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Introduction: Onychomycosis is a frequent complaint in dermatological practice and corresponds to the most common nail disease. The treatment of onychomycosis remains a challenge, as several factors end up compromising and making treatment difficult. Nail abrasion is considered a useful method in many cases. However, there is controversy about this approach, as there is an aerosol formation that could contaminate the environment and cause fungal changes or hypersensitivity reactions by the disseminated dust. We conducted a pilot study to investigate the fungal viability of nail particles from nails with onychomycosis after abrasion procedure. Methods: In this study, nail dust from the gloves and mask, used in the procedure, was collected from 9 patients with clinical and dermoscopic diagnoses of onychomycosis. Results: Hyaline septate hyphae were found in 12 materials (gloves and/or masks) from 7 patients. However, these hyphae were morphologically deformed or mutilated in all exams. In Mycosel® agar, there was no growth of any fungus. Discussion/Conclusion: The absence of dermatophyte isolation in all fungal cultures may demonstrate that the deformed fungal structures shown are not viable and would not present risks of contamination after nail abrasion.

Onychomycosis is one of the most common nail disorders and may be difficult to distinguish from other causes of nail dystrophy, based on clinical grounds alone. With this study, we aimed to describe the use of fungal testing by dermatologists and family physicians in their daily current practice, analyze their respective familiarity with nail disease diagnosis, and ultimately treatment decision-making by both groups. An online survey was distributed among Portuguese dermatologists, trainees, and family physicians by email. The survey focused on the diagnostic impression, use of diagnostic methods to confirm a fungal infection, and the subsequent assessment of treatment. One hundred fifty-one responses were obtained, 60 (39.7%) from dermatologists and 91 (60.3%) from family physicians; 98.3% of dermatologists mentioned usually requesting a fungal testing at their local institution or outside, while this percentage was 50.5% among family physicians (p < 0.001). Regarding the diagnosis, the median of correct diagnosis by the dermatologist group was higher (10/15) than the family physicians (6/15). Considering the treatment strategy, we observed that in the dermatologists’ group it would result in unnecessary treatment in a median of 2 cases, while in the family physicians’ group, in a median of 4 cases.

Introduction: Transverse overcurvature of the nail (TON) represents one of the main reasons for dermatological consultations due to nail conditions. Association between TON and subungual hyperkeratosis is common and simulates onychomycosis, constituting a difficult differential diagnosis by clinical features. Many cases are treated in daily practice with antifungal therapy even without mycological confirmation. The aim of this study was to determine the prevalence of onychomycosis among patients with TON associated with subungual hyperkeratosis. Methods: All subjects with clinical diagnosis of TON and subungual hyperkeratosis were subjected to a thorough clinical history, detailed clinical examination, digital photography, and collection of nail clipping and subungual debris for histopathological and microbiological examination (direct microscopy). Results: Sixty-five samples were collected from 62 female (95.4%) and 3 male (4.6%) participants. Age range was between 34 and 83 years (mean age, 61.2 years). Twenty-eight samples were positive for onychomycosis, giving a 43.07% prevalence rate of onychomycosis among TON associated with hyperkeratosis. Discussion/Conclusion: According to our data, the prevalence of onychomycosis in patients with TON associated with subungual hyperkeratosis was 43.07%, confirming the need to rule out fungal infection in TON associated with subungual hyperkeratosis prior to considering any unnecessary antifungal treatment.

Introduction: Nail involvement in psoriasis occurs in up to 30–50% of patients, and 5–10% may have isolated nail disease. Onychoscopy, a noninvasive tool, might obviate the need for nail biopsy, which is a diagnostic gold standard. Objective: The aim of this study was to evaluate onychoscopic features of nail unit in patients with nail psoriasis. Methods: Fifty-five patients with clinically diagnosed and histologically documented nail psoriasis were recruited. Onychoscopy was performed for each nail (excluding the 5th toenail). Clinically, 443/550 fingernails and 101/440 toenails were involved. The frequency distributions of various onychoscopic features was assessed and compared using the χ2 test (p value Results: With onychoscopy, additional 52 fingernails and 64 toenails showed psoriatic involvement. Pitting was the commonest finding in fingernails (60.5%) followed by subungual hyperkeratosis (SUH) (52.8%), onycholysis (40.8%), and dotted capillaries in hyponychium, proximal, and lateral nail folds (38.6 vs. 35.8 vs. 35.8%). In toenails, we observed SUH (85.1%), nail plate thickening (82.1%), onycholysis (77.2%), and dotted capillaries in hyponychium and nail folds (59.4 vs. 53.4 vs. 45.5%). Fuzzy lunula was a novel onychoscopic finding noted in 33.6% fingernails and 4.95% toenails (p < 0.00001). Limitations: Small sample size. Conclusions: Onychoscopy may aid in diagnosing nail lesions even before the clinical signs are apparent.

Introduction: Hypertrophy of the nail folds is a common condition. It occurs by alteration of shape, partial loss, or absence of the nail, resulting in loss of the nail fold physiological limit. This can also occur by the friction of the nail with the nail fold. Consequently, there is an increase in the volume of the lateral or distal nail fold and a decrease in the space of the nail bed and the nail plate. Management of this onychodystrophy may be conservative or surgical. Case Presentation: We present a case of distal nail embedding after trauma, submitted to conservative treatment. Combined techniques were required as trichloroacetic acid application, rolled cotton padding maneuver, artificial resin nail technique, and orthesis. After 14 months, good functional and aesthetic results were obtained, with correction of the anatomical shape of the nail unit. Conclusion: The conservative techniques for hypertrophy of the nail folds are a useful option with good functional and aesthetic results. The indication must be precise, considering the history of the patient and after discarding bone alterations by image exams. The disadvantage of the method is the long treatment time and constant visits to the doctor’s office.

Background: Surface abnormalities of the nail may be due to nail diseases or chemical abuse. So, every nail plate change does not require medical treatment. The aim of our study was to support the benefit of glycolic acid (GA) in both pathological conditions and dry, discolored nails due to cosmetics. Methods: A prospective single open label uncontrolled study is conducted in our department from January until April 2017. We divided our cases into 2 groups: G1 (consequences of cosmetics) and G2 (pathological conditions). In G1, we used 1–2 coat of GA 50% in 1–2 sitting at weekly intervals, but we needed multiple sittings (6–12 weeks) in G2 with 2–4 coats. Results: We have collected 20 cases: 12 in G1 and 8 in G2. In G1, 8 patients had good response. In G2, 6 had good response. Adverse effects were tolerable. Conclusion: Good response in G1 was also noted in the Indian report. The improvement in the chemotherapy side effect led us to widen the sample in order to have more credible results. GA 50% peels can offer aesthetically better looking nails. However, larger studies with a longer follow-up are required to validate the results.

Onychomatricoma is a primary benign neoplasm of the nail matrix. Currently, a limited number of cases have been reported, so it is still considered a rare neoplasia. However, it is debatable if this condition is underdiagnosed and underreported. Onychomycosis is an important differential diagnosis of onychomatricoma, and sometimes, both these conditions may even coexist in the same nail. As the tumor grows, tissue microenvironment is more vulnerable to dermatophytes. Probably, the altered keratin appears to be susceptible to fungal invasion. Careful clinical assessment and dermoscopic evaluation help nailing the diagnosis. Usually, total nail avulsion is the preferred therapeutic approach when they coexist. Herein, we present a case of a middle-aged woman with onychomycosis and onychomatricoma affecting a single fingernail. The proposed therapy was oral terbinafine for 6 months followed by a conservative surgery. There were dramatic changes in dermoscopic features after fungal treatment, which, to our knowledge, have not been previously reported.

Introduction: Pachyonychia congenita (PC) is a rare dermatosis that confers lifelong physical and emotional morbidities in affected patients. However, the clinical findings, treatments, and psychosocial impact of this disease have not been adequately described. The International PC Research Registry (IPCRR), a multinational initiative to collect data on PC patients, has allowed an opportunity to distinguish the salient features of this disease. We aimed to characterize the breadth and extent of nail disease, treatments, and quality of life in PC patients, and to describe any significant differences in clinical presentation or treatment of PC subtypes. Methods: The most recent IPCRR patient survey data consisting of an 857-response questionnaire and a 102-response addendum were analyzed in a retrospective analysis. The survey data were collected as part of a multinational, multicenter initiative and comprise the largest representative population of PC to date. Participants (survey respondents) were included in the study based on questionnaire responses and a genetic confirmation of having a PC subtype. Results: A total of 857 survey responses were collected. Genetic variations among PC subtypes influence nail disease onset and severity of symptoms. Nail disease negatively impacts patients’ emotional health, especially during the adolescent and young adult years. Nail treatment tools vary little in terms of effectiveness and acquired infection rates. Conclusion and Discussion: Patients with different PC subtypes have distinct clinical nail presentations and psychosocial impact. Genetic testing should be used to confirm PC diagnoses. Further characterization of PC, especially the rarer subtypes, may allow for more individualized patient education.

Nail diseases are rarely given significant importance in general consultation and their specific examination is often neglected, while localization to the nails could be an initial sign of a syndrome or a systemic disorder. Although rarely, nail alterations could be a sign of a systemic disorder, in which a prompt observation is crucial for an early diagnosis. We describe the case of an elderly woman with a long history of nail dystrophy, previously labelled as nail fragility. On enquiry, similar nail changes were discovered to have affected the patient’s son, who was visited the following week. Diagnosis of the Nail-Patella Syndrome (NPS) was suspected on the basis of nail alterations in both patients and confirmed by complementary radiographic examination. Screening for severe renal complications, which could have negatively affected the prognosis and have led to end-stage renal disease, followed. The prompt diagnosis of NPS and the associated diseases are mandatory for a correct management of these patients.

Cutaneous manifestations of tuberculosis (TB) are rare, particularly from an exogenous source. Involvement of the nail apparatus is extremely rare and has only previously been reported as a secondary involvement. We report the case of a 76-year-old female patient referred to our department with onychodystrophy with purulent drainage of the first left finger, which had developed during the preceding year. She had no previous traumatic history and had received treatment with multiple cycles of oral antibiotics and antimycotics, with no clinical improvement. Physical examination showed paronychia and onychodystrophy of the entire nail plate. Biopsy evaluation revealed epithelioid granulomas with central foci of necrosis, and laboratory cultures were positive for Mycobacterium tuberculosiscomplex. Chest computed tomography excluded primary pulmonary TB. X-ray of the left hand revealed the presence of dactylitis on the distal phalanx. Based on these findings, the patient was treated with rifampicin, isoniazid, pyrazinamide, and ethambutol for 2 months and with rifampicin and isoniazid for 7 months, resulting in complete resolution of the lesions. Cutaneous TB is a diagnostic challenge, particularly in rare cases such as involvement of the nail apparatus. It should be considered as a diagnostic hypothesis in cases of painless paronychia with refractory purulent drainage and associated onychodystrophy.

Nail diseases in children do not account for a significant proportion of pediatric consultations, and most of the time the nails are not observed by the clinician, overlooking their importance. Specific examination of the nails is neglected, while localization to the nails could be an initial sign of a syndrome or a systemic disorder. Nail diseases in the pediatric population differ from those in adults in terms of diagnostic approach and management; some of them even are manifested mainly or exclusively in children. Pediatric patients with underlying systemic disorders are more likely to manifest acquired disorders of the nails. Although rare, nail diseases in children are a source of anxiety for the parents. Examination of the nails is an essential part of pediatric physical examination. A correct clinical history and careful examination help the clinician to distinguish the different conditions and to decide on the correct management of nail diseases in young patients. A classification of nail dystrophies according to age is somewhat arbitrary and a unique classification does not exist. Nail diseases in the pediatric population can be divided according to age groups where a predilection appears in most of the cases. Moreover, certain abnormalities may be lifelong once acquired, but their presentation may be modified by age, worsening or improving during life. This review describes many of the nail conditions that are seen in the pediatric population aging from newborn to toddler, starting with physiological aspects to better recognize the pathological conditions.

Wide differences in the cure rates of onychomycosis in various clinical studies can be avoided if we bear in mind some insights that will help us make study results more consistent. We suggest less rigid criteria in defining the cure rate, the inclusion of all toenails in studies, and the exclusion of nails with a history of trauma. Rather than address patients as a homogenous group, regardless of age, we suggest dividing them into age groups. Researchers should not forget inflammatory diseases that can imply changes on the nails and should take into account the duration of onychomycosis, nail changes caused by asymmetry, and the possibility of dermatophytoma.

Purpose: Onychomycosis is the most common nail disorder and causes morbidity and impaired quality of life (QOL). Patient-reported outcomes (PRO) are patients' assessment of their health status or treatment response. PROs help assess what is most bothersome to patients to identify targets for intervention. We sought to review the PRO instruments currently used to assess QOL and treatment response in onychomycosis patients. Procedures: A systematic review was performed by searching PubMed, Embase, CINAHL, and PsycINFO databases through December 31, 2016, to identify all English language literature on onychomycosis, PRO, and QOL. Results: Currently, 5 validated PRO instruments exist specifically for onychomycosis. Oral therapies were most extensively studied using PRO instruments. QOL data generally correlated with clinical change, although patients sometimes reported improvement without any clinically significant nail clearance. The only psychometrically validated PRO instrument used to evaluate treatment response is the OnyCOE-t™. Conclusions: Clinicians may underestimate the impact of onychomycosis on patients. With recent initiatives from health-care management organizations to improve patient experience and the recent approval of expensive and nonsuperior topical antifungal medications, PROs will be increasingly important in onychomycosis to assess patient priorities and optimize treatment. Future research should evaluate these instruments in special populations and fingernail disease.

Brachyonychia is a rare manifestation in patients with chronic kidney disease. Longtime disease, secondary hyperparathyroidism, and hemodialysis are common conditions among those who present it. We evaluated 8 cases who presented brachyonychia in the nephrology department and compared the clinical versus the radiographic findings, and evaluated how the tissue adjusts to the underlying bone structure, giving different forms to the nails. We conclude that brachyonychia and acroosteolysis in chronic kidney disease suggest long-term disease, secondary hyperparathyroidism, and hemodialysis, besides it being a good model on how the bony structure defines the soft tissue morphology.

Introduction and Objectives: Nail apparatus melanoma (NAM) is an uncommon tumor, especially in Caucasians. The prognosis of patients affected by NAM was analyzed and correlated with the histopathological criteria and the surgical management of the tumors. Materials and Methods: We collected data regarding NAM referred to the Skin Cancer Unit of the Dermatology Department of the University of Bologna, from 1992 to January 2012. Results: Out of 1,327 melanoma cases diagnosed between 1992 and 2012, 42 patients were affected by NAM (2.93%). All the patients were Caucasian. Two deceased patients with insufficient medical records and 1 woman with a personal history of breast cancer were excluded. Thirty-nine cases entered this study: 24 were women (67%) and 15 men (33%). The mean age at diagnosis of NAM was 57.3 years (range 29-88 years). Statistical analyses showed that prognosis was significantly correlated with the Breslow thickness (≥/Conclusions: In our experience, the surgical management (disarticulation with respect to functional surgical excision) did not influence the prognosis of NAM patients. The latter was affected by the histopathological characteristics (Breslow thickness, regression and mitoses) and location (fingers vs. foot).

Background: Nail psoriasis is a painful and disfiguring nail disease that often leads to invasive biopsies. Dermoscopy of the hyponychium can be useful in the diagnosis showing twisted coiled vessels. Structural features of nail psoriasis have been described with optical coherence tomography (OCT). Objectives: To investigate vascular features of nail psoriasis using dynamic OCT. Methods: This was an observational, prospective, controlled study in which psoriasis patients with psoriatic nail changes and healthy control patients underwent OCT imaging of the distal nail plate and proximal nail fold. Vertical and horizontal OCT images were analyzed to describe structural and vascular features and to quantify blood flow at depth. Results: Sixteen psoriatic nails and 16 control nails were included. Psoriatic nails had significantly increased blood flow in the proximal nail fold at depths of 0.72 mm (p = 0.035) and 0.76 mm (p = 0.027). Nail thickness was significantly greater in psoriatic nails compared to control nails (p = 0.0016). Compared to control nails, psoriatic nails had dilated, disorganized blood vessels superficially in the proximal nail fold. Limitations: The main limitation of our study is the relatively small sample size. Conclusions: OCT can identify structural and vascular features specific to nail psoriasis.

Background: The nail bed may epithelialize and develop dermatoglyphics after long-standing onycholysis. We have called this phenomenon the disappearing nail bed (DNB). DNB may present as a shortened or narrow nail bed. Methods: Examination of all 20 nails was performed in each patient enrolled to the study. DNB was defined as the presence of a nail which is at least 20% shorter and/or narrower than the identical nail on the opposite hand or foot. Age, sex, and nail history were recorded. Fungal studies were done on all patients with DNB if that nail exhibited clinical signs of onychomycosis. Results: Of 540 patients, 71 (13.15%) showed DNB. Sixty patients had only the toenails involved, and 10 patients had only the fingernails involved. One patient had both toenails and fingernails involved. The average age for fingernail DNB was 67.2 years and 69.6 years for toenails DNB. Nail history was remarkable for biting in 8 patients, nail trauma in 11 patients, and surgery in 12 patients. With respect to the toenails, onychomycosis was found in 22 patients of the DNB group. Conclusions: Our study suggests that DNB is a common phenomenon, which is more likely to appear in advancing age and is associated with onychomycosis.

Photodynamic therapy (PDT) is a noninvasive treatment that utilizes light treatment along with application of a photosen- sitizing agent. In dermatology, PDT is commonly used and approved for the treatment of oncological conditions such as actinic keratosis, Bowen disease and superficial basal cell carcinoma. In the last 2 decades however, PDT has also been used for the treatment of several nonneoplastic dermato- logical diseases. The present review summarizes published data on PDT application in skin appendage disorders. Our literature review shows that: (a) PDT may be a suitable treat- ment for acne, folliculitis decalvans, hidradenitis suppurati- va, nail diseases, and sebaceous hyperplasia; (b) there is a lack of agreement on PDT features (type, concentrations and incubation period of used substances, number and frequen- cy of PDT sessions, optimal parameters of light sources, and patient characteristics [e.g., failure to previous treatments, disease severity, body surface area involved, etc.] which should guide PDT use in these diseases); (c) further research is needed to establish international guidelines helping der- matologists to choose PDT for the right patient at the right time.

The nail is considered to be a specialised modification of the skin – an ‘epidermal appendage’. However, the phrase ‘hanging on by your fingernails’ belies a vital aspect of nail microanatomy that has been overlooked, namely that the nail is functionally integrated with the musculoskeletal system. The current article reviews how the nail is functionally linked to the distal phalanx and several distal interphalangeal joint structures, including extensor tendon fibres and the collateral ligaments. New histological images exploring this link are provided. The extensor tendon in particular continues from its bony insertion to envelop the nail root, and the collateral ligaments form an integrated network on the sides of the joint, helping to anchor the nail margins. This virtual continuum of connective tissue structures merges with a thick periosteum on the distal phalanx and with the numerous cutaneous ligaments that anchor the fatty pads of the finger pulp to the skin.

Onychomycosis is a frequent infection. Contagion rarely depends on direct contamination, but rather on environmental propagule dispersion including the intervention of fomites. The potential release of fungal cells in the environment from the affected nails has not been thoroughly studied. Observations made by histomycology suggest that arthroconidia and chlamydoconidia issued from invading fungi can be involved. In addition, the sporodochium, which is an exophytic fungal ball, may be attached underneath the distal free edge of some onychomycoses. It might represent an important source of fungal propagules in patients with poor nail trimming.

Background: Non-dermatophytic onychomycoses represent 1.45–17.6% of all fungal nail infections. Epidemiological studies have shown that Aspergillus spp. are emerging fungal agents of toenail onychomycosis. Indeed, after Scopulariopsis spp. the genus Aspergillus is the second most common agent of non-dermatophytic onychomycosis. The diagnosis and treatment of toenail onychomycosis caused by non-dermatophyte moulds are not always straightforward. Objectives: The aims of this study were to describe the clinical appearance of toenail onychomycosis due to Aspergillus spp., to investigate the pathogenetic role of these agents and to evaluate the efficacy and safety of weekly intermittent terbinafine (500 mg/day for 1 week each month for 3 months) in the treatment of these patients. Patients and Methods: Mycological study of 2,154 patients with onychodystrophy revealed 1,228 onychomycoses (57%) including 71 cases due to non-dermatophytic fungi (5.6%). Non-dermatophytic onychomycosis caused by Aspergillus spp. represented 2.6% of all onychomycoses. The subjects were 34 patients (22 females, 12 males, age range 30–82 years) observed between September 1999 and December 2001, with toenail onychomycosis caused by Aspergillus spp. confirmed by standard techniques (microscopic examination and culture according to the criteria of English), histological examination of nail clippings and scanning electron microscope examination of the cultures whenever necessary. Results: The clinical features suggesting onychomycosis due to Aspergillus spp. are chalky deep white nail, rapid involvement of lamina and painful perionyxis without pus. Standard mycological tests (direct microscopy and fungal culture) and histological examination confirmed the pathogenetic role of Aspergillus spp. in onychomycoses. In particular, the histological examination was positive in 28 cases (82%) and useful in identifying typical aspects of Aspergillus spp. nail infections. At the follow-up, 12 months after the start of therapy with pulsed terbinafine, clinical and mycological recovery was confirmed in 30 of the 34 patients (88%). Conclusions: Treatment of non-dermatophytic onychomycosis with terbinafine usually requires at least 3 months of continuous systemic therapy. Our study of 34 patients confirms that terbinafine is particularly effective in the treatment of Aspergillus spp. nail infections and that a pulsed regimen is more economical and less demanding.

Background: With the increased awareness of onychomycosis and the increasing use of antifungals for this indication, it is prudent to be concerned about the possible emergence of resistant strains. There has been substantial work on the development of standardized methods for testing the in vitro resistance of various fungi and yeasts to the currently available antifungal agents. However, relatively little research has been published concerning the resistance of dermatophyte species. Objective: We report the results of a retrospective study analyzing the relationship between in vitro and clinical resistance in strains of Trichophyton rubrum cultured from patients with recalcitrant dermatophyte toe onychomycosis. Materials and Methods: We analyzed the in vitro resistance of dermatophyte strains obtained from 18 patients with chronic onychomycosis who failed antifungal therapy with itraconazole or terbinafine. Multiple-sequential strains from 11 patients were included in the study. Susceptibility testing of these strains was performed against 4 antifungals, itraconazole, ketoconazole, terbinafine and ciclopirox, using the broth microdilution method as per the NCCLS M27-A guidelines. A record of clinical characteristics that may relate to patient treatment and therapy was maintained. Results: All of the strains were susceptible to 3 of the 4 antifungal agents tested. Although there was no direct correlation between clinical resistance and in vitro resistance, increased minimum inhibitory concentration values for ketoconazole were observed in strains obtained after treatment from 3 of 18 patients evaluated in the study. In all but 1 patient, we were able to identify other factors that may have been responsible for treatment failure. Conclusions: With the more common use of antifungals to treat various fungal infections, development of increased resistance in the causative organisms remains a possibility. However, factors other than fungal resistance may also be implicated in treatment failure.

The therapeutic outcome of onychomycoses is uncertain. Comparative short-term efficacy studies on antifungals abound and report contradictory findings. Few unbiased follow-up studies have scrutinized the long-term outcome. Basically, none of the current antifungals can guarantee cure in all instances. In addition, relapses are not rare. The causes of therapeutic failure in onychomycoses are multiple. The most important are the lack of diagnostic accuracy, inadequate antifungal choice or delivery modality, and presence of dormant conidia, sequestrated mycelium pockets or resistant fungal species. The concept of fungicidal drug derived from selected in vitro studies appears irrelevant in clinical practice.

Background:Scopulariopsis brevicaulis is a common non-dermatophyte mould that can cause onychomycosis. Objective: To evaluate the efficacy and safety of the oral antifungal agents griseofulvin, ketoconazole, itraconazole, fluconazole and terbinafine in the treatment of S. brevicaulis.Patients and Methods: In a prospective, comparative, parallel-group, single-blinded, randomized, non-industry-sponsored study, patients with toe onychomycosis caused by S. brevicaulis sp. were randomized and treated with one of 5 oral antifungal agents, i.e. griseofulvin, ketoconazole, itraconazole (pulse), fluconazole or terbinafine. The treatment regimens were: griseofulvin 600 mg twice daily for 12 months, ketoconazole 200 mg daily for 4 months, itraconazole pulse therapy given for 3 pulses, with each pulse consisting of 200 mg twice daily for 1 week with 3 weeks off between successive pulses, terbinafine 250 mg daily for 12 weeks and fluconazole 150 mg daily for 12 weeks. Results: There were 59 patients (48 males, 11 females, mean age 35.6 years, range 25–53 years). All patients had clinical evidence of distal and lateral onychomycosis, with moderate to severe disease of the target nail. Between the treatment groups there was no significant difference in the mean age of the patients or the mean area of involvement with onychomycosis at baseline. The efficacy parameters were clinical cure (CC) and mycological cure (MC). At month 12 after the start of treatment, the response was: griseofulvin, CC 3/11, MC 0/11, CC + MC 0/11; ketoconazole, CC 10/12, MC 8/12, CC + MC 8/12; itraconazole, CC 12/12, MC 12/12, CC + MC 12/12; terbinafine, CC 12/12, MC 11/12, CC + MC 11/12, and fluconazole, CC 8/12, MC 8/12, CC + MC 8/12. Adverse effects consisted of: griseofulvin, gastro-intestinal symptoms, allergic reaction, photodermatitis, hepatic and renal dysfunction in 11 patients with discontinuation of treatment in 3 patients; ketoconazole, hepatic dysfunction but no symptomatic changes in 2 patients; itraconazole, nausea and vomiting in 2 patients; terbinafine, taste disturbance in 2 patients, nausea in 3 patients, and fluconazole, severe gastro-intestinal events in 5 patients. None of the patients receiving ketoconazole, itraconazole, terbinafine or fluconazole discontinued treatment. Conclusions: Itraconazole and terbinafine demonstrate efficacy against some cases of S. brevicaulis toe onychomycosis. These agents also appear to be safe in the course of therapy for toe onychomycosis. Griseofulvin is ineffective against toe onychomycosis caused by S. brevicaulis. Ketoconazole is not recommended for toe onychomycosis given its potential for adverse effects, particularly with the availability of the newer antifungal agents.

In contrast to epidermal lipid metabolism, the lipid biochemistry of nails has yet been poorly investigated. Our purpose was to define a reference population of healthy individuals as a base for the better understanding of nail diseases and age-induced changes. Therefore, we developed a method of processing and extracting the nail plates enabling us to assess the most relevant epidermal lipid classes by HPTLC. Our study revealed that nail plate lipid composition varies with age and sex: the lipid composition of the fertile years shows distinct profiles compared to that of childhood and old age, suggesting an influence of sex hormones on nail lipogenesis. Our results open the possibility in the future of an easier comparison between healthy and diseased nails and enable us to investigate factors influencing nail lipid composition such as drugs, metabolic diseases, toxic agents, cosmetics and nail therapeutics.

The epidemiology and ecology of onychomycosis are complex and little understood. Most is known about tinea unguium, dermatophytic nail infection, and its causative agents. This is often categorised according to the precise locus on the nail of the infection. The principal infectious propagules are thought to be the arthroconidia or chlamydospores which form within the solid substratum of invaded nail tissue. The process of infecting new hosts appears to be facilitated by abrasion, moistening and scratching. The role of the non-dermatophyte yeast Candida as an agent of onychomycosis per se may have been overestimated. The range of interactions between dermatophytes and non-dermatophytes in nails is complex and poorly understood. There may be at least six distinct ecological categories of non-dermatophyte isolations from nails. It would be of clinical interest to know which species found in mixed infections were never able to advance beyond 'secondary colonisation', as they would not require specific treatment.

Background and Objective: Occurrence rates of clinical features of nail psoriasis vary considerably in the literature. Little information is available on subjective complaints of patients affected by psoriasis of the nails. Method: Interviews with 1,728 psoriatic patients concerning their nail changes and complaints are reviewed. Results: The results indicate that pitting and deformation are the most common clinical aberrations in psoriatic nails, with a positive association between the duration of skin lesions and nail psoriasis. No relation was found between age and nail psoriasis in this group. Remarkably, 51.8% of patients suffered from pain caused by the nail changes, and a large group of patients was restricted in their daily activities, housekeeping and/or profession (58.9, 56.1, 47.9%). Treatment was disappointing: only 19.3% showed marked improvement during treatment. Conclusion: This indicates that psoriasis of the nails is a more important individual and social-economic problem than previously assumed and that development of new treatments is needed.

Background: The effect of low-dose cyclosporin A (CsA) on psoriatic onychopathy has not yet been thoroughly studied. Purpose: To measure the changes in nail surface contours during a 3-mg/kg/day CsA therapy. Method: In vivo optical profilometry was performed at regular intervals in 5 psoriatic patients to derive mean roughness (Ra) and mean depth of roughness (Rz) values of nails. Segmental Rz served to evaluate long-term onychochronobiology. Results: Untreated psoriatic trachyonychia was best described by Rz which showed large interindividual differences. A progressive improvement in segmental Rz took place after 2–3 months of maintenance therapy. Conclusion: CsA improves psoriatic onychopathy after an apparent lag phase. The maximum improvement may only be reached during the CsA tapering phase.

Background:Exophiala jeanselmei is a dematiaceous fungus that may cause invasive diseases, particularly among immunocompromised hosts. Most reports mention cutaneous or subcutaneous lesions, but no case of nail involvement due to this fungus has been reported until now. Case Report: A 60-year-old man presented with hyperkeratosis and black coloration of the nails of the two thumbs and the two big toes of 4 years’ duration. He was a renal transplant recipient and had been treated with prednisone and azathioprine. E. jeanselmei was present on direct examination, then isolated in cultures on repeated samplings from all pathologic nails. He was cured after 6 months of treatment with itraconazole. Commentary: We describe the first case of nail infection due to E. jeanselmei. Itraconazole, which provides a broad spectrum of action on fungal species and achieves high levels of active substance in many tissues, including the nails, appeared to be efficient upon such a nail localization of E. jeanselmei.

Scytalidium dimidiatum is a geophilic dematiaceous, non-dermatophyte mould that can become a pathogen for plants and humans particularly in tropical and subtropical regions. We report 4 cases of S. dimidiatum onychomycosis presenting clinically as thickened and dark toenails. The skin of the soles was scaly. The time and location of the contaminations were uncertain. Indeed, the patients were ancient immigrants from the Maghreb to Belgium. They were also regularly travelling to their countries of origin. They were also often barefoot in the same Belgian mosque. The disease was unresponsive to current oral antifungal treatments.

9 Caucasian patients who developed longitudinal melanonychia during 3′-azidodeoxythymidine (AZT) treatment for HIV infection are reported. The occurrence of nail pigmentation was not related to drug dosage or to the severity of the HIV infection. AZT as well as other drugs acting on DNA synthesis or transcription seem to be a quite frequent cause of longitudinal melanonychia.

The generalized form of lichen nitidus (LN) with oral and nail changes is extremely rare in childhood. We report a 10-year-old boy with generalized LN associated with oral involvement and onychodystrophy. Oral lesions showed yellowish papules on the gums. The nails had longitudinal striations and pits on the finger-nails, and transversal ridging of the big toes was found. Cutaneous and mucosal lesions as well as onychodystrophy spontaneously cleared within 8 months.

In a multicentre, randomised, double-blind, 48-week clinical trial, 118 patients with toe-nail onychomycosis were given terbinafine (250 mg daily) or placebo for 12 weeks, followed by 12 weeks of observation. Non-responders were offered 12 further weeks of terbinafine (250 mg daily) from week 28. Each patient had 8-12 consecutive nail specimens collected from the same nail, allowing for an assessment of the fungal nail flora from 1,321 nail specimens. By week 48, the overall mycological cure rate for terbinafine patients was 94%. 64% of patients had an underlying dermatophyte infection with at least 1 non-dermatophyte mould or yeast isolated from at least 1 specimen. These contaminants often overgrow or mask the presence of a dermatophyte. In only 2.5% of all patients was the same non-dermatophyte isolated from 2 or more consecutive specimens, probably representing secondary colonisation which exploits nutrients released by the underlying dermatophyte. The presence of incidental non-dermatophyte contaminants or secondary colonisers did not affect treatment outcome, and in this study treatment of the primary dermatophyte pathogen with terbinafine cleared the nails from infection in all cases. 80% of patients remained mycologically negative after 2 years.

Warty dyskeratoma is described in an unusual location. Clinically it appeared as a longitudinal reddish ridge bordered on each side by brown splinter haemorrhages forming a nearly continuous line. The free margin of the nail plate was slightly fissured distal to the red band. In the distal groove, histology showed deep epithelial digitations which lined a crater-like area. Numerous multinucleate giant cells, marked dyskeratosis and acantholytic suprabasal clefts were visible inside this tumour resembling Darier's nail disease.

Skin changes associated with carpal tunnel syndrome have rarely been reported. A 60-year-old patient was referred to our Department of Dermatology for evaluation of an aseptic gangrene of the distal phalanx of the third finger of her left hand, progressive nail dystrophy, sclerodactylia and spontaneous ulcerations. These features were seen on the digits with sensory supply from the median nerve. The patient had hand paresthesias for at least 10 years. No abnormal results were found in biochemical, hematological or immunological determinations. An echo-Doppler study of the upper limbs was normal. An electromyographic study was consistent with a bilateral carpal tunnel syndrome (CTS). Ulcerative and mutilating CTS can occasionally produce sclerodactylia with ulcerative lesions on distal fingers, nail dystrophy and acro-osteolysis as a consequence of mechanical compression of the autonomic fibers of the median nerve. The clinical picture includes Raynaud's phenomenon in some patients. Correct diagnosis is important, since ulcerative and mutilating CTS is a marker of a severe neural lesion, which is amenable to treatment by surgical decompression.

Background: Whether idiopathic atrophy of the nails (IAN) should be considered a separate entity or a clinical variant of nail lichen planus is still controversial. Objective: We report here the pathological study of 2 patients with IAN. Methods: Our patients had similar clinical features consisting of severe nail atrophy with and without pterygium. Results: The nail matrix architecture was markedly deformed with complete disappearance of the keratogenous zone that was replaced by a 3- to 10-cell-thick granular layer. Conclusion: The hypothesis that IAN is an acute and self-limited variety of lichen planus is still the most presumable. Even though this hypothesis can not be definitely proven, it is nevertheless not excluded by the clinical and pathological findings of our cases.

Only 2 cases of histiocytoid hemangioma localized in the nail apparatus have been reported in the literature. We describe here a patient affected by multiple histiocytoid hemangiomas involving the 3rd right digit and fingernail. The pathological features were typical for a diagnosis of histiocytoid hemangioma showing vascular proliferation characterized by enlarged endothelial cells associated with inflammatory cells. Phenotypic characterization of the proliferating cells confirmed their vascular origin.

We report 3 patients, without bleeding disorders, presenting with onychomadesis and focal haemorrhages at multiple proximal nail folds or in the nail tissue. In one of our patients it was possible to check the appearance of a drop of blood on each side, beneath the proximal nail fold when he pressed the pulp of the fingers of his previously fractured forearm on a hard surface. All patients had major peripheral or major peripheral and central neurological deficits, prior to the nail bleeding. Peripheral vascular dilatation produced by paralysis of the vasoconstrictors in the nail area slows the venous return in the dilated vessels, mainly in the proximal nail fold.

The incidence of brittle nails is higher in women than in men. Repeatedly a suspected cause for the higher incidence of brittle nails in women is the frequent exposure to water. This study was aimed at clarifying whether wet working conditions increase the incidence of brittle nails in women and men in a similar degree. We determined the incidence of brittle nails in 511 persons in professions that involve frequent hand contact with water. The data were compared to those of a large, non-selected control group. 50% of the female probands showed the sign of brittle nails (control group: 30.4%, p less than 0.05). Only 13.5% of the male test persons of this study had brittle nails; the difference to the control group (13.2%) was not significant. It is discussed that in women the bridges between nail corneocytes are possibly weaker than in males as a constitutional characteristic. Accordingly, frequent alternating periods of hydration and drying increase the incidence of brittle nails particularly in women.

We report on 2 cases of patients with warts underlying the proximal nail fold which presented as tender erythematous nodules. The remarkable feature in both cases was a significant oedema of the proximal nail fold, resembling a reaction to a foreign body. One patient responded well to mild keratolytic treatment. The second patient was treated surgically with crescentic excision of the distal portion of the proximal nail fold. It is important to recognise this tumour variant in order to avoid unnecessary or excessive intervention.

Transverse grooves of the nails, designated as Beau's lines, were observed in a patient with malignant lymphoma given chemotherapy. Beau's lines disappeared in the treatment-free intervals. This observation supports the concept that these lines are the result of the suppressed growth of the nail matrix caused by antimitotic drugs.

We report the case of a 56-year-old woman with a history of episodes of vomiting and coma. Hyperammoniemia, hypouremia, hypercitrullinemia and the decreased arginino-succinic synthetase activity on skin fibroblast cultures permitted us to diagnose citrullinemia. We think that the skin changes, i.e. atrophy of the epidermis, thin and short collagen bundles, dystrophic elastic fibers, increased fundamental matrix, were due to the undernutrition state and were not specific. The dosage of the amino acids of the total skin showed a decreased hydroxylation of lysine in the insoluble fraction, and the presence of pro-line and hypdroxyproline in the soluble fraction. These metabolic changes were not specific and evidenced the disorganization and the lysis of the connective tissue due to the undernutritional state. The nail changes, i.e. clubbed fingers and ‘half-and-half nail’ syndrome, were not specific either. The hair changes mentioned by other authors in newborns and young children, i.e. sparse and brittle blond hair, presence of transverse opaque bands (‘irregularly banded hair’), were not present in our case. We only found changes in the cuticle and some trichorrhexis which were not specific of the disease either.

13 patients with distal subungual onychomycosis in a total of 48 dermatophyte-infected nails were treated with chemomechanical, partial nail avulsion followed by topical miconazole for 8 weeks. On examination, 6 months after cessation of therapy, 42% of the nails were cured by clinical and mycological criteria. The therapeutic response was related to the pretreatment extension of subungual hyperkeratosis. Periungual skin irritation was common during the initial avulsion period. Miconazole solution was well tolerated and this treatment modality proved to be a valuable alternative to other remedies for the treatment of onychomycosis limited to a few number of nails.

A case of inflammatory linear verrucous epidermal naevus is described. Unusual features were the widespread and bilateral distribution, nail involvement, and the abundance of capillaries in the dermis.

Bilateral first-rib hypoplasia, a skeletal anomaly not previously associated with the nail-patella syndrome, is reported occurring in a young woman possessing numerous other features of this potentially lethal condition.