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Onychopapilloma

• Benign• Longitudinal erythronychia• Distal subungual hyperkeratotic papule underthe free edge of nail ( hyponychium)

• Sometimes a notch at distal end of band• Often has splinter hemorrhages• Etiology not certain

– ? HPV?• Originates in distal matrix/ proximal nail bed.

Onyhchopapilloma:Surgical removal

• Distal matrix• Proximal nail bed

Onyhchopapilloma:Surgical removal

Squamous cell carcinoma in situ Squamous cell carcinoma in situ

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Squamous Cell Carcinoma of the Nail

• History usually tender /painful• Features subtypes

– Verrucous– Eczematous like– Onycholytic/oozing– Paronychial/ habit tic like– Longitudinal erythronychia// L melanonychia

– Biopsy techniques• Path / HPV?

• TreatmentDalle, S., Depape, L., Phan, A., Balme, B., Ronger Savle, S. & Thomas, L.Squamous cell carcinoma of the nail apparatus: clinicopathological study of 35 cases.British Journal of Dermatology 2007

Preoperative diagnoses in series of 35 cases.SCC, squamous cell carcinoma./nail unit

Squamous cell carcinoma in situ of nail unit

Amelanontic melanoma in situ

Amelanotic Subungual Melanoma

• 25 % of subungual melanomas areamelanotic

• Painless pink subungual macule• often causes a longitudinal split or defectin nail plate over time

Occsionally verrucous lesions of nail foldsand hyponychium

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Erythronychia from externaltrauma

Longitudinal Erythronychia:red lines in nail

• DDX– Onychopapilloma– Glomus– SCC– Dariers/ LP (onychorrhexis)– Aging ridges– External trauma, filing

• Thin overlying plate allows red to show

Longitudinal Erythronychia

• Most common– Solitary digit

• Onychopapilloma• Glomus tumor

– Multiple digits• Inflammatory /genetic , aging ridges, buffing/filingsurface of nail plate

• Must consider– Amelanotic melanoma– Squamous cell carcinoma

What’s New Nail Surgery• Anesthesia• Surgical techniques• Manage the specimen

Newman DH Ann Emerg Med 01 OCT 2007; 50(4):476 7

Waterbrook AL Ann Emerg Med 01 OCT 2007; 50(4): 472 5

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Plastic Reconstr Surg. 126:2031. 2010

Epinephrine is Safe in Nail SurgeryThomson CJ, et al A critical look at the evidence for and

against elective epinephrine use in the finger.PlastReconstr Surg. 2007 Jan;119(1):260 6..

Lalonde D, et al A multicenter prospective study of 3,110consecutive cases of elective epinephrine use in thefingers and hand: the Dalhousie Project clinical phase.J Hand Surg [Am]. 2005 Sep;30(5):1061 7.

Krunic AL et al Digital anesthesia with epinephrine: an oldmyth revisited. J Am Acad Dermatol. 2004 Nov;51(5):755 9.

Anesthetic Agents for Nail Blocks

Agent Onset Pain on injection

Duration

Lidocaine w/epi

without epi

Seconds/ minutes

moderate 2 hours

<2 hoursBupivocaine Marcaine

45min high 8 hours

RopivacaineNaropin

Seconds /minutes

low 7-8 hours

• Block: Wing vs Ring ?• Vibration/ 30 g needle /buffer• Time

How to get perfect nailanesthesia every time!

Painless Nail Surgery

Less painLess timeLess bleedingLess drugLess risk

Best method for kids

Wing Block

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J Bone Joint Surg Am. 2005 May;87(5):986 92.Preoperative skin preparation of the foot and ankle: bristles and alcohol are

better.Keblish DJ, Zurakowski D, Wilson MG, Chiodo CP.

Brigham Foot and Ankle Center, Faulkner Hospital, Boston, Massachusetts,USA. djkeblish@annapolis.med.navy.mil

• 100 volunteers – various foot scrub methods• Alcohol vs povidone iodine, brush vs sponge

• Alcohol plus brush superior

Surgical skin prep: preoperative

Manage the nail biopsy specimen:

Need concise and clear guidelines for specimen submission:

• Orientation of tissue• Clear information to histotechnicians• Reproducible among different

laboratories

+

Tissue

Inking to maintain orientation

Tissue is placed onfilter paper template

Melanoma

Print template at www.phoeberichmd.com

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Place biopsy in cassette

CassetteTissue onPaper Digit

Cover with sponge to hold in place

Cassette

Tissue onPaper Digit

Sponge

Submit in an excess of10% fresh formaldehyde

Submit nail plate separately from soft tissue

Summary of Matrix/Bed Biopsy

• Use cartoon diagram• Inking one end for orientation• Submitting plate separately from soft tissue

Copy template on to filter paper. Download template from web phoeberichmd.com

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Keratin 17 mutation in pachyonychia congenita type 2patient with early onset steatocystoma multiplex. JDermatol 2008

NAIL KERATINSKeratin 6, 16 and 17

Mutations in Keratins 6 and16 lead to PachyonychiaCongenita Type 1

Mutations in K 6 and 17lead to PC 2

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Important Mutations in PC• Keratin genes KRT6a and KRT16 inType 1– Gene locus 12q13 in KRT6a ,Gene locus17q12 q21 in KRT 16

• KRT6b and KRT17 in Type 2– Gene locus 12q13 in KRT6B ,Gene locus17q12 q21

• There was ablation of endogenousK6a expression in two keratinocyte celllines after transfection with thesiRNA’s against K6a3 .

Leachman SA, et al. Clinical and pathologic featurees of pachyonychiacongenita. J Investig Dermatology Symp Proc. 2005; 10:3 17.

Liao H, et al. A spectrum of mutations in keratins K6a, K16 and K17causing pachyonychia congenita. J Dermatolo Sci. 2007; 48:199 205

Nail Psoriasis

Dermatologic conditions of the nails

• Psoriasis–Nail psoriasis limited to the nails 5%– Anecdotally, most treatments that improvepsoriasis on the skin will improve nail psoriasis• Possible Exception : UVB• delay due to nail growth

–Very few evidence based trials for nailpsoriasis

– Evidence based data on several of the biologics

A significant association exists between theseverity of skin and nail psoriasis

Zahra Hallaji, MD,a,b Farshad Babaeijandaghi,MD,c Mahdi Akbarzadeh,MSc,d Seydeh ZeinabSeyedi, MD,c et al.

J AM ACAD DERMATOLJANUARY 2012

N=100

Nail Psoriasis

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• Sanchez Regana, JEADV; 2012

Classical therapyBiologicals

Nail Psoriasis treatment. Sanchez Regana, JEADV; 2012

UST

Onychomycosis and Nail Psoriasis

• About 1/3 of psoriatics have concomitantonychomycosis

• toenails >>> fingernails• More often yeasts and non dermatophytemolds than in non psoriatics who have approx90% dermatophytes

• Koebner reaction?

Intralesional Corticosteroid Injection

• Triamcinolone 3 5 mg /cc ( up to 10mg/cc)dilute with plain lidocaine

• 30 g needle• Vibration Gate theory of pain transmission

– massager Hitachi Magic Wand; order online

• Cold Spray : Gabauer• Inject slowly, superficially, in PNF

Nail Psoriasis Treatment : Where dowe start?

• If mild nail psoriasis in pt without nail or jointsymptoms or concerns : topical or minimaltreatments

• For mild to moderate nail disease in absenceof skin or joint involvement : topical,intralesional, other classical systemic meds.

• Moderate to severe nail disease with orwithout significant skin or joint disease,systemic therapy (classical or biologic) isappropriate.

Psoriasis and onychomycosis (OM):• How often does are both present?

– 17% 30 % of psoriatics have om

– 285 pts with nail psoriasis17% had onycho

10 pts developed om prior to psoriasis tx4 during treatment

Koebner reaction from fungus ???

Szepietowski JC, Salomon J. Do fungi play a role in psoriatic nails?Mycoses. 2007Nov;50(6):437 42.

• Organisms– Candida albicans 3

– Candida paropsilosis] 3– E floccosium

3– T rubrium 2– T mentagrophytes 2– Asperigilus 1

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0.3

mg/kg/day

0.3 mg/kg/day

Tosti , 2009 Arch Dermatology

0.3 mg/kg/day

Onychomatricoma

• Nail matrix lesion—– ?tumor or reactive– Epithelial and stromal components– Distinguish from spindle cells tumors (fibroma,angiofibroma, acral fibrokeratoma, etc)

Onychomatricoma

• Far more common than reported• May be a cause of pincer nail• Easily excised• Recurrence relatively high• Different clinical features

Lichen Planus of the nail

• Primary lesion of nail LP is onychorrhexis:longitudinal ridges in nail plate– Rapidly scarring atrophy and pterygium

• Chronic progressive ridges that can end in matrixscarring

• Trachyonychia : LP is one of several conditionsthat present with trachyonychia– More common in children– Trachyonychia variant of LP does not lead toscarring, atrophy and pterygium

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Onychomycosis

• How to manage onychomycosis in pediatricpatients?

What to do about onychomycosis dueto molds and yeast?

Clinics in dermatology 2010

Non dermatophyte molds NDM Black OM ususally scytalidium,aspergilus or t rubrum.

Onychomycosis vs tinea ungium• 2 12% of OM due to non dermatophyte molds (NDM)

up to 22% in some parts of world• Not keratinolytic must rely on previous destruction of

keratin or trauma• Predisposing: family hx, foot wear, trauma, diabetes

(52%), immunosupression• Scopulariopsis , aspergillus, fusarium, scytalidium,

acremonium• Dx: if dermatophyte present

– microscopy mycelium, arthrospores etc must be seen– Culture present in 5/20 isolates

13.6 % incidence of NDM in 413 cases

• Fusarium 26 cases• Scopularius in 17 cases• Acremonium in 9• Aspergillus in 7• 30 of 50 showed proximal disease withinflammation of nail fold

• Geographical differences around the world.

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Pediatric Onychomycosis