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Acral melanoma (AM) is a malignant cutaneous melanocytic tumour specifically located on the palms, soles, and nail apparatus, which are areas of glabrous (hairless) skin. Acral lentiginous melanoma, a subtype of AM, represents a histopathological subtype diagnosis of cutaneous melanoma with unique morphological and structural features. Despite clear definitions, the misuse of these terms and the inconsistency in reporting the histopathological features of AM cases have become a major obstacle to the study of the disease. In this review, we discuss the epidemiology, histopathological features, prognosis, and genetic profile of AM, highlighting the differences observed when histopathological subtypes are considered. The increasing global effort to characterise AM cases from ethnically diverse populations would benefit greatly from a more consistent classification of the disease. more...

The nail apparatus serves as a protective layer over the dorsal aspect of each distal phalanx of both hands and feet. Besides protection, other functions include serving as part of defense or attack mechanisms, scratching, and dexterity. Nail development has been a subject of interest since the 19th century, from both the phylogenetic and ontogenetic points of view. Despite the early spark of interest, nail embryology has yet been analyzed by a relatively small number of scientists. In the Department of Anatomy of “Carol Davila” University of Medicine and Pharmacy, we performed a morphological analysis on 41 embryos and fetuses with gestational ages that varied between 6 and 29 weeks. more...

Onychomycosis is a type of fungal infection caused by dermatomycetes, yeast or filamentous fungi, in which the nail apparatus is affected. Due to the insufficient activity of effective cellular immunity, the nail apparatus tends to be invaded by fungal pathogens when exposed to certain risk factors, being an ideal ecological niche for long-term persistence of fungi. This explains why onychomycosis, as a rule, is chronic infection, proceeding without signs of active inflammation.In the absence of treatment of onychomycosis, there is a significant risk of complete destruction of the nail plate with the involvement of the surrounding skin, as well as the spread of infection, as a rule, due to autoinoculation. The need and possibility of therapy should be considered for each patient with onychomycosis. However, the decision on the choice of methods and a specific drug should depend on a number of individual factors.The article considers the factors influencing the efficiency of topical therapy for onychomycosis. It has been shown that before choosing a therapy for onychomycosis, several factors must be taken into account: the type of pathogen, subtype of onychomycosis, anatomical localization (hands, feet), matrix involvement, the number of affected nails, the thickness of the affected nail plate, and the coexistence of other mycoses in other locations. Topical antifungal drugs contain high concentrations of active substances, but to improve permeability and increase the efficiency of topical therapy, they require the use of auxiliary means (mechanical, instrumental, chemical, physical). According to the results of international studies, the amorolfine molecule demonstrates significant advantages, having the lowest minimal inhibitory concentration for the destruction of onychomycosis pathogens, penetrates deep into the lower layers of the nail even after a single application. Antifungal varnish Amoderm Neo has broad antifungal activity, a minimum spectrum of side effects, is recommended for topical treatment of dermatophytic and non-dermatophytic onychomycoses, complex therapy of onychomycosis and their prevention., Онихомикоз является разновидностью грибковой инфекции, обусловленной дерматомицетами, дрожжами или мицелиальными грибами, при которой поражается ногтевой аппарат. В связи с недостаточной активностью эффективного клеточного иммунитета ногтевой аппарат имеет склонность к инвазии грибковыми патогенами при их воздействии на фоне определенных факторов риска, являясь идеальной экологической нишей для длительного персистирования грибов. Это объясняет, почему онихомикоз являются, как правило, хронической инфекцией, протекает без признаков активного воспаления.При отсутствии лечения онихомикоза существует значительный риск полного разрушения ногтевой пластины с вовлечением в процесс окружающих кожных покровов, а также распространения инфекции, как правило, за счет аутоинокуляции. У каждого пациента с онихомикозом следует рассматривать необходимость и возможность проведения терапии, однако решение о выборе как методов, так и конкретного препарата должно зависеть от ряда индивидуальных факторов.В статье рассмотрены факторы влияния на эффективность топической терапии онихомикоза. Показано, что перед выбором терапии онихомикоза необходимо учитывать несколько факторов: вид возбудителя, подтип онихомикоза, анатомическую локализацию (кисти, стопы), вовлечение матрикса, количество пораженных ногтей, толщину пораженной ногтевой пластины и сосуществование других микозов с различным расположением. Местные противо­грибковые препараты содержат высокие концентрации действующих веществ, но для улучшения проницаемости и повышения эффективности топической терапии требуют использования вспомогательных средств (механических, аппаратных, химических, физических). По результатам международных исследований молекула аморолфина де­монстрирует существенные преимущества, обладая наименьшей ингибирующей концентрацией для уничтоже­ния возбудителей онихомикоза, глубоко проникает в нижние слои ногтя даже после однократного нанесения. Противогрибковый лак «Амодерм Нео» обладает широкой противогрибковой активностью, минимальным спект­ром побочных эффектов, рекомендован для топического лечения дерматофитных и недерматофитных онихомикозов, комплексной терапии онихомикозов и их профилактики., Оніхомікоз є різновидом грибкової інфекції, зумовленої дерматоміцетами, дріжджами або міцеліальними грибами, при якій уражається нігтьовий апарат. У зв’язку з недостатньою активністю ефективного клітинного імунітету нігтьовий апарат має схильність до інвазії грибковими патогенами при їхньому впливі на тлі певних чинників ризику, тому що є ідеальною екологічною нішею для тривалого персистування грибів. Це пояснює, чому оніхомікоз є, як правило, хронічною інфекцією, що протікає без ознак активного запалення. За відсутності лікування при оніхомікозі існує значний ризик повного руйнування нігтьової пластини із залученням до процесу навколишніх шкірних покривів, а також поширення інфекції зазвичай за рахунок автоінокуляції. У кожного пацієнта з оніхомікозом слід розглядати необхідність і можливість проведення терапії, проте рішення про вибір як методів, так і конкретного препарату має залежати від низки індивідуальних чинників. У статті розглянуто фактори впливу на ефективність топічної терапії оніхомікозу. Показано, що перед вибором терапії оніхомікозу необхідно враховувати кілька факторів: вид збудника, підтип оніхомікозу, анатомічну локалізацію (кисті, стопи), залучення матриксу, кількість уражених нігтів, товщину ураженої нігтьової пластини і співіснування інших мікозів з різним розташуванням. Місцеві протигрибкові препарати містять високі концентрації діючих речовин, але для покращення проникності і підвищення ефективності топічної терапії потребують використання допоміжних засобів (механічних, апаратних, хімічних, фізичних). За результатами міжнародних досліджень молекула аморолфіну демонструє суттєві переваги, володіючи найменшою інгібуючою концентрацією для знищення збудників оніхомікозу, глибоко проникає в нижні шари нігтя навіть після одноразового нанесення.Протигрибковий лак «Амодерм Нео» володіє широкою протигрибковою активністю, мінімальним спектром побічних ефектів, рекомендований для топічного лікування дерматофітних і недерматофітних оніхомікозів, комплексної терапії оніхомікозів та їхньої профілактики. more...

Onychodystrophies are various pathological processes in the nail apparatus of infectious and non-infectious nature, related to changes in its morphology. The most common cause of nail changes is a fungal infection. However, onychodystrophy can be a manifestation of dermatological diseases, trauma, medication, systemic and tumor processes. Since the clinical symptoms of onychodystrophies are unspecific, sometimes it can cause difficulties in making a diagnosis. This photo gallery presents clinical pictures of diseases that a physician may encounter in everyday practice. more...

Glomus tumors of the hand are benign vascular tumors, which develop at the expense of the neuro-myo-arterial glomus. They represent about 1% -5% of all hand tumors. Their diagnosis is frequently delayed by the absence of specific signs, its confirmation is based on anatomopathological examination. Their treatment is based on complete surgical excision and restitution of the nail apparatus, the only guarantees of a good evolution without recurrence. We report the case of a recurrence of a glomus tumor of the ring finger in a woman where the pains reappeared 6 months after the first intervention. more...

Nail apparatus melanoma (NAM) is a rare dermatologic malignancy. Its prognosis is poor because it is often diagnosed late. However, progression and survival of NAM patients have only been studied among small populations. Early biopsy could help to identify suspicious lesions at a less invasive stage. While surgery is generally seen as the treatment of choice, the extent of excision margins and the use of sentinel biopsy remain debated. This systematic review aims to summarize the treatment procedures and observed prognosis in the literature during the last two decades and present pooled survival and progression rates of NAM by using meta-analysis. A systematic review on studies assessing pathology, treatment and prognosis of NAM was carried out up to end of 2018. After evaluation of eligible studies, the main emerging topics were outlined and pooled survival outcomes estimated. A total of 30 articles out of 624 identified records were included for systematic review. Finally, meta-analysis of pooled mortality rates including 18 studies was 4.6 × 100 patient-years (95% CI: 2.7, 6.8) equivalent to 5-year cumulative survival of 77.0%. Additionally, the pooled progression rate based on 17 studies was 6.3 × 100 patient-years (95% CI: 4.1, 8.9) with estimated 5-year cumulative progression-free survival of 68.5%. While the optimal extent of surgical treatment remains debated, prompt biopsy could help to identify early lesions. This is the first study to present pooled survival and progression rates by meta-analysis. more...

O tratamento da micose do aparelho ungueal permanece um desafio nos dias de hoje. O foco infecioso encontra-se retido numa estrutura anatómica específica onde não se consegue por vezes uma resolução permanente, o que significa que a onicomicose se torna frequentemente uma condição crónica que retoma o estado ativo no intervalo de vários anos. A prioridade nos recentes desenvolvimentos da farmacoterapia da onicomicose foi atribuída à monoterapia tópica com o intuito da sua utilização em doentes que não toleram a medicação oral ou preferem um fármaco tópico e, com a vantagem adicional, de combiná-los com fármacos orais e/ou dispositivos médicos para expandir as possibilidades de tratamento atuais. Esta revisão engloba as opções terapêuticas da onicomicose no status quo. Dois novos fármacos tópicos, efinaconazol e tavaborol, foram aprovados no ano 2014 pela entidade reguladora competente Food and Drug Administration (FDA). more...

Introduction and Objectives: Onychomycosis, or fungal infection of the nail apparatus by dermatophytes or nondermatophytes, is more than just a cosmetic problem. Dermatophytes are known to cause 90% of toenail and atleast 50% of fingernail onychomycosis. Our study offers insight into the unique current epidemiological aspects of onychomycosis in our region, including the less known nondermatophytemolds;. Since histopathology of nail clippings using Periodic Acid Schiff is clearly an invaluable tool in diagnosing onychomycosis, we integrated and comparatively evaluated it with the tests of routine mycology for the same. Materials and Methods: Patients in Rajarajeswari Medical College and Hospital (a tertiary care hospital) presenting with clinically apparent onychomycosis were included in this study. Each specimen of subungual debris and nail clippings was divided into two portions- one for direct microscopy and the other for culture. Nail clippings alone were used for PAS staining. Results: The present study was carried out on 40 clinically suspected cases of onychomycosis in the Department of Microbiology, Rajarajeshwari Medical College and Hospital over a period of one year. Out of 40 samples, 14(35%) samples showed fungal elements in 20% KOH, in 12(30%) samples fungal culture was positive and 19(47.5%) were PAS stain positive. Out of 12 isolates, 5(41.6%) were dermatophytes and 7(58.4%) were nondermatophytes. Keywords: KOH, PAS, Dermatophytes, Nondermatophytes, Nail infection, Onychomycosis. more...

The nail apparatus is a complex area with great functional and cosmetic importance. The appearance of tumors is rare, frequently misdiagnosed with delaying the diagnosis. A series of cases is presented, where squamous cell carcinoma of nail apparatus underwent resection and reconstructive surgery in a relatively short time from their diagnosis, with a good oncological, functional, and cosmetic result. more...

Bullous pemphigoid (BP) is the most frequent autoimmune blistering disorder. The immune reaction targets BP180 and BP230 antigens, 2 components of junctional adhesion complexes at the basement membrane zone. Clinical aspect includes multiple tense bullae on urticarial plaques of the skin. Although the nail apparatus may be affected by the immune process, nail changes have been rarely reported during BP. We report a case of a 72-year-old woman diagnosed with BP who subsequently developed a secondary nail loss of the 2 thumbs and the left middle finger. Also, she presented onycholysis of the fourth left finger with the aspect of roller-coaster of the proximal border at dermoscopy. Steroid therapy at high doses was ineffective and the nail atrophy was permanent. more...

The nail plate is made up of tightly packed keratin-rich cells. Factors such as the special distribution of the intermediate filaments in each layer (dorsal, intermediate, and ventral), the relative thickness of the layers, and their chemical composition define the characteristics of each nail. The main objective of this study is to determine nail consistency by calculating a predictive model based on elemental composition analysis using scanning electron microscopy. Nail consistency was determined in 57 participants (29 women and 28 men) in two age groups (young people and adults). Elemental composition was analysed in each layer using scanning SEM-EDS, and nail plate thickness was measured by image analysis. A total of 12 elements were detected in nail plates, of which carbon, nitrogen, phosphorus, sulphur, and calcium showed significant differences between layers (p-values &le, 0.01). The level of calcium in the dorsal layer was the main predictive variable in calculating the predictive model of consistency, with 75.4% correctly classified cases. Elemental analysis in each layer of the nail plate by SEM-EDS can be used to develop a predictive model of nail consistency that will help health professionals to objectively determine nail consistency. more...

Avulsion of the nail plate is the most accomplished surgical procedure among the nail apparatus surgeries. Since it is not possible to use the removed nail to cover the nail bed, some materials have been suggested, however, they are generally not available for use and often at a high cost. To evaluate the use of Bacterial Cellulose (BC) dressing as a biological nail (Bio-Nail) after partial or total avulsion of the nail plate. Twenty-six candidates for nail avulsion, were randomized into two groups: Control, using Vaseline with gauze (11 patients) and Experimental group, BC group, using the Bio-Nail (15 patients). The patients were followed up during the 180-day period. The distribution of the patients in the groups was homogeneous for both sociodemographic and clinical data. The occurrence of infection (1 case in the control group) was not statistically relevant. The BC group had lower pain intensity (p = 0.011) with earlier temporal resolution when compared to the control group (p = 0.003). The BC group presented earlier reepithelization (p = 0.022) and better quantitative (p = 0.021) and qualitative conditions (p = 0.011) for the exudate. Regarding satisfaction, all the patients were satisfied. Good preservation of the nail plate area was observed in the BC group at the end of the 180-day period (p = 0.024). Average time of BC dressing permanence was 16.4 ± 7.1 days. BC showed to be appropriate as a dressing after partial or total avulsion of the nail plate. BC is a Bio-Nail promising for nail bed healing. more...

Both dermatologists and pathologists sometimes find daunting the evaluation of melanonychia (especially subungual melanocytic lesions) because of the fear of performing nail surgery due to the risk of dystrophy, difficulties processing and interpreting nail biopsy specimens, and a general lack of experience in the field. Nevertheless, mastery of nail biopsy techniques, correct processing and orientation of specimens, and familiarity with the histologic particularities of the nail apparatus can attenuate the undoubted complexity and facilitate the tasks involved. Longitudinal excision is the biopsy technique that ensures the simplest histologic interpretation, and it is associated with a low risk of nail dystrophy when performed correctly. Clinical and epidemiological data are crucial. Subungual melanoma in childhood, for instance, is very rare and even lesions with atypical clinical and/or histologic features are probably benign. The presence of suprabasal melanocytes and other findings that would suggest malignancy at other sites are considered normal in the nail apparatus. Subungual melanoma shows a lentiginous pattern in the early stages of disease, and detection of an inflammatory infiltrate accompanying atypical lentiginous subungual lesions would appear to be one of the first diagnostic findings. more...

Background: There are no proper management guidelines for nail apparatus melanoma (NAM). Objective: This study aimed to describe the clinical features, the presence of locoregional and distant metastases and disease-free and overall survival of NAM treated at our institution. Methods: A retrospective cohort review of patients with single, primary localized histopathologically confirmed NAM was performed. Collected data consisted of patients’ characteristics and tumor features. In addition, local recurrence, locoregional metastases, distant metastases, disease-free survival (DFS) and overall survival (OS) were used as the main outcomes in our analysis. Results: Thirty patients with NAM were included. The overall survival (OS) in our patients at 5 and 10 years was 85.6 and 73.4%, respectively. DFS was significantly higher in patients with primary tumor location in the hand and without tumor-infiltrating lymphocytes (p value = 0.01 and 0.04, respectively). The patients with in situ melanoma or Breslow thickness Conclusion: Primary tumor location in the hand and lower tumor thickness might be correlated with better patients’ survival. The study results suggest that total amputation might not be necessary in all NAM cases. more...

Background: Blue nevus of the nail apparatus is a rare entity and only isolated cases are reported in the literature. Objective: The aim of this study was to better characterize blue nevus at the nail unit. Methods: Retrospective analysis of all nail unit blue nevi from the Nail Group of the French Society of Dermatology was compared to the literature. Results: Eleven cases were retrieved from 2002 to 2019 with an average age of 45 years. The majority were women (9/11) and acquired (10/11). Hands were more frequently involved (9/11) with a predilection for the thumb and 2 cases were located on the hallux. Nail unit blue nevus mostly presented as a well-delimited blue spot of the lunula (9/11) and histologically was of the common type (10/11). There was no malignancy. Conclusion: Nail unit blue nevus is a rare asymptomatic benign entity, mostly acquired on the thumb or the hallux of women. The most frequent presentation is a painless blue spot on the lunula. Congenital blue nevi seem to only affect the paronychium. Main differential diagnosis is melanoma and histopathological examination is mandatory., SCOPUS: ar.j, info:eu-repo/semantics/published more...

Onychotillomania, or nail-picking disorder, is an uncommon and misdiagnosed behavioral pattern focused on the nail apparatus. It is demarcated by the compulsive or irresistible urge in patients to constantly injure their own nails, with the fingers or tools, inflicting noticeable or even irreversible self-destruction of the nail unit. Despite its rarity, this self-injurious coercion often poses a diagnostic and therapeutic challenge. Not only do many patients deny nail manipulation, but also the disorder has long been recognized to present itself with a wide range of clinical features, which hampers early and indisputable diagnosis. Furthermore, onychotillomania constitutes a persistent and hardly manageable problem, mostly because of its psychocutaneous nature as well as its high propensity to coexist with underlying neuropsychiatric illnesses or other behavioral disorders. However, the medical literature concerning obsessive nail picking still remains relatively scarce. Herein, we present an extraordinary, yet very intriguing case of a Caucasian patient with onychotillomania and onychophagia coexistence masquerading a weird inflammation-like lesion. more...

Background Subungual squamous cell carcinoma (SSCC) and subungual melanoma (SUM) are rare tumors. Several case reports of association of SSCC with SUM (SSCC-SUM) have been published. Objective We sought to document the clinical, dermoscopic, and histologic features in a case series of SSCC-SUMs and describe their relative frequency compared with those of SSCC and SUM. Methods All patients who underwent surgical exploration of the nail apparatus with a dermatopathologic examination from 2012 to 2015 were reviewed retrospectively to identify all cases of SSCC, SUM, and SSCC-SUM. For patients with SSCC-SUM, clinical characteristics were obtained from electronic medical records. All histologic specimens were reviewed by 3 dermatopathologists. Results The medical records of 456 patients were reviewed. SSCC was diagnosed in 78 (17%), SUM was diagnosed in 63 (14%), and SSCC-SUM was diagnosed in 9. Patients with SSCC-SUM accounted for 11% of those with a diagnosis of SSCC (9 of 78) and 14% of those with a diagnosis of SUM (9 of 63). Limitations This was a single-institution retrospective study. Conclusion The association of SSCC and SUM is relatively frequent in patients with SUM and warrants further consideration to understand the underlying mechanisms involved. more...