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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

CASE CONFERENCE:Nail Disorders

KAREN ESTRELLA

05/12/2010

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 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
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
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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