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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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Case conference nail disorders

CASE CONFERENCE:Nail Disorders

KAREN ESTRELLA

05/12/2010


Do you check the nails of your patients

Do you check the nails of your patients?


History

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


Normal nail

Normal nail

  • EMBRIOLOGY:

    • starts to develop at 10-11 wks

    • keratinizes from 15 wk

    • fully formed by birth


Normal nail1

Normal nail

  • ANATOMY:


Consult dermatology

Consult DERMATOLOGY:

  • Dark linear, uniform, well demarcated linear ban along the nail bed, involving proximal nail fold

    Melanonichia striata


What is melanonychia

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


Melanonychia etiology benign

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


Melanonychia etiology iatrogenic

Melanonychia etiology: iatrogenic

  • CHEMOTHERAPY

    • Metotrexatem

    • Bleomycin

    • Doxorubicin

    • Ciclophosphamide

    • 5-fluoruracil

  • OTHERS

    • Steroids,

    • Ibuprofen

    • Phenytoin

    • Zidovudine, lamivudine

    • Ketokonazole, fluconazole


Melanonychia etiology malignancy

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


Melanonychia work up

Melanonychia work-up

  • Dermatoscopic evaluation:

    • Of the free edge of nail bed


Melanonychia dermatoscopic evaluation continued

Melanonychia: Dermatoscopic evaluation continued


Melanonychia work up continued

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


Melanonychia treatment

Melanonychia Treatment

  • Tx of underlying condition

  • Removal of agent

  • If melanoma: complete removal of hyperpigmented section


Other nail disorders

OTHER NAIL DISORDERS


Congenital disorders ectodermal defects

Congenital disorders:(Ectodermal defects)

  • ANONYCHIA

    • Associated with nail-patella sd., deafness

  • PACHONYCHIA

    • Associated with: hyperhidrosis, leukokeratosis: TM, cornea, mucosas


Congenital disorders continued

Congenital disorders continued

  • HYPOPLASTIC

    • Phenytoin

    • Warfarin

    • Fetal alcohol syndrome


Associated with systemic disorders

Associated with systemic disorders

  • CLUBBING

    • hypoxic stages

  • KOILONYCHIA (spoon nails)

    • Iron deficiency


Associated with systemic disorders1

Associated with systemic disorders

  • HALF & HALF NAILS

    • liver, kidney failure

  • SPLINTER HEMORRHAGES

    • endocarditis

  • RIDGING-TRANSVERSE LINES

  • - malnourishment


Acquired nail disorders infection

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


Acquired nail disorders dystrophy distortion discoloration

Acquired nail disorders: dystrophy(distortion, discoloration)

  • TRAUMA

    • Subungual hematoma

  • PSORIASIS


Acquired nail disorders dystrophy continued

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


Thank you

Thank you : )


References

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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