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CASE CONFERENCE: Nail Disorders

CASE CONFERENCE: Nail Disorders. KAREN ESTRELLA 05/12/2010. Do you check the nails of your patients?. History. 3y/o M seen at SBC for 1 st WCC -no acute concerns except for: changes in nail bed of left 2 nd nail for 1 year. Normal nail. EMBRIOLOGY : starts to develop at 10-11 wks

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CASE CONFERENCE: Nail Disorders

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  1. CASE CONFERENCE:Nail Disorders KAREN ESTRELLA 05/12/2010

  2. Do you check the nails of your patients?

  3. History 3y/o M seen at SBC for 1st WCC -no acute concerns except for: changes in nail bed of left 2nd nail for 1 year

  4. Normal nail • EMBRIOLOGY: • starts to develop at 10-11 wks • keratinizes from 15 wk • fully formed by birth

  5. Normal nail • ANATOMY:

  6. Consult DERMATOLOGY: • Dark linear, uniform, well demarcated linear ban along the nail bed, involving proximal nail fold Melanonichia striata

  7. What is melanonychia? • Tan, brown or black pigmentation from the proximal nail fold and cuticle to the free distal end of the nail plate • Usually affects 1 or 2 digits • Due to: melanocyte activation (physiologic), benignmelanocyte hyperplasia (nevi), or melanoma. • Most common in african-american or hispanics

  8. Melanonychia etiology: benign • LOCAL • Trauma • Radiation • Nail bitting • Foreign body • Infection Single bands • SYSTEMIC • Addison, Cushing, Hyperthyroidism, • Hemosiderosis • Alcaptonuria • Psoriasis • LES, scleroderma • Malnutrition Multiple bands

  9. Melanonychia etiology: iatrogenic • CHEMOTHERAPY • Metotrexatem • Bleomycin • Doxorubicin • Ciclophosphamide • 5-fluoruracil • OTHERS • Steroids, • Ibuprofen • Phenytoin • Zidovudine, lamivudine • Ketokonazole, fluconazole

  10. Melanonychia etiology: malignancy • Age: adults • Brown-black band greater than 3 mm • Change in nail band morphology despite treatment • Digit involved: The thumb is more likely to be affected by subungual melanoma than the great toe; the great toe is more likely than the index finger to be affected by subungual melanoma. • Extension onto the adjacent cuticle and proximal and/or lateral nail folds (Hutchinson sign) • Family or personal history of dysplastic nevus or melanoma

  11. Melanonychia work-up • Dermatoscopic evaluation: • Of the free edge of nail bed

  12. Melanonychia: Dermatoscopic evaluation continued

  13. Melanonychia: work-up continued • Nail bed Sampling: • Punch bx: 3mm, from proximal matrix • Risk of permanent nail dystrophy • Nail-shave bx : 4-6mm, central portion of nail bed • lateral-longitudinal • If suspicion for subungueal melanoma: full thickness

  14. Melanonychia Treatment • Tx of underlying condition • Removal of agent • If melanoma: complete removal of hyperpigmented section

  15. OTHER NAIL DISORDERS

  16. Congenital disorders:(Ectodermal defects) • ANONYCHIA • Associated with nail-patella sd., deafness • PACHONYCHIA • Associated with: hyperhidrosis, leukokeratosis: TM, cornea, mucosas

  17. Congenital disorders continued • HYPOPLASTIC • Phenytoin • Warfarin • Fetal alcohol syndrome

  18. Associated with systemic disorders • CLUBBING • hypoxic stages • KOILONYCHIA (spoon nails) • Iron deficiency

  19. Associated with systemic disorders • HALF & HALF NAILS • liver, kidney failure • SPLINTER HEMORRHAGES • endocarditis • RIDGING-TRANSVERSE LINES • - malnourishment

  20. Acquired nail disorders: infection • ONYCHOMYCOSIS • yellowish, brittle • Unusual before puberty • - Systemic antifungal tx • PARONYCHIA • Red, tender, swelling of prox or lateral fold • Acute: S. aureus • Chronic: Candida albincans

  21. Acquired nail disorders: dystrophy(distortion, discoloration) • TRAUMA • Subungual hematoma • PSORIASIS

  22. Acquired nail disorders: dystrophycontinued • TRACHYONYCHIA (Twenty nail dystrophy) • School children • Yellow or gray color nails, (+) pitting, friable • Progresses in 6-18 months, self-limited • Some cases associated with alopecia areata, atopic dermatitis

  23. Thank you : )

  24. References • Cohen, B. pediatric Dermatology. Mosby LTD, Spain: 1999. pg 201-208 • www.dermaimaging.com/?cat=39 • http://www.ncbi.nlm.nih.gov/pubmed/10411404 • http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0365-05962009000200013&lng=en&nrm=iso>. ISSN 0365-0596.  doi: 10.1590/S0365-05962009000200013. • http://emedicine.medscape.com/article/1375850-overview • http://www.medscape.com/viewarticle/718695_7

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