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Onychomycosis is a common progressive fungal infection of the nail bed, matrix, or plate leading to destruction and deformity of the toenails and fingernails. The prevalence of onychomycosis is increasing in the United States, particularly in the growing population of Latino patients. In this study, we evaluated the efficacy and safety of efinaconazole solution 10% in Latino patients with onychomycosis. Once-daily application of efinaconazole solution 10% may be an effective topical option for treatment of onychomycosis in this patient population.

Although there are limited data available on gender as an outcome variable in the treatment of onychomycosis, differences in disease prevalence and impact in males versus females have been observed. This article provides a gender subgroup analysis based on results from recent studies evaluating the efficacy, safety, and tolerability of efinaconazole topical solution 10% in the treatment of onychomycosis. Data were collected from two 52-week, prospective, multicenter, randomized, double-blind studies of patients 
(age range, 18-70 years) randomized to receive either efinaconazole topical solution 10% or vehicle for treatment of onychomycosis. Results from this analysis indicated that once-daily application of efinaconazole topical solution 10% may provide a useful topical option for treatment of mild to moderate toenail onychomycosis, especially in female patients.

Primary localized cutaneous nodular amyloidosis (PLCNA) is a rare disorder that manifests as the cutaneous formation of nodules composed of light-chain amyloid. Although the type of amyloid deposit is similar to primary systemic amyloidosis, there seems to be little, if any, crossover between the 2 diseases. Because reports of PLCNA are sparse, there is no established protocol for treating this disease. This case report presents a 42-year-old man with a visually striking presentation of PLCNA on both feet with some of the lesions possibly being secondary to trauma, a rare phenomenon. The lesions had been present for more than 4 years, and there were no signs or symptoms of systemic amyloidosis. The lesions responded well to a combination of complete curettage followed by CO2; laser ablation. Primary localized cutaneous nodular amyloidosis is rare and difficult to treat, with high rates of recurrence and a concern for progression to systemic amyloidosis. The diagnosis, workup, treatment, and monitoring of PLCNA also are discussed.

Toenail onychomycosis is a common disease with limited treatment options, as treatment failures and relapses frequently are encountered. Many patients experience long-term disease that affects multiple toenails and causes substantial discomfort and pain. Although many patients prefer topical therapies, treatment efficacy with ciclopirox and amorolfine lacquers has been disappointing. Efinaconazole solution 10% is a new triazole antifungal agent specifically developed for the treatment of onychomycosis. Efinaconazole has shown a broad spectrum of antifungal activity in vitro and is more potent than ciclopirox against common onychomycosis pathogens. It has lower keratin binding and quicker drug release from keratin than ciclopirox and amorolfine and exhibits remarkably greater in vivo activity. Efinaconazole has limited or no potential for drug interactions and a low resistance potential. Efinaconazole provides a viable alternative to oral therapy for the treatment of toenail onychomycosis.

Congenital hemidysplasia with ichthyosiform nevus and limb defects (CHILD) syndrome is a rare X-linked hereditary disorder. Presentation varies from ichthyosiform nevus to complete limb amelia. We present a 17-year-old adolescent girl who presented with a 16-cm exophytic mass of the right foot that had been growing for 7 years as well as knee contracture. Deformed nails with onychorrhexis were noted bilaterally. History of multiple nonlinear erythematous skin lesions covered by dry waxy scales involving multiple body folds with sharp midline demarcation was obtained. The patient's family history was negative for consanguinity and similar conditions. Radiography showed right leg hypoplasia and osteopenia. These findings fulfill the diagnosis of CHILD syndrome. Microscopically, psoriasiform epidermal hyperplasia with marked orthohyper-keratosis and neutrophilic exocytosis were noted. The papillary dermis was packed with foamy macrophages consistent with xanthomatous changes, namely verruciform xanthoma. Verruciform xanthoma, although rarely found in other conditions, is a characteristic finding.

Typically, the amount of mycotic nail involvement in onychomycosis (fungal infection of the nail) before and after drug therapy is determined visually. Because there is an inherent element of subjectivity, it is difficult to accurately measure and compare results across clinical trials or to assess how much improvement has been achieved in response to therapy. We developed a simple tool for measuring mycotic nail involvement. This novel tool consists of a large grid containing 5 toenail templates of varying nail morphologies that are derived from the actual shape of the toenail of the great toe in several males and females, and one standardized computer-generated nail shape. The toenail templates are presented in 7 different sizes to match different nail sizes. Each toenail template is further divided into 8 segments, each comprising approximately 12.5% of the total nail surface. Measurement of the percentage of mycotic nail involvement is accomplished by the following procedure: (1) placing tracing film over the target toenail; (2) tracing the outline of the entire toenail, followed by tracing the affected portion of the toenail on the same film; (3) placing the tracing film over a nail template on the grid that best fits the shape of the toenail; and (4) counting the number of grid segments that correspond to 50% or more involvement. To assess feasibility, the tool was used in a large randomized trial involving over 30 sites and 500 subjects with onychomycosis. This tool is a more accurate and less biased alternative to visual assessment for measuring nail involvement or progression of nail clearing.

Alefacept is the first biologic agent approved by the US Food and Drug Administration for moderate to severe chronic plaque psoriasis. Prior clinical studies excluded patients with palmoplantar psoriasis or erythroderma. We report 2 patients with recalcitrant psoriasis who responded completely to a full course of alefacept. One patient presented with severe palmoplantar psoriasis recalcitrant to acitretin and methotrexate; another patient presented with erythroderma and was transitioned successfully from cyclosporine A. Alefacept provides another treatment option for palmoplantar and erythrodermic psoriasis and should be considered in the management of patients with these conditions.

Palmoplantar psoriasis is a disabling condition characterized by recurrent crops of sterile pustules with associated erythema, fissuring, and scaling. Genetic and environmental factors have been implicated in its etiology. Topical treatments are frequently ineffective. Other treatment options include systemic retinoids, psoralen-UVA (PUVA), and a combination of both. We report a case of successful treatment of recalcitrant palmoplantar psoriasis with etanercept in a 59-year-old woman unresponsive to other treatment modalities.

A 32-year-old white man had a 5-month history of a progressively worsening rash on the dorsal aspect of his left foot. He stated that he engaged in self-tattooing of the left foot prior to the onset of the rash. Further questioning revealed that he had mowed the lawn wearing only sandals on the same day that he had tattooed his foot. The rash was diagnosed as lymphocutaneous sporotrichosis based on clinical appearance, biopsy examination, and fungal culture. Clearing of the lesions was documented following 4 months of therapy with itraconazole. The remaining granulomatous lesions were flattened with intralesional corticosteroid injections.

We report the case of a 28-year-old man who had prominent hyperkeratotic plantar and palmar warts, and flat warts on his face and chest. By DNA hybridization, human papillomavirus 1 and/or 2, and 3 DNA were detected from the tissues of these skin lesions. Results of laboratory investigations revealed leukopenia, eosinophilia, anti-HBs antigen and anti-hepatitis C virus antibody, and decrease in the OKT4/OKT8 ratio. He had no abnormality in cellular immunity. He was treated with multiple modalities, but was successfully treated with electrocautery to the plantar and palmar warts, and cryotherapy with liquid nitrogen to the flat warts. Nine years after the initial treatment, almost no recurrence was recognized.

The clinical diagnosis of cardiac myxomas remains a challenge despite the advent of echocardiographic technology. These tumors may produce a variety of clinical and laboratory findings that can mimic systemic disease and obscure the proper diagnosis. Although histologically benign, cardiac myxomas may cause significant morbidity and mortality via intracardiac obstruction and arterial embolism. Possible long-term sequelae may be avoided by early recognition and prompt surgical excision. We briefly review the various findings associated with cardiac myxomas (nonfamilial and familial) with emphasis on cutaneous presentations. An illustrative case of left atrial myxoma with cutaneous findings contributing to the diagnosis is discussed. Certain skin lesions and multifocal clinical findings should alert the clinician to consider cardiac myxoma in the differential diagnosis.

An atypical case of crusted scabies in a patient with acquired immunodeficiency syndrome is presented in which lesions at the time of evaluation were confined to the scalp and feet. Because of the unusual presentation, the scalp involvement (which clinically mimicked seborrheic dermatitis) was initially missed. Although both the crusted variant of scabies and scabietic involvement of the scalp are well documented to occur in immunocompromised patients, to our knowledge scabies confined to the scalp and feet has not been previously reported.

Nodular amyloidosis is uncommon and is due to a local production of amyloid by aberrant plasma cells. Localized bosselated plantar amyloidosis has been reported before but we present the first case to our knowledge of bilateral plantar amyloidosis. The clinical presentation as well as therapeutic options for this uncommon entity are reviewed.

Antimalarial agents have long been known to cause a variety of pigmentary disturbances. Quinidine, a cincha alkaloid and D-isomer of quinine, is widely used for the treatment of ventricular arrhythmias. A paucity of literature, however, exists concerning quinidine-associated hyperpigmentation. We describe a case of focal ceruloderma we believe to be secondary to quinidine therapy.

A patient with erythema on the dorsum of the left foot after the removal of gypsum fixation applied for the treatment of bone fracture is reported. Both the clinical and histopathologic features led to the diagnosis of mucor infection.

The incidence of primary and secondary syphilis in the United States peaked in 1990, exceeding the number of reported cases since 1948. Uncommon manifestations of secondary syphilis seen more frequently in the preantibiotic era may be less well recognized today. One such manifestation is the condyloma latum, or split papule of the toe web. Two patients with condyloma of the toe web are presented and the previous literature is reviewed. Condyloma latum is a common manifestation of secondary syphilis; however, condyloma latum of the toe webs is unusual. Failure to recognize toe web condyloma latum may delay diagnosis and treatment.

Inflammatory linear verrucous epidermal nevi are rare lesions that have many similarities to psoriasis on histologic examination, and are resistant to therapy. The two lesions reported occurred in patients with positive results of tests for human immunodeficiency virus 1 and showed features consistent with psoriasis. Results of tests for immunohistochemical markers were also consistent with previous findings and expected staining patterns in lesions of psoriasis. Our findings suggest that inflammatory linear verrucous epidermal nevi represent a clonal dysregulation in growth, probably secondary to an inflammatory stimulus. Since human immunodeficiency virus 1 has been associated with onset and exacerbation of psoriasis, perhaps this virus or another secondary infection associated with human immunodeficiency virus 1 infection could also play a role in the onset of this rare lesion.

The petechial glove and sock syndrome is a recently described febrile dermatosis characterized by acral edema, petechiae in a characteristic distribution, and enanthem, which has been associated in several cases with parvovirus B19 seroconversion. We report an additional case of petechial glove and sock syndrome that further corroborates the role of parvovirus B19 as a causative agent of this syndrome in adults.

Tinea nigra is a relatively uncommon fungal infection presenting as a pigmented macule of the palms or soles. Since the lesion can easily mimic a melanocytic process, it is important to recognize the infection before recommending unnecessary surgical procedures. A case of tinea nigra that responded to treatment with topical ketoconazole is presented.

Four patients with colorectal cancer treated with tegafur (a fluoropyrimidine structurally similar to 5-fluorouracil) noted a macular, spotted hyperpigmentation limited to the palms, soles, nails, and glans penis. Histopathologic examination disclosed epidermal basal hyperpigmentation with a lentiginous pattern. Mucocutaneous lesions resolved spontaneously two months after treatment was discontinued. This peculiar phenomenon seems to represent a previously unreported side effect of this cytotoxic drug.

We report two patients with infantile acropustulosis; one patient with a history of atopic dermatitis and the second with an abnormally high IgE serum value. Atopy has not been reported previously in patients with infantile acropustulosis. Immunofluorescent studies of involved skin gave negative results.

A case of linear porokeratosis of Mibelli is presented. Although there was no suggestion clinically of a perforating disorder, histologic examination revealed a cornoid lamella penetrating into the dermis. Special stains did not show any evidence of a transepidermal elimination syndrome.

A patient with T. rubrum WSO is reported. The presence of this pathogen, a rare cause of this condition, can be confirmed by examination of smears and cultures taken from scrapings of the white spots on the nail plate.

A typical patient with this uncommon premature aging syndrome was followed over a period of four and a half years until his death. He presented the characteristic clinical features, as well as the complications, of Werner's syndrome. About one hundred forty cases of this recessively inherited syndrome have been reported. Most patients become recognizable in their thirties by their short stature, typical facies, premature graying, hair loss, cataracts, atrophy of skin and subcutaneous tissue, and acral sclerosis. Advanced peripheral vascular disease occurs early; angina, skin cancer, diabetes mellitus, and internal malignancy are common. Most patients die before the age of fifty years either from complications of anteriosclerotic vascular disease or malignancy.

A case of generalized idiopathic pigmented purpuric eruption with distinctive and rare palmar-plantar involvement is presented. The clinical and histopathologic features, differential diagnosis, and nosology of the idiopathic pigmented purpuric eruptions are presented.

Three patients with acquired digital fibrokeratoma are presented herein. This tumor may be confused clinically with other lesions including supernumerary digits, fibromas, neuromas, and neurofibromas. As a result, the histologic picture is most helpful in making a correct diagnosis. Since this lesion has been noted to occur in areas other than the digits, a more appropriate designation may be "acquired fibrokeratoma".

The common manifestation of pompholyx is easily recognized by the clinician. Morphologic variants are known in which the predominant lesions are pustules or desquamation with or without erythema. A patient is described herein whose eruption was composed mainly of arciform, annular, and target-like vesicles. Pompholyx (bubble) is a preferred term because "dyshidrosis" denotes a dysfunction of sweating, which does not occur in this condition. The causes of this eruption have not been determined, but it is likely that a certain genetic predisposition and multiple environmental factors are responsible. Pompholyx should be considered in the differential diagnosis of eruptions with annular pattern.

"Black heel" (calcaneal petechiae) is a traumatic lesion affecting the back or posterolateral aspect of the heel. It is seen almost exclusively in adolescentes or young adults engaged in active sports, notably basketball, but also football, lacrosse, tennis, and so forth. The lesion is disposed horizontally at the upper dege of the calcaneal fat-pad and consists of grouped punctate hemorrhages, the nature of which is revealed by repeated paring of the lesion. The nature of the pigment is shown by specialized stains. "Black heel" is probably more common than is realized. It is likely to be cuased by a shearing or pinching stress from abrupt contact of th foot with a floor or hard ground. As it si usually symptomless, it may be disregarded or only observed by chance. However, it has been confused clinically with a melaonoa, and as it is such a trivial self-healing process, it is important that it be recognized for what it is.

Nineteen cases of keratosis punctata of the palmar creases are presented. This entity, currently regarded as a variant of keratosis punctata of the palms and soles, is seen almost exclusively in blacks. It is benign, mostly asymptomatic, and sometimes familial without any sex predilection. The clinical lesions are pits and keratotic papules confined to the creases of the palms and volar surfaces of the fingers. The soles are rarely affected but a new finding reported here is the involvement of the side of feet in eight of the nineteen cases.

Sire the basis for this study. All cases were clinically diagnosed as porokeratosis plantaris discreta (PPD). Biopsies were done in fifteen cases. Of these, eleven were confirmed as PPD and four had histopathologic features of a wart. Porokeratosis plantaris dicreta is a localized plantar hyperkeratosis that is resistant to therapy. It is often mistaken for a wart. PPD should be considered in the differential diagnosis of keratotic lesions on the sole.