Let’s find out the damage related to nail disease
1. Nail Anatomy
The nail consists of the nail plate and supporting tissues: the nail folds, the nail germ, the nail bed, and the lower part of the nail.
The nail plate is a hard, fairly transparent, slightly curved structure consisting of tightly bound keratinocytes.
Surrounding and protecting the nail plate are 3 nail folds (1 proximal and 2 lateral). The upper surface of the nail fold is nearly continuous with the skin of the finger and the lower surface is continuous with the nail germ. The cuticle/eponychium is a thin band of keratinized epithelium attached to the margin of the proximal nail fold, which protects the nail.
The nail germ is the birthplace of the nail plate, which includes the proximal nail germ and the distal nail germ. The proximal nail germ is the site of the upper surface of the nail plate, and the distal nail is the lower surface of the nail plate. A clinically visible part of the distal nail germ, most evident in the thumb, is a milky crescent-shaped structure called the lunula.
The nail bed is continuous with the edge of the crescent and extends to the lower part of the nail, which is the structure that supports the nail plate. The distal part of the nail bed has a transverse band that is dark pink (for Caucasians) or brown (for Africans) called the onychodermal band.
The subungual part is located at the distal end, and subungual keratosis can be seen in many diseases.
2. Nail psoriasis
Psoriasis is a chronic, progressive, lifelong disease of unknown etiology with diverse clinical manifestations, in addition to skin lesions, mucosal lesions, nails and joints.
Nail lesions occur in 30-50% of psoriasis patients, often accompanied by skin lesions. If there is only nail damage, it is difficult to diagnose, need to have a nail biopsy
The clinical presentation depends on whether the nail germ or nail bed is affected. Nail damage:
- Pitting: is the most common manifestation, more often in fingernails than toenails, caused by a disorder of the keratinization process in the proximal part of the nail. More than 20 pitted lesions are suggestive of nail psoriasis, and more than 60 lesions are almost certainly psoriasis.
- Tranverse groove: formed by the same mechanism as nail pitting, the nail germ is damaged on a large scale.
- Trachyonychia: sandpaper-like, nonspecific, seen in many other diseases such as lichen planus, alopecia areata, atopic dermatitis.
- Nail white line: due to damage to the middle of the nail germ, causing parakeratosis, scabbing on the underside of the nail plate, not on the upper surface of the nail plate as pitting signs.
- Destroy the proximal end of the nail.
Injury to the nail bed:
- Oil drop sign: due to the phenomenon of point-by-point parakeratosis in the nail bed, causing the nail to be separated into points, which is the place of accumulation of serum and cell residue.
- Nail separation: due to damage to the oil drop spreading to the distal tip or due to psoriasis affecting the distal end of the nail bed, the lower part of the nail.
- Subungual keratosis: more often on the toes than on the fingers. Squamous cells do not shed, but accumulate. + Splinter hemorrhage: nonspecific, hemorrhagic lesions in lines about 2 – 3 mm long at the distal nail.
- Pustules of extremities: due to the formation of pustules that completely destroy the nail plate.
- Depilation: The part near the nail plate is separated from the nail germ because the nail stops growing suddenly.
3. BASIC DAMAGES OF NAIL (Nail disorders)
The nail is a special part, composed of the nail plate, the nail germ and the nail bed. Abnormal signs in the nail are not only due to local causes but also can be manifestations of many other systemic diseases. About half of nail abnormalities are due to infection, 15% due to inflammation or metabolism, and 5% due to malignancies, pigmentation disorders.
3.2 Abnormal signs of nail sprouts
The nail bud is the birthplace of the nail plate, so disorders in the nail germ can be observed in the nail plate.2.1. Beau’s line
These are horizontal grooves in the surface of the nail plate due to the temporary inactivation of the nail germ.
Groove depth: indicates the presence of nail germ damage.
The width of the groove: indicates the time of injury.
- Trauma: most common.
- Pathology of the proximal nail folds: eczema, chronic infection, periungitis.
- Multiple Beau lines on all nails suggest systemic cause: drug, fever, generalized redness…
3.2.1 Nail detachment (onychomadesis)
The mechanism is similar to Beau’s line, but the nail germ is more severely damaged causing the nail plate to detach from the proximal nail fold.
3.2.2 Signs of nail pitting
These are small indentations on the nail plate formed due to the disorder of the keratinization process in the nail germ.
- Deep nail pitting, uneven distribution: psoriasis, atopic dermatitis.
- Shallow nail pitting, evenly arranged: alopecia areata.
3.2.3 Trachyonychia/ twenty nails dystrophy
Characteristic manifestations: the nail plate becomes rough due to the formation of many longitudinal notches (originating from multiple foci of keratinization disorders in the proximal nail germ).
Causes: alopecia areata (common), psoriasis, lichen planus (rare), eczema (very rare).
3.2.4 Longitudinal notch
These are grooves along the nail plate, accompanied by atrophy of the nail plate, showing diffuse nail germ damage.
Causes: lichen planus, blood supply disorder, trauma, tumor compressing nail germ, slight ridge may be signs of aging.
3.2.5 Spoon-shaped concave nails (koilony-chia)
The nail plate is concave in the middle and curved up on the sides like a spoon. The unknown mechanism may be related to perfusion, endocrine abnormalities, decreased metalloenzymes or sulfur-containing amino acids, trauma or other skin conditions. Reason:
- Acquired: due to iron deficiency anemia (nails will gradually return to normal after 5-6 months if supplemented with Iron); due to infection: fungus; skin pathologies: psoriasis, lichen planus, scleroderma; Raynaud’s syndrome; endocrine pathology; due to injury.
3.2.6 Thickening of the horns under the nail
As the inflammatory process disturbs the keratinization process, keratinocytes accumulate at the distal end of the nail bed and the subungual part.
- Nail fungus
- Atopic dermatitis
3.3 Abnormal signs in the nail bed
3.3.1 Nail separation (onycholysis)
The distal nail plate is separated from the base of the nail.
Causes: trauma, onychomycosis, psoriasis, light-induced nail separation: occurs alone or in combination with drugs such as tetracyclines.
3.3.2 Bleeding splinter
Are dark red longitudinal lines due to hemorrhage seen in the nail plate.
Usually at the distal end of the nail plate, occurs due to trauma, psoriasis, onychomycosis.
Rarely appear in the proximal nail plate, if present, it is usually a systemic pathological manifestation such as endocarditis, vasculitis, antiphospholipid syndrome.
3.4 Abnormalities due to dyschromia (nail dyschromia or choro-monychia)
This is a condition in which the pigmentation of the nail is changed due to exogenous or endogenous causes:
3.4.1 Longitudi-nal melanonychia
Lesions are one or more brownish-black longitudinal bands, arising from the proximal to distal nail fold, common in black individuals. This is the most common type of black nail (melanonychia).
Activation of melanocytes in the nail germ (normally melanocytes in the nail germ are inactive): trauma, drugs, pregnancy, radiation, Addison’s disease, HIV, Laugier’s syndrome -Hunziker, Peutz – Jegher, post-inflammatory,… In which, the cause of injury (usually due to rubbing the toe 4 or 5 of the foot when wearing shoes) is the most common, possibly accompanied by bleeding.
Melanocyte proliferation: less benign, cancerous.
Longitudinal black stripes can be seen at any age, with one or more fingers, making it difficult to distinguish clinical causes, especially in adults, pathology is still the gold standard for definitive diagnosis. . In adults, if clinical malignancy is suspected based on the ABCDEF rule (see also nail malignancies), der-moscopy can be used for more accurate screening. When evaluating black nail lesions by der-moscopy, it is necessary to evaluate in 3 sequences: (1) whether the black pigment in the nail is caused by melanin or not, (2) if it is the melanin pigment, it is due to activation or proliferation. melanocytes, (3) if proliferative, the lesion is malignant or benign.
Children: often caused by benign melanoma in the proximal nail folds, due to agents that activate melanocytes in the nail germ, but rarely due to melanoma, therefore, biopsy should be avoided. if not necessary to avoid permanent nail atrophy and monitor closely. Suspicious features for biopsies include: increased lesion width, discolored lesions, mixed coloration, periungual pigmentation, or associated plate atrophy, requiring close follow-up because There are several reported cases of nail melanoma in adults resulting from the longitudinal black stripe of the nail in childhood
3.4.2 Hutchinson’s sign
Dark brown pigmentation appearing in the whole periungual area is a sign of melanoma of the nail. Attention should be paid to distinguishing it from Hutchinson’s pseudo-sign: pigmentation in the nail plate observed through the cuticle is mistaken for pigmentation in the nail fold.
3.4.3 White nails (leukonychia)
White nail is a condition in which the normal pigment of the nail plate turns white, including:
True leukony-chia: the proximal part of the nail plate forms the upper surface of the nail plate, while the distal part of the nail germ forms the lower surface of the nail plate. In true nail whites, the distal part of the nail is damaged, so the upper surface of the nail plate is normal but the color changes, there are white bands due to the presence of parakeratosis cells on the underside of the nail plate. There are variations of this type:
Full nail whitening:
Congenital: rare disease, usually autosomal dominant, in some cases recessive.
Associated with systemic diseases such as diabetes, cirrhosis, renal failure, heart failure, Bart Pum-phrey syndrome (deafness, white nails, knuckle pad).
Horizontal white line: arc-shaped bands 1 – 2mm wide also called Mee lines are common in acute arsenic or thallium poisoning, in addition, due to contraction, chemotherapy or heavy metals (lead, strontium), pilocarpine and sulfone -amide. Besides, there are also systemic diseases such as cardiovascular (heart failure, myocardial infarction), digestive (colon ulcer), blood disease, cancer (breast cancer, Hodgkin’s tumor, sickle cell anemia) ), infections, kidney disease (renal failure, transplant rejection), joint disease (systemic lupus erythematosus).
Dotted white nail: psoriasis and trauma. White line along the nail: Darier’s disease.
Pseudoleukonychia: the surface of the nail plate is peeled off into cotton-like debris.
Shallow white nail fungus: formed by keratin deposits and fungal particles.
Chemical destruction of nail keratin.
Transparent leu-konychia: can occur in all nails, when applying pressure on the nail plate, the white color disappears. Since this is an abnormality of nail bed color (usually due to nail bed edema), the white color does not migrate as the nail grows longer.
White Terry Nails:
• Related: liver disease, is a common symptom, accounting for 80% of patients with cirrhosis.
• Characteristics: the nail plate is milky white, covering the lunula, only about 1-2 mm from the free edge of the nail is normal in color, affected in all nails.
Lindsay’s half-and-half nails:
• Related: kidney disease, which affects up to 25% of patients with chronic kidney disease requiring dialysis, can be seen in normal people.
• Characteristics: the nail plate is milky white on the proximal side which hides the lunula while the distal half remains pink/red.
• Nail white bands (Mueh-rcke line): white bands across the nail forming pairs, associated with cancer chemotherapy, hypoalbuminemia, unilateral trauma related. Characteristic: white bands parallel to the lunula, separated from each other by pink normal nail bands.
- Due to infection with pyocyanin-producing Pseudomonas aeruginosa, pyoverdin produces a bluish-black pigment under the nail plate that is separated from the nail bed.
- Causes of bacterial nail infections include: Gram-negative bacteria (usually p. aeruginosa, but also Klebsiella spp.) and Gram-positive bacteria such as s. aureus in that p. aeruginosa is the most common cause.
- This is a bacillus, aerobic, Gram-negative producing blue pigments such as pyoverdin and pyocyanin, the mechanism of nail infection is not clear, because it does not belong to bacteria in normal nails.Risk factors: constant exposure to water, heavy use of chemical soaps, trauma, and causes of nail separation (eg, psoriasis, onychomycosis,…).
- Color change nail plate: dark blue.
- Can be included with distal nail separation
Differential diagnosis: subungual hemangioma, melanoma, infections caused by Aspergillus, Candida and Proteus, exposure to chemicals containing pyocyanin or pyoverdin.
Avoid factors that aggravate the disease, wear two layers of gloves (cotton and rubber) when having a lot of contact with water, soap, chemicals.
Topical: silver sulfadiazine, flouro-quinolone, Gentamicin, drops to-bramycin twice a day for 2 weeks. Oral medication: Ciprofloxacin for 2-3 weeks in severe, prolonged cases. Usually the drug takes effect quickly after a few weeks of use.
Surgery to remove the green tissue when topical or oral medications are not effective.
3.4.4 Yellow nail syndromeYellow nails can be a normal phenomenon in the elderly or associated with systemic disease, taking drugs. Systemic diseases include: hypercarotenemia, skin diseases (psoriasis, onychomycosis), jaundice and respiratory diseases (in yellow nail syndrome).
Typical yellow nail syndrome includes: yellow nail, lymphedema, respiratory disorders – chronic bronchitis, bronchiectasis, sinusitis, pleural effusion. The mechanism of nail modification of this syndrome is not clear, possibly due to oxidation in the nail plate causing accumulation of lipofuscin. Manifestations include:
- Nail color: light yellow, dark yellow.
- The nail plate is thick, curved horizontally or vertically.
- There is no cuticle on the nail (cuticle).
- Usually affects all 20 fingers and is accompanied by separation of the nail.
Treatment: 10-30 % of cases of yellow nail syndrome have self-healing nails. Treatment includes taking high doses of Vitamin E, treating underlying respiratory disease.
3.4.5 Red nails (erythonychia)
Classification depends on where the pigment occurs: in the nail plate, in the nail crescent, or in the nail bed.
Red pigmentation in the nail plate is usually caused by exposure to environmental chemicals such as eo-sin, fuschin, hydroquinone or by nail polish products.
Red nail crescent is often easily observed in the thumb, associated with many systemic diseases such as cardiovascular, skin diseases, endocrine, digestive, hematological,… The mechanism is unknown but may be related to Varicose veins, increased arteriolar perfusion, the nail plate in the crescent of the nail is thin.
Longitudinal red stripes involve both the nail sickle and the nail bed, due to damage to the nail germ. If present alone, it may be related to the local tumor but may also appear in the thumb of the hemiplegic side. If multiple fingers are present, it is often related to skin diseases such as Darier, lichen planus or cases of graft-versus-host disease, primary systemic am-yloidosis…
Ingrown toenail is a phenomenon where the nail plate is too curved horizontally.
Causes: unknown, including genetic and acquired. In particular, ingrown toenails due to tight shoes are most common. Other causes include: nail tumor, nail fungus, other skin diseases, ..
Longitudinal red stripes involve both the nail sickle and the nail bed, due to damage to the nail germ. If present alone, it may be related to the local tumor but may also appear in the thumb of the hemiplegic side. If multiple fingers are present, it is often related to skin diseases such as Darier, lichen planus or cases of graft-versus-host disease, primary systemic am-yloidosis…
4. nail damage in room lichen (Nail lichen planus)
Nail lesions seen in 10% of patients with lichen planus (LP) may be associated with mucocutaneous lesions but may also be the sole manifestation of the disease. Lesions may appear on one, several or all nails, more commonly on fingers than toes.
Swollen proximal nail folds change color.
- Longitudinal notch: absent in psoriasis.
- Formation of triangular excess tissue (pterygium) in the proximal nail fold: characteristic of LP.
- Diffuse nail germ damage: complete loss of nail plate.
- Red nail crescent: localized or diffuse.
- Longitudinal pigmentation changes.
Injury to the nail bed:
Separation of nails
Treatment is mainly based on individual studies, with no specific treatment guidelines.
4.3.1 Local treatment
With limited damage.
Topical corticosteroids are considered the first choice: clobetasol propionate 0.05% overnight dressing. The application time can be extended for 1-3 months depending on the clinical response, after achieving the clinical response, reduce the dose for maintenance therapy.
Inject intralesional triamcinolone 2mg into the proximal nail fold.
Tacrolimus topical, overnight dressing, moisturizing.
4.3.2 Systemic treatment
In cases of diffuse lesions that do not respond to treatment or when there are irreversible lesions such as pterygium.
Corticosteroids: intramuscular injection of triamcinolone ace-tonide 0.5 mg/kg/month or prednisolone 40 mg/day for 2 weeks then 30 mg/day for 2 weeks reduces inflammation after 4 weeks.
Retinoids: Acitretin, alitretinoin. Administration of alitretinoin 10-30 mg/day significantly reduced symptoms after 4-6 months.
Methotrexate 10-20 mg/week subcutaneously relieves symptoms after several weeks.
Biologic drugs: TNF-inhibitors – a: Use of etanercept to improve symptoms after 6-9 months after failure of other methods.
Other drugs: antimalarial, dapsone, aza-thioprine.
5. Ingrown toenails or onychocryptosis
Nail puncture is a phenomenon where the anterior angle of the lateral margin of the nail plate pokes and tears the soft tissue in the lateral nail plate, causing the nail folds to swell, become painful, and infected. The disease usually occurs in the big toe. Causes: improper nail trimming, wearing tight shoes, nail diseases such as onychomycosis, dystrophy.
The disease manifests itself in three stages:
Stage I (mild inflammation): pain, mild swelling due to damage to the epithelium of the lateral nail fold.
Stage II (V.A): lateral nail folds are painful, edematous, exudative and purulent.
Stage III (severe inflammation): granular tissue covers the nail plate
Depending on the stage of the disease, according to the guidelines of the American Association of Family Physicians.
Mild, moderate lesions: stage I, stage II without pus can be treated conservatively.
Soak in warm, soapy water, apply antibiotic ointment or cream, medium to strong corticosteroid ointment; place a bundle of cotton thread or dental floss under the lateral margin of the puncture nail; put nail brace.
If conservative treatment fails, consider surgical removal of part of the nail plate with or without excision of the nail bed. If pain and infection are repeated many times, it is necessary to destroy the nail germ by applying phenol 80-88% solution, electrocautery, radiofrequency or CO2 laser.
Moderate to severe lesions: stage II pus, stage III surgery.
5.4 Some more pictures of fleshy nails
6. Acute paronychia
Acute paronychia is an acute bacterial infection of one or more nail folds that progresses for less than 6 weeks.
The most common cause is staphylococcus aureus, Streptococcus pyogenes, and Pseudomonas pyocyanea.
Infections are usually caused by direct or indirect trauma to the nail folds, usually minor trauma or by the habit of thumb sucking, when the damage is caused by both skin microflora and anaerobic bacteria in the nail bed. oral cavity such as Fusobacterium, Peptostrep-tococcus.
Usually only 1 finger, onset: redness, edema, pain in the proximal and lateral nail folds usually 2-5 days after the injury. May start as a superficial, purulent bacterial lesion below the nail fold. If due to Pseudomonas, the nail bed may turn blue.
If left untreated, it will lead to subungual abscesses, pyelonephritis, and permanent nail plate dystrophy. In addition, repeated acute episodes may progress to chronic inflammation (lasting more than 6 weeks).
Usually not necessary.
If deep infection is suspected or clinically difficult to determine if there is an abscess or cellulitis, imaging methods such as ultrasound, X-ray may be indicated.
Routine pus culture is not recommended because the results are usually of no diagnostic value and do not affect treatment.
Based on clinical, laboratory indication when the lesion is clinically unknown.
Pressure test: applied to see if there is an abscess. How to do it: the patient presses the affected thumb and finger together, creating a small pressure that causes the skin of the nail fold to turn white, if there is an abscess, the lesion margin will be lost.
According to guidelines from the American Association of Family Physicians, treatment depends on the degree of inflammation and the presence of an abscess.
If only mild inflammation, no cellulitis:
Soak in warm water, topical antibiotics, with or without corticosteroids. The use of topical corticosteroids reduced the time to disease progression without any risk.
Antibiotics in nine categories include: Mupirocin, gentamicin, if Pseudomonas infection is suspected, topical flu-oroquinolone can be used. Antibiotics containing Neomycin should not be used because the risk of allergic reactions is about 10%.
If there is an abscess, it is necessary to make an incision to clean:
If the incision is good, antibiotics are usually not needed, and topical antibiotics may be considered.
The use of systemic antibiotics is limited to clear cellulitis, immunocompromised patients, or severe systemic disease.
Use moisturizing lotion after washing your hands.
Avoid prolonged contact with soaps and detergents.
Avoid impact injury, biting, picking or nail sucking.
Do not cut the cuticle on the nail (cuticle).
Blood sugar control in patients with diabetes.
Cut nails short, keep them clean.
Use Rubber gloves when in contact with irritants, preferably with cotton inside.
7. Chronic peritonitis (Chronic paronychia)
Chronic paronychia is an inflammatory disease in the fingernails or toenails lasting more than 6 weeks with manifestations: redness, sensitivity, pain, swelling.
In the past, chronic VQM was considered a fungal infection of the nail folds, so treatment was mainly antifungal. Current opinion is that this is an inflammatory response to allergens and irritants occurring around the proximal nail fold. Repeated episodes of inflammation lead to fibrosis of the proximal nail folds, failure to regenerate the cuticle, thereby allowing more chemicals and allergens to penetrate. Besides, this is a persistent disease that is difficult to treat, often seen in housewives or housekeepers, so prevention methods play a very important role. In the past, maintenance antifungals were used, but recently, topical corticosteroids have shown better efficacy. In persistent cases with poor response, surgery can be performed.
7.2 Causes, risk factors
Many factors combine to cause cuticle destruction, exposing nail folds and grooves.
Since Candida can often be isolated from damaged nails, it was previously thought that the cause of chronic bacterial vaginosis is Candida. However, in many cases, when the physiological barrier of the skin is restored to normal, candida also disappears or vice versa, in patients with cured chronic VQM, strains can still be isolated. Candida in lesions demonstrates that complete elimination of Candida does not play an important role in the treatment process. Therefore, recent views have suggested that chronic hepatitis is not a fungal disease but an eczematous disease. Therefore, treatment with topical or systemic corticosteroids is effective while systemic antifungal therapy has poor results.
Commonly ill subjects: cleaners, laundries, food vendors, housewives, maids, bartenders, chefs, nurses, swimmers, diabetics or those who are sick. HIV treatment.
Other less common causes include:
Infections (bacterial, fungal, viral).
Metastatic cancer, subungual melanoma, subungual scc (must be ruled out if chronic adenomyosis does not respond to conventional therapies).
Diseases such as psoriasis, bullous diseases such as pemphigus.
Toxicity of drugs: retinoids, epidermal growth factor receptor (EGFR) inhibitors such as cetux-imab and protease inhibitors. In HIV patients, indina has produced a retinoid-like effect and is the most common cause of chronic VQM in this population. Retinoids also cause chronic VQM, the mechanism probably by weakening the nail plate, followed by small nail debris creating microtrauma.
Skin redness, tenderness, swelling, proximal toenail folds, no cuticle above the nail (cuticle), there may be pus under the nail fold.
One or more nails may be affected, usually on the 1st, 2nd, and 3rd fingers of the dominant hand.
The nail plate is thick, discolored, has Beau’s line sign (due to nail germitis).
Time to progression: more than 6 weeks. Prolonged illness with recurrent, self-limited flare-ups.
7.4 Differential diagnosis
Cancer metastasis to the nail
Carcinoma should be considered if chronic inflammation does not respond to symptoms
7.5.1 General measures
Purpose: avoid factors that aggravate the disease and limit the damage caused by nail picking and plucking.
Avoid exposure to humid environments and contact irritants such as soaps and detergents.
Keep the affected area dry and apply moisturizer immediately after washing your hands. When in contact with irritants, use rubber gloves, preferably a layer of cotton gloves inside.
Limit damage by cutting nails short and avoiding nail picking, thumb sucking, and self-incision to drain the lesion. You should choose the right socks to avoid nail damage. Diabetics need good blood sugar control.
7.5.2 Drug treatment
In the past, Candida was considered to be the main causative agent, so antifungals were the first-line therapy, but it was suggested that the effect of antifungal drugs in chronic bacterial vaginosis was due to both antifungal and anti-inflammatory effects. anti-inflammatory activity of the active ingredient.
Today there is much evidence that chronic VQM is an eczematous disease, therefore the American Family Physician Association has issued guidelines for the use of topical corticosteroids as a first choice for the treatment of chronic VQM (corticoids at also have less risk and cost less than systemic antifungals). Topical drugs with a combination of corticosteroids and antifungals can be used or tacro-limus 0.1% ointment can be used. Apply the drug twice a day to the edge of the nail.
The study of Tosti et al., after 3 weeks of treatment of chronic VQM with meth-ylprednisolone aceponate 0.1% topical, the rate of improvement or cure was up to 87.5%, while that rate was in the group using Tosti et al. oral itraconazole 200 mg/day and terbinafin 250 mg/day were only 34.4% and 33.3%, respectively. According to a study by Rigopoulos, tacrolimus 0.1% applied twice a day for 3 weeks and then followed up after 6 weeks was significantly more effective than beta-methasone 17-valerat 0.1% (13/14 patients in the tacroli group). mus recovered, no recurrence after 6 weeks compared with only 8/14 recovered patients of the other group).
For persistent, difficult-to-treat cases, local corticosteroids (triamcinolone) can be injected. If VQM is severe and has many fingers, systemic corticosteroids can be used in a short time to treat inflammation and pain.
If chronic VQM does not respond to topical treatment and other preventive measures, systemic antifungal therapy can be used before invasive treatment is introduced.
Other special cases: VQM due to EGFR inhibitors such as cetuximab can be treated with the antibiotic doxycycline. In patients with VQM due to indinavir, alternative antiretroviral therapy (maintaining lamivudine and other protease inhibitors) can be used.
Purpose: remove inflammatory tissue, help local and systemic drugs absorb better, regenerate cuticle on the nail (cuticle).
Indications: Chronic persistent VQM not responding to other methods.
Method: trim the proximal nail fold, with or without partial/complete cut of the nail plate.
Chronic VQM responds slowly to treatment. Remission often takes weeks-months, so both the doctor and the patient need to be patient. With mild – moderate cases, after 9 weeks of treatment, it is effective. With persistent cases, it is possible to cut off the proximal nail folds with removal of the nail plate for a high cure rate.
Besides, whether the treatment is cured or not depends on the prevention methods (protecting the skin barrier in the nail folds).
9. RICE GROUNDES periungual warts (Periungual warts)
Rice grain is a disease caused by Human papilloma virus. Warts around the nail are common in patients who have a habit of biting their nails.
Lesions are initially horny papules, small as pinheads standing separately, then growing, clustering together, rough surface, gray, dirty brown or black. The rice grain in the proximal nail fold often causes thickening of the horn around the nail, while the rice grain in the nail bed often causes the nail plate to be pushed up, accompanied by the separation of the nail. Occasionally, squamous cell carcinoma can be mistaken for periungual warts or appear on the background of angiosperm lesions.
Diagnosis is mainly based on clinical symptoms.
Supportive testing includes pathology and PCR typology.
Pathology: epidermal thickening, parakeratosis, increased spines, papillae formation, vascular occlusion in the dermis.
Typing PCR: HPV type identification does not affect the choice of treatment.
According to the American Association of Family Physicians’ guidelines for treating rice grains:
The first choose:
Salicylic acid: can be used with concentrations up to 70%, but this method takes time, requires patients to adhere to treatment.
Cryotherapy: about 10-30 seconds on average, creating a frozen ring about 1-2mm around the edge of the lesion, needing 3-4 treatments. This method is simple but can cause scarring and pain.
Cantharidin: not yet approved by the FDA.
Bleomycin: 15UI vial, mix with 30ml physiological salt, take 0.3ml and inject into the lesion. Can be re-injected every 3-4 weeks until the lesion clears. The disadvantage of this method is that it can cause pain, scarring, nail destruction, and Raynaud’s phenomenon.
Imiquimod: 5% cream used twice a day for 2-12 months.
PDL: after 2-3 courses, the cure rate is about 48-93%.
10. Nail disorders in autoimmune diseases
Nail abnormalities in scleroderma
Change the nail plate
Perfusion abnormalities, Raynaud’s syndrome (vasoconstriction): pale or purple nails.
Anemia of extremities:
Congestive distal nail bed
Prolonged tissue ischemia leads to fibrosis of the nail germ, creating a false image of a club finger, also known as breaking nail, which manifests as an excessive longitudinal curvature of the nail plate (clubbing nail is a Angle between the proximal nail fold and the nail plate >180°, occurs due to hypertrophy of the connective tissue at the tip, proliferation of fibrous tissue at the base, may or may not be accompanied by cyanosis; seen in cardiovascular diseases , Respiratory,…)
Inflammation of the nail germ leads to pitting of the nail.
Splinter hemorrhage: When present in the distal nail plate, it is usually due to trauma but proximal is an indicator of vascular injury.
Nail fungus: secondary.
10.1 Change of nail fold capillaries
Cutolo in 2002 proposed three stages of microvascular damage in scleroderma:
Early: few large, dilated capillaries, no sign of capillary loss.
Action: many giant capillaries, hemorrhage, loss of capillaries, remodeling of capillaries.
Late: the number of capillaries decreases sharply, the avascular areas increase, the capillaries are arranged as messy as the branches of a tree.
Transform the part around the nail
Cuticle: rough, thickened, hemorrhagic.
Proximal nail folds: white due to anemia.
Changes due to anemia:
Triangular excess tissue under the nail (pterygium).
Painful pitted scars, can progress to necrosis, gangrene.
Other: petechiae, psoriatic lesions.
10.1 Nail abnormalities in other connective tissue diseases
Nail abnormalities are more common than toenails.
Nail fold capillary abnormalities are the most common disorder.
Normally, the soft u-shaped capillaries are regularly arranged.
May have features similar to scleroderma, hence the term “scleroderma capillary change” on nail angiography, when two of the following are present:
• Dilated capillaries.
• Hemorrhage (with > 2 petechiae per nail or extensive hemorrhage).
• Confused capillary distribution.
• The quantity is greatly reduced.
• Capillaries are twisted, crossed or twig-shaped.
Other abnormalities: splinter hemorrhage, triangular excess tissue under the nail (pterygium), red lunula, longitudinal notch, secondary onychomycosis.
10.2 Nail abnormalities in alopecia areata
Alopecia areata is non-scarring hair loss that manifests as well-demarcated, circular or oval patches of hair loss on the scalp or other body hair. The disease is thought to be an autoimmune disease, but genetic factors may also be involved. The disease can manifest in the nail in about 10-40% of cases, in cases where the nail is present, hair loss is more severe.
Pitting nail: shallow pitting, evenly lined up different from psoriasis is deep pitting, uneven distribution.
Trachyonychia: There are many notches along the nail that make the nail plate rough like sandpaper.
There are horizontal concave lines or vertical concave lines.
11. Drug – induced nail disorders
Drug-induced nail lesions usually involve multiple nails or all 20 nails, and may involve the nail germ, nail bed, periungual tissue, or even blood vessels.
Progression is related to the use of the drug, which usually disappears after discontinuation of the drug but can persist for a long time thereafter. The changes are asymptomatic, cause only cosmetic problems, or can cause pain, discomfort, and interference with daily activities.
Unclear can be caused by:
Toxicity on nail epithelium.
Consequences of accumulation and excretion of drugs in the nail plate, causing nail pigmentation.
Nail pigmentation can be the result of drug deposition in the dermis, and thus changes both skin and mucous membranes.
Changes in perfusion, causing necrosis, damage to the nail bed vasculature cause splinter hemorrhage or subungual hemangioma.
Changes are caused by systemic drugs, but topical drugs can also cause symptoms, especially pigment changes, irritant or allergic contact dermatitis.
Manifestations depend on the part of the nail affected
Drug-induced nail germ changes
Beau’s sugar is one of the most common side effects of chemotherapy, often the result of drug toxicity affecting tissues with strong mitotic activity such as nail germ, hair follicle germ, mucosa.
Manifestations are horizontal grooves on the surface of the nail plate (see also nail abnormalities). Multiple Beau lines on one nail: due to multiple chemotherapy treatments, the distance between the lines corresponds to the interval between treatments.
All chemotherapy drugs can cause Beau’s line, usually after a short period of high doses or after a combination of drugs (Docetaxel – Cisplatin – fluorouracil). It can also be seen after radiation therapy.
Without treatment, the nail will gradually grow out, causing the Beau line to be pushed away and disappear.
Manifestations of nail peeling or deep grooves that separate the nail plate into two parts (see also nail abnormalities).
The mechanism is similar to Beau’s line but to a more severe degree, it is common with high-dose chemotherapy but can also be seen after high-dose carbamazepine, lithium carbonate, cephalo-ridin and cloxacillin therapy. There have also been reports of nail detachment following the use of valproic acid, an antiepileptic drug.
Real nail white:
Characteristics: Normally, the nail plate is transparent because it is composed of non-nucleated keratinized cells, allowing the pink nail bed below to be seen. When the keratinocytes in the distal nail germ are modified, the nail plate cells remain nucleated, reflecting light, giving it a milky appearance (see also nail abnormalities).
11.3.1 Drug-induced nail bed changes
Features: the nail plate is separated from the nail bed. Drug-induced nail detachment is the result of damage to the nail bed epidermis or from complete destruction of the epidermis due to the formation of hemorrhagic vesicles (in this case, the patient was very painful).
Causes: use of taxanes (docetaxel, paclitaxel), anthra-cyclines (doxorubicin) and immunosuppressants (sirolimus, rituximab). Injury is dose related, when the dose is reduced, symptoms will be relieved. In addition, nail separation is an uncommon side effect of retinoids due to increased stratum corneum of the nail bed.
Separation of nails due to light:
Causes: drugs, slow skin porphyrin, the disease can be spontaneous.
Features of light-induced nail separation when using drugs: due to the effect of UV rays, the drug separates the nail plate from the nail bed. This is a rare manifestation, in many nails, the thumb is usually not.
There are three types of light-induced nail separation:
• Distal, crescent-shaped nail, surrounded by pigmented margins.
• Defect at the proximal end of the foundation plate.
• Separation of the nail plate in the center, the margins on both sides are not affected, with subungual hemorrhage.
Drugs that can cause this phenomenon: tetracycline, psoralen, after exposure to natural sunlight or artificial light sources. In addition, due to quinolones, psychotropic drugs, diuretics, Griseofulvin has been reported to also cause this phenomenon.
Patients should avoid prolonged exposure to the sun.
Transparent nail white:
Features: see more nail irregularities. White transparent nail due to drugs has two forms:
• Half – and – half’ nails: the proximal portion of the nail plate is abnormally white, the crescent is not visible, while the distal part remains pink, red or brown.
• Muehrcke’s line: in addition to drugs, it is also due to hypoalbuminemia.
Treatment: usually asymptomatic, does not require treatment, disappears after drug discontinuation.
11.3.2 Perimedical nail vascular changes
Periungitis and infectious granulomatosis:
• In acute periungitis: the nail folds are swollen, hot, red, painful, often in many nails, manifests soon after using the drug, usually goes away on its own.
• In drug-induced pyogenic granulomas: often in many nails, but toenails are most common due to extensive rubbing, usually manifesting in the lateral nail folds. granulomas often penetrate rapidly into the subungual space and nail bed.
Causes: systemic or topical retinoids, antivirals (especially indinavir), EGFR inhibitors (eg, cetuximab, gefitinib), and Capecit
abine. Retinoids cause this condition by shedding keratinocytes, causing squamous accumulation under the nail, promoting an inflammatory response, in addition, retinoids also have angiogenic effects. Signs are dose related, usually appearing about 3 months after starting the drug. Treatment: with corticosteroids, antibacterial, sometimes need to reduce the dose of retinoid.
11.3.3 Drug-induced nail vascular changes
Characteristic: can be splinter hemorrhage due to nail bed vascular injury or nail bed hemangioma, more often in the toe due to impact. Subungual haemorrhage is often associated with drug-induced light nail detachment, particularly quinolones.
Causes: quinolones, chemotherapy (causes thrombocytopenia), multikinase inhibitors such as sorafenib, sunitinib that inhibit the capillary endothelial growth factor receptor. Also due to anti-inflammatory drugs Aspirin, anticoagulants warfarin, platelet aggregation inhibitors, retinoids such as acitretin.
Features: may present as Raynaud’s syndrome or as severe as gangrene of the toes.
Cause: bleomycin (due to increased collagen synthesis, glycosaminoglycan), beta-blocker.
Amputation may be necessary if gangrene is severe.
11.3.4 Drug-induced nail pigmentation changes
Characteristics: the action of the drug on the melanocytes of the nail germ causes activation of these cells, causing the production of melanin. If only one group of cells is affected, the nail plate is black, and if it is diffuse, the entire nail plate will have many brown to black longitudinal bands. The black bands may also be horizontal parallel to the crescent, indicating intermittent chromatin production with each chemotherapy course. Often suffers from multiple nails, slow recovery, sometimes lasts a lifetime.
Cause: anti-tumor drugs such as doxorubicin, bleomycin, cyclo-phosphamide, danunorubicin, dacar-bazin, 5-fluorouracil, methotrexate and hydroxyurea.
Characteristics: some drugs are eliminated by the nail germ, thus accumulating in the nail plate, causing pigmentation, gradually eliminated as the nail grows (eg due to clofaz-imin). In addition, some pigment deposits in the subungual dermis (eg, drugs, hemosiderin, melanin), which do not fade with nail growth, are often accompanied by pigmentation in the skin and mucous membranes (especially in the skin and mucous membranes). tetracycline derivatives such as minocyclin), in addition to prolonged use of antimalarial drugs (amodiaquine, chloroquine, mepacrin, quinacrin).
12. Nail Benign Tumors
MRI: aids in diagnosis when clinical is unclear. Tumor hyperintense on T2, if the tumor is present for more than 1 year, there may be associated bone erosion.
Ultrasound: difficult to detect tumors < 2mm.
Treatment Treatment is surgery
Direct access: access to the foundation bed after removing the foundation.
Side access: from the side of the nail plate to avoid scratching the nail germ.
12.1 Myxoid cysts
It is the most common cyst on the nail, seen mainly in older women.
It is hypothesized that the cyst forms due to the leakage of synovial fluid from the perforation in the distal interphalangeal synovial membrane. 64-75% of mucinous cysts are associated with intervertebral osteoarthritis.
The color block is clear, dome-shaped, glossy surface at the tendon nail, when pricking the cyst with a sharp needle, there is a gel-like mucus flowing out, the main ingredient is hyaluronic acid. If the cyst compresses the nail germ, it can cause nail dystrophy or longitudinal fissures.
Surgery: ligation of the bulge between the cyst and the joint socket.
Non-surgical: high recurrence rate, including: puncture, drainage, sclerotherapy, local steroid injection, cryotherapy.
12.2 Periungual fibroma
It is a benign skin-colored tumor that can sometimes be divided into 2-3 parts resembling a “garlic branch”, the tumor usually originates in the proximal, medial surface of the proximal nail fold. If you press .on the nail germ, it will create a groove along the nail plate. In tuberous fibroids with multiple fibroids, it is also known as Koenen’s tumor despite the similar histological nature.
12.3 Nail papilloma (onychopapil – loma)
A benign tumor of the nail bed and distal nail germ, usually asymptomatic.
Longitudinal red stripe, longitudinal black stripe, nail white or localized subungual keratosis.
There may be splinter hemorrhage or distal nail separation.
In which the most common symptoms, in order, are: keratosis at the distal nail plate, red longitudinal stripes of the nail, splinter hemorrhage and trauma to the thumb.
Consider surgery if the patient is painful, highly sensitive, or has cosmetic problems.
12.4 Onychoma – tricoma
Starting from the root.
Clinical: longitudinal yellow bands, horizontal curvature of the nail plate, splinter hemorrhage.
Dermoscopy: multiple foci of distal nail plate, parallel white or gray longitudinal stripes, splinter hemorrhage.
The tumor grows slowly and is usually painless.
13. Malignant tumours of the nail
13.1 Nail Melanoma
Nail melanoma accounts for 1-2% of all melanomas, and usually occurs in the thumb or big toe in adults. The tumor may originate in the nail germ or nail bed; may or may not be pigmented.
Tumor in the nail germ:
Black stripe along the nail: the most common sign, irregular border.
Hutchinson’s sign: pigment appears in the proximal nail fold cuticle, which should be distinguished from Hutchinson’s pseudo-hutchinson’s sign – pigment in the nail plate observed through the transparent cuticle is misleading as pigment in nail folds.
Tumor in the nail bed: red, black or brown tumor under the nail plate, progressing to ulceration, bleeding, may resemble granuloma. Classification is based on clinical morphology and dermoscopy.
Based on morphology can be classified into 5 types of illustrations in the table below:
The gold standard is based on pathology.
The clinical ABC rule for early diagnosis of nail melanoma proposed by Levit:
A (age): age varies from 20 – 90, peak is from 50 – 70.
B (band): brown, black pigment band, > 3mm in diameter and blurred, irregular margins.
C (change): the width of the longitudinal pigment band increases rapidly.
D (digit involved): thumb > big toe > index finger > 1 finger > multiple fingers. Or (dominant hand): dominant hand.
E (extension): pigmented lesions develop extending to the proximal or lateral nail folds (Hutchinson’s sign) or to the free margin of the nail plate.
F (family): personal or family history of melanoma, dysplastic ne-vus syndrome.
Finger amputation, lymph node dissection if there is metastasis.
13.2 Squamous cell carcinoma of the nail
It is the most common malignant tumor of the nail.
Usually presents as scc in situ (Bowen’s disease) over a long period of time. Bowen’s progression is slow, less invasive, common in the age group 50 – 69, male/female ratio is 2/1, usually affects the fingers, especially the thumb.
Risk factors: exposure to radiation, arsenic, HPV and genetic disorders. About 60% of nail patients had HPV infection (hand-genital contact) of which 75% were able to isolate HPV 16.
There are many manifestations and are easily confused with other diseases such as angiospermia, onychomycosis, bone bud, epidermoid cyst, ripening, nail germ tumor or melanoma.
Symptoms: nail separation, partial or diffuse subungual keratosis, granulomatous mass, secondary lesions: ulceration, macular degeneration, granulomatous tissue.
Bowen’s disease should be considered when there are keratolytic lesions under the nail with red or black longitudinal stripes (this type is often associated with HPV 16 and 56).
Histopathological features are similar to scc on the skin.
Indications X-ray to evaluate bone structure, consider amputation indication.
Mohs surgery to save organization, ensure patient quality of life.
Non-surgical methods: radiation therapy, photodynamics, Imiquimod cream or 5 fluorouracil, but do not control the cancer area.
Good, less metastasis. HPV-associated and non-HPV-associated nail cancers have similar rates of metastasis, however, nail scrapers with high-risk HPV infection are more invasive and have a higher recurrence rate.
14. NAIL DAMAGE BY CONTINUOUS AND GENUINE SKIN DISEASES (Congenital and inherited nail disorders)
Nail damage can be present at birth or in infancy; sometimes the most important symptom to diagnose the disease.
14.2 Congenital bullous epidermolysis bullosa
This is a congenital bullous disease caused by a dominant or recessive gene mutation, all forms have lesions in the nail.
Injuries in the nail bed: recurrent blisters create scarring in the nail bed, causing nail separation, thickening and shortening of the nail.
Damage to nail germ: cause thinning of nail plate, nail atrophy. Periungual granulomas with complete loss of the nail are characteristic of the congenital bullous epidermolysis bullosa.
14.3 Darier’s Disease
Darier is an inherited dominant disease that manifests in the nails consisting of a V-shaped split and red or white longitudinal stripes on the nail plate. The drawing of an arrow points to the V-shaped nail splitter.
14.4 Congenital deviation of big toe
Features: the nail plate is deflected to the side, there is no damage elsewhere. Often bilateral, the nail may thicken to a triangular shape and change its surface due to repeated trauma.
Causes: It may be due to an abnormality of the ligament connecting the nail germ to the periosteum of the distal toe or excessive stretching of the extensor tendon of the thumb.
Treatment: 50% self-improvement. Surgery is recommended for severe cases that do not improve on their own, usually between the ages of 2 and 5.
14.5 Nail-patella syndrome
Features: nail hypoplasia with bone and kidney abnormalities. May be affected only in the fingernail, usually the thumb: hypoplasia or absence of the nail plate, triangular sickle is also a feature of the disease. Bone abnormalities: absence or hypoplasia of the patella, abnormality of the radial head, iliac crest (diagnosed by X-ray).
Cause: LMX1B gene mutation on chromosome 9q34.1, dominant inheritance.
Early diagnosis helps detect and prevent progression of kidney damage.
14.6 Congenital thickening of nails
Characteristics: thick, curved nails appear early due to keratosis under the nail accompanied by thickening of the palms and soles. 50% of the changes appear at birth, 75% appear within the first 5 years of age. Before the age of 10, the main symptom is pain, which greatly affects the quality of life.
Suggestive symptoms: Toenail dystrophy with keratosis and pain in the soles of the feet in a patient > 3 years old.
Cause: dominant mutation of genes (KRT6A, 6B, 16, 17).
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