CASE CONFERENCE: Nail Disorders
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CASE CONFERENCE:Nail Disorders
KAREN ESTRELLA05/12/2010
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Do you check the nails of your patients?
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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
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Normal nail
• EMBRIOLOGY: – starts to develop at 10-11 wks– keratinizes from 15 wk– fully formed by birth
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Normal nail• ANATOMY:
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Consult DERMATOLOGY:
• Dark linear, uniform, well demarcated linear ban along the nail bed, involving proximal nail fold
Melanonichia striata
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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), benign melanocyte hyperplasia (nevi), or melanoma.
• Most common in african-american or hispanics
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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
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Melanonychia etiology: iatrogenic
• CHEMOTHERAPY– Metotrexatem– Bleomycin– Doxorubicin– Ciclophosphamide– 5-fluoruracil
• OTHERS– Steroids, – Ibuprofen– Phenytoin– Zidovudine, lamivudine– Ketokonazole,
fluconazole
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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
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Melanonychia work-up• Dermatoscopic evaluation:– Of the free edge of nail bed
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Melanonychia: Dermatoscopic evaluation continued
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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
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Melanonychia Treatment
• Tx of underlying condition• Removal of agent• If melanoma: complete removal of
hyperpigmented section
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OTHER NAIL DISORDERS
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Congenital disorders:(Ectodermal defects)• ANONYCHIA
– Associated with nail-patella sd., deafness
• PACHONYCHIA– Associated with:
hyperhidrosis, leukokeratosis: TM, cornea, mucosas
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Congenital disorders continued
• HYPOPLASTIC– Phenytoin– Warfarin– Fetal alcohol
syndrome
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Associated with systemic disorders
• CLUBBING– hypoxic stages
• KOILONYCHIA (spoon nails)– Iron deficiency
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Associated with systemic disorders• HALF & HALF NAILS– liver, kidney failure
• SPLINTER HEMORRHAGES– endocarditis
• RIDGING-TRANSVERSE LINES - malnourishment
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Acquired nail disorders: infection• PARONYCHIA
– Red, tender, swelling of prox or lateral fold• Acute: S. aureus• Chronic: Candida
albincans
• ONYCHOMYCOSIS- yellowish, brittle- Unusual before
puberty- Systemic antifungal tx
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Acquired nail disorders: dystrophy(distortion, discoloration)
• TRAUMA– Subungual hematoma
• PSORIASIS
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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
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Thank you : )
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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