proper condition is caused by hypertro- after application, the ointment is Hypertrophy of the lateral lip hypertrophy of lateral lip and trimming of nails and good foot- phy of the nail fold, then debulk- occluded for seven days. The sof- accompanies long-standing ingrow- secondary infection. wear. Conservative treatments ing this soft tissue is preferred. tened nail can then be removed ing nails. Nails are unaffected, but nail shedding resulting from recur- include removing the spicules, For pincer nail deformities, with clippers. the lateral soft tissue overgrows (see rent sporting trauma or nail avul- massaging the nail folds, and a nail brace technique may be figure 11). sion. Hypertrophy of the distal soft uplifting the lateral nail fold with required or alternatively, surgical Distal nail embedding occurs after tissue occurs. New nail can pene- cotton wool or dental floss tape. correction may be needed. cont’d page 22

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Tumours

TUMOURS of the nail unit are either benign or malignant, and can A be classified according to the ana- tomical site of involvement. Com- mon benign tumours include warts, fibrokeratomas (see figure 12), mel- anocytic naevi of the nail matrix, glomus tumours (see figure 13) and myxoid (mucous) . B Malignant tumours include Bow- en’s disease, squamous cell carci- noma and malignant melanomas. Figure 12. Fibrokeratoma emerging Figure 14. Myxoid : note nail plate Figure 17. Subungual haematoma: from proximal nail sulcus and depression and longitudinal groove. note distal convex edge of the Myxoid cysts growing on the nail causing a well haematoma. These are the most common nail demarcated longitudinal depression. tumours. They are usually located in A Figure 16. Malignant melanoma of the or distal nail folds, and suggests a the proximal nail folds of fingernails big toe with Hutchinson’s sign: spread melanoma. Nail plate abnormalities and appear as soft, flesh-coloured, of pigmentation on to the proximal (a) can result from matrix damage, and cystic small nodules. They can com- and distal (b) nail folds. subungual lesions can ulcerate and press the nail matrix and produce Image courtesy Professor Rod Sinclair be associated with onycholysis. nail plate depression with a groove Subungual haematomas can (see figure 14). be present, but bone involvement is mimic melanomas when there is They are connected via a tract uncommon and lesions rarely metas- repeated microtrauma to the nail to the distal interphalangeal joint tasise. Treatment involves surgical plate. Dermoscopy can assist in where there may be associated removal of the entire lesion, with diagnosis and discolouration usually osteoarthritis. Definitive treatment Mohs surgery being the most effec- moves distally with the nail growth involves removing the cyst and ligat- tive. (see figure 17). About 25% of mela- ing the connection to the joint. Other Figure 13. Glomus tumour is a B If there is bone involvement, then nomas are amelanotic, have minimal options, associated with higher benign vascular neoplasm of the amputation is required. or no pigment and can resemble relapse rates, include cryotherapy, glomus body characterised by small, pyogenic granulomas or ingrowing intralesional corticosteroid injec- bluish-red spot with no associated Melanoma toenails. tions, puncture and drainage, and nail deformity. It may be associated Melanomas of the nail plate appa- Accurate diagnosis includes clini- sclerotherapy. with pain and treated with surgical ratus are rare and account for cal findings, dermoscopy and his- excision. 0.18-3.5% of all melanomas. They tological confirmation. A punch Bowen’s disease and can lead to onycholysis and longitu- arise, in 76% of cases, from the nail biopsy of nail bed, matrix or plate squamous cell carcinoma dinal melanonychia with associated matrix, but can be found in the nail can be performed if the width of Bowen’s disease — (see figures 15a hyperkeratosis. bed and lateral folds. the band is less than 3mm, but if it and 15b) intra-epithelial squamous Squamous cell carcinoma may Presentation is varied (see figures is larger than this, a transverse nail cell carcinoma — usually affects fin- develop from Bowen’s disease and Figure 15. Bowen’s disease causing 16a and 16b) and includes longitu- matrix biopsy should be used. gers in older males. It presents as a is the most common malignant (a) destruction of the nail plate dinal melanonychia with a blurred Excision margins of these melano- verrucous periungual or subungual tumour of the nail apparatus. It pre- (subungual) and (b) verrucous margin and varying widths. Hutch- mas are controversial and their prog- plaque that can ulcerate. It may sents as a bleeding, ulcerating peri- periungual plaque. inson’s sign describes the extension nosis is poor, with a 50% five-year exhibit crusting and ulceration and ungual or subungual mass. Pain may Image courtesy Professor Rod Sinclair. of pigment on the proximal, lateral survival rate. Lichen planus

NAIL involvement occurs in 10% sion of the proximal nail fold over of patients with lichen planus, but the nail plate with fusion of the nail it is frequently seen in the absence fold to the nail bed and eventual of skin, mucosal or scalp disease. destruction of the nail plate, can be There are numerous clinical mani- seen in severe cases. As nail involve- festations depending on whether ment can lead to permanent and the matrix or nail bed is involved, extensive nail destruction, early and include nail fragility, longitu- treatment is necessary. dinal ridging (see figure 18), thick Treatment includes oral predni- nails (see figure 19) with onychol- solone (0.5mg/kg for 2-6 weeks), ysis, post-inflammatory melanon- systemic retinoids (acitretin), ychia, and trachyonychia or ‘rough Figure 20. Trachyonychia (rough nails) methotrexate or intralesional tri- nails’ (see figure 20). Figure 18. Lichen planus, note early Figure 19. Lichen planus with severe as seen in alopecia areata but often amcinolone (10mg/mL) if disease Dorsal pterygium, gradual exten- longitudinal ridging. thickening of nails and melanonychia. due to lichen planus. is limited to a few fingernails.

Yellow nail syndrome Nail procedures

YELLOW nail syndrome is charac- Figure 21. Yellow nail syndrome with NAIL unit disease can be difficult terised by the triad of yellow nails, overcurvature of the nails, absence of to diagnose. Histopathology can lymphoedema and respiratory dis- cuticle and yellow discolouration. be helpful to obtain a diagnosis for ease. Respiratory disorders include difficult dermatoses affecting the , , bronchitis paronychia. Secondary onycholy- nail. Clinicians are often reluctant and pleural effusions. To diagnose sis may occur. to biopsy the nail as there is con- the disorder, two of the three fea- The nail plate is not always yel- cern regarding permanent scarring tures need to be present either cur- low, but can range from pale yel- or dystrophy, as well as lack of rently or in the past. low to orange. Initially, several training in this field. Histology of The cause of yellow nail nails may be affected, but even- nail clippings can be used to assist syndrome is not known but tually all 20 nails will become in diagnosis and prevent the need hypotheses include genetic, immu- involved. for biopsy. Conditions where this nodeficiency, autoimmunity and Nail lesions can improve spon- may be helpful include onychomy- paraneoplastic. Nail changes occur taneously and can mirror control cosis, dermatophytoma, psoriasis in most patients. of respiratory disease. Treatments and subungual haematoma. Nail findings (see figure 21) include vitamin E (1200 IU/ day) include arrested or slow nail and prolonged oral itracona- Nail clippings for histology growth (less than 0.2mm/week), zole (400mg/day for one week a In order to maximise yield, at least overcurvature of the nail and month) or fluconazole (150mg per 4mm nail length must be obtained. absence of the cuticle with mild week). cont’d page 24

22 | Australian Doctor | 29 January 2016 www.australiandoctor.com.au How To Treat – Ten important nail disorders

from page 22 Key points As opposed to nail clippings per- Case study • A single acquired streak of longitudinal formed for fungal culture, the nail melanonychia (cover page) in a white-skinned need not be cleaned with an alcohol MARLENE, a 50-year-old female shop assistant, middle finger had deteriorated and now reveals adult is a melanoma until proven otherwise and swab prior to collection. The nail presented with a one-year history of a problem dystrophy with subungual hyperkeratosis (see fig- requires dermatology assessment and likely a should be cut with a heavy-duty nail with both thumb and right middle finger nails ure C). biopsy. clipper, with the specimen extending (see figures A and B). She had never previously A specimen was once again sent for fungal • Squamous cell carcinoma of the nail apparatus as far proximally as possible. The had either skin or nail problems, but her sister had microscopy and culture, and Candida albicans is the most common malignant tumour affecting nail plate should be placed in forma- a history of nail problems. There was no family was isolated. She was started on fluconazole this site. It has a relatively good prognosis and lin and sent for pathology. If fungal history of skin pathology. Marlene had seen her 100mg weekly and after three months, dramatic little risk for metastasis. culture is required, the subungual GP who had performed nail clippings, which improvement in the nail was noted, with resolu- debris should be removed with a were negative for a fungal infection, but had com- tion at six months (see figure D). • Onychomycosis is most commonly due to curette and sent for microbiology menced her on oral terbinafine for six months, Nail disease can be the only sign of psoriasis dermatophyte infection and will not clear (microscopy and culture). with no benefit. in 5% of patients. Psoriasis of the nail can look spontaneously. Clinical features revealed onycholysis of all three identical to onychomycosis, but if fingernails alone • Onychomycosis of the fingernail is rare in the Nail biopsy digits with a brown-red onychodermal band at the are involved, always consider psoriasis over fungal absence of toenail involvement, and in isolation A punch biopsy (usually 2-3mm) proximal border of the onycholysis, suggestive of infection. is more likely to be psoriasis. psoriasis. She had no clinical stigmata of psoriasis. Traditionally it was thought that patients with may be useful to help diagnoses • Acute paronychia needs urgent systemic Marlene was treated with intralesional triamci- psoriasis did not get fungal infection as their nails or even treat nail disease. The antibiotic therapy to prevent permanent nail nolone injected into the matrix on two occasions grow too fast. However, patients with nail psoria- nail is soaked in warm water for damage. 5-10 minutes to soften the nail. at three-month intervals. After six months, her sis now have a 50% greater increase risk of onych- The procedure is then performed thumbnails were remarkably better, however, her omycosis than age-matched controls. • Chronic paronychia occurs most often with after anaesthesia — either infiltra- occupations requiring frequent hand wetting. Figure A. Figure C. tive wing block or proximal nerve • Assess the shape of the toe and foot when Thumb nail at Middle nail after toenail dystrophy is present and consider block. The nail plate is ideally presentation. six months of removed so the area to be biopsied intralesional podiatry referral as correct footwear/orthotics can be visualised. The nail plate triamcinolone. which can be beneficial. can be removed by a bigger punch • Onycholysis left untreated can become chronic (4mm) than the intended biopsy regardless of the cause. size. The biopsy is then performed. The circular defect need not be sutured, but can be covered by Figure B. Figure D. References the re-attached nail plate and fold Middle nail at Middle nail 1. Eisman S, Sinclair R. Fungal nail infection: diagnosis presentation. after six months and management. BMJ 2014; 348:g1800. (which must then be sutured in of weekly 2. Gupta AK. Nails and the clinician. Clinics in place). A thick dressing should be fluconazole. Dermatology 2013; 31:Special Issue applied for 48 hours to protect the 3. Baran, R. et al. A Text Atlas of Nail Disorders. area from pain or trauma, and to Diagnosis and Treatment. Martin Duntz, London, prevent excess bleeding. 1996.

Instructions Complete this quiz online and fill in the GP evaluation form to earn 2 CPD or PDP points. How to Treat Quiz We no longer accept quizzes by post or fax. The mark required to obtain points is 80%. Please note that some questions have more than one correct answer. Ten important nail disorders GO ONLINE TO COMPLETE THE QUIZ — 29 January 2016 www.australiandoctor.com.au/education/how-to-treat

1. Which TWO statements regarding b) Nail avulsion and debridement can be useful b) Toenail psoriasis is easily distinguished from nail unit statements are correct? onycholysis are correct? in severe disease, non-dermatophyte mould onychomycosis. a) Myxoid cysts are the most common nail a) Onycholysis refers to detachment of the nail infection or when dermatophytomas are c) Irregular nail pitting, onycholysis with an tumours. plate from the nail bed. present. erythematous border, and the ‘oil drop’ sign b) Subungual haematomas can mimic b) Onycholysis usually starts at the proximal c) Allowing the nail to grow out, thus ridding the are diagnostic of psoriasis. melanomas when there is repeated edge of the nail. nail bed of the infection, is appropriate in mild d) Treatment of nail psoriasis depends on site microtrauma to the nail plate. c) Asymmetrical fingernail involvement is more cases with only one nail involved. and severity of disease in the individual, but c) About 25% of melanomas are amelanotic suggestive of a local cause or cutaneous d) There are no randomised controlled trials is generally disappointing. with minimal or no pigment, and can pathology, such as psoriasis. as yet to recommend laser therapy for resemble pyogenic granulomas or ingrowing d) Treatment is aimed at improving the cosmetic onychomycosis, but numerous lasers have 6. Which THREE are causes of brittle toenails. appearance of the nail. been approved. nails? d) Bowen’s disease usually affects fingers and a) A known gene defect. is most commonly seen in older females. 2. Which THREE regarding onychomycosis 4. Which THREE statements regarding b) Idiopathic. are correct? paronychia are correct? c) Nutritional deficiencies. 9. Which TWO statements regarding lichen a) Clinical features that are highly suggestive a) Acute paronychia presents with swelling, d) Drugs. planus are correct? of onychomycosis include friable nails and throbbing pain, heat and redness. a) Nail involvement occurs in 10% of patients spikes. b) If episodes of acute paronychia are site- 7. Which TWO statements regarding with lichen planus. b) Toenail infection is seven times more likely recurrent, staphylococci and — less ingrown toenails are correct? b) Nail involvement is infrequently seen in the than fingernail disease. commonly — beta-haemolytic streptococci a) All toes are equally affected. absence of skin, mucosal or scalp disease. c) Onychomycosis of the nails is most commonly should be considered. b) Ingrown toenails are thought to arise from c) The effect of lichen planus on nails is a result of Candida albicans. c) Chronic paronychia is characterised by the imbalance between the widths of the transient. d) Onychomycosis is an infection and should inflammation of the proximal nail fold with nail plate and the nail bed, and associated d) Clinical manifestations include nail fragility, always be treated. erythema, oedema and absent cuticle. hypertrophy of the nail folds. longitudinal ridging and thick nails. d) Treatment of chronic paronychia addresses c) Surgery is the preferred initial option as few 3. Which THREE statements regarding prophylaxis, maintenance and active therapy. conservative measures succeed. 10. Which THREE are characteristics of the management of onychomycosis are d) Treatment involves educating about yellow nail syndrome? correct? 5. Which TWO statements regarding psoriasis prevention, with proper trimming of nails and a) Yellow nails. a) Oral treatments are generally more effective are correct? good footwear. b) Lymphoedema. than topical therapies, but have potential a) All patients with skin psoriasis will have nail c) Cardiac disease. adverse effects and drug interactions. psoriasis. 8. Which THREE regarding tumours of the d) Respiratory disease.

CPD QUIZ UPDATE The RACGP requires that a brief GP evaluation form be completed with every quiz to obtain category 2 CPD or PDP points for the 2014-16 triennium. You can complete this online along with the quiz at www.australiandoctor.com.au. Because this is a requirement, we are no longer able to accept how to treat Editor: Dr Claire Berman the quiz by post or fax. However, we have included the quiz questions here for those who like to prepare the answers before completing the quiz online. Email: [email protected]

Next week’s How To Treat compares the normal paediatric ECG with the normal adult ECG, details the evolution of the trace from paediatric to the adult, and offers tips for interpreting the Next paediatric ECG. The author is Dr Christian Turner, consultant staff specialist, paediatric cardiology and electrophysiology, Sydney Children’s Hospitals Network, Westmead, NSW; and clinical week associate lecturer, University of Sydney, Westmead, NSW.

24 | Australian Doctor | 29 January 2016 www.australiandoctor.com.au