Longitudinal erythronychia: Suggestions for evaluation and management

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Presentation transcript:

Longitudinal erythronychia: Suggestions for evaluation and management Nathaniel J. Jellinek, MD Journal of the American Academy of Dermatology Volume 64, Issue 1, Pages 167.e1-167.e11 (January 2011) DOI: 10.1016/j.jaad.2009.10.047 Copyright © 2010 American Academy of Dermatology, Inc. Terms and Conditions

Fig 1 Onychopapilloma presenting as LLE and demonstrating V-shaped distal onycholysis. Journal of the American Academy of Dermatology 2011 64, 167.e1-167.e11DOI: (10.1016/j.jaad.2009.10.047) Copyright © 2010 American Academy of Dermatology, Inc. Terms and Conditions

Fig 2 Onychopapilloma presenting as LLE and demonstrating distal onycholysis and hyperkeratosis of the distal nail bed and hyponychium. Journal of the American Academy of Dermatology 2011 64, 167.e1-167.e11DOI: (10.1016/j.jaad.2009.10.047) Copyright © 2010 American Academy of Dermatology, Inc. Terms and Conditions

Fig 3 Onychopapilloma presenting as wedge-shaped LLE and demonstrating nail bed splinter hemorrhages and distal onycholysis. Journal of the American Academy of Dermatology 2011 64, 167.e1-167.e11DOI: (10.1016/j.jaad.2009.10.047) Copyright © 2010 American Academy of Dermatology, Inc. Terms and Conditions

Fig 4 Onychopapilloma presenting as a fine band of LLE. Journal of the American Academy of Dermatology 2011 64, 167.e1-167.e11DOI: (10.1016/j.jaad.2009.10.047) Copyright © 2010 American Academy of Dermatology, Inc. Terms and Conditions

Fig 5 Onychopapilloma presenting as LLE with a tear-drop-shaped origin in the lunula, and distal splinter hemorrhages (A). B, Direct dermatoscopy using water-soluble jelly shows splinter hemorrhages and a pink lucency in the lunula. Journal of the American Academy of Dermatology 2011 64, 167.e1-167.e11DOI: (10.1016/j.jaad.2009.10.047) Copyright © 2010 American Academy of Dermatology, Inc. Terms and Conditions

Fig 6 Onychopapilloma presenting as LLE (A and B). C, Direct dermatoscopy using water-soluble jelly shows more subtle clinical features, splinter hemorrhages and V-shaped distal onycholysis. Journal of the American Academy of Dermatology 2011 64, 167.e1-167.e11DOI: (10.1016/j.jaad.2009.10.047) Copyright © 2010 American Academy of Dermatology, Inc. Terms and Conditions

Fig 7 A, Poorly defined band of LLE mimicking longitudinal melanonychia. B, Dermatoscopy highlights erythronychia and splinter hemorrhages. Histopathologic examination showed onychopapilloma. Journal of the American Academy of Dermatology 2011 64, 167.e1-167.e11DOI: (10.1016/j.jaad.2009.10.047) Copyright © 2010 American Academy of Dermatology, Inc. Terms and Conditions

Fig 8 A and B, Onychopapilloma presenting as LLE. C, Marked telangiectasia on lunula highlighted by dermatoscopy. Journal of the American Academy of Dermatology 2011 64, 167.e1-167.e11DOI: (10.1016/j.jaad.2009.10.047) Copyright © 2010 American Academy of Dermatology, Inc. Terms and Conditions

Fig 9 A, Onychopapilloma presenting with two bands of LLE and marked unilateral onycholysis. B, Dermatoscopy demonstrates marked funnel-shaped red dyschromia and telangiectasia on the lunula, a feature not apparent on direct examination or with a 7× loupe. Journal of the American Academy of Dermatology 2011 64, 167.e1-167.e11DOI: (10.1016/j.jaad.2009.10.047) Copyright © 2010 American Academy of Dermatology, Inc. Terms and Conditions

Fig 10 A, An unusual case of an onychopapilloma presenting as LLE on the great toe with a thin band of distal true leukonychia. B and C, Trap-door avulsion shows red discoloration of the distal matrix and a subtle longitudinal ridge of nail bed. Journal of the American Academy of Dermatology 2011 64, 167.e1-167.e11DOI: (10.1016/j.jaad.2009.10.047) Copyright © 2010 American Academy of Dermatology, Inc. Terms and Conditions

Fig 11 Glomus tumor presenting as LLE, with distal nail plate splitting and onycholysis. Journal of the American Academy of Dermatology 2011 64, 167.e1-167.e11DOI: (10.1016/j.jaad.2009.10.047) Copyright © 2010 American Academy of Dermatology, Inc. Terms and Conditions

Fig 12 Amelanotic melanoma in situ presenting as LLE. Note prominent distal onycholysis. Journal of the American Academy of Dermatology 2011 64, 167.e1-167.e11DOI: (10.1016/j.jaad.2009.10.047) Copyright © 2010 American Academy of Dermatology, Inc. Terms and Conditions

Fig 13 A, Preoperative LLE, demonstrating a narrow red band, distal onycholysis, and splinter hemorrhages. B, After a longitudinal partial nail plate avulsion; band is visualized with splinter hemorrhages. C, After a narrow longitudinal excision. D, Short-term (10-week) follow-up, without obvious residual erythronychia. Journal of the American Academy of Dermatology 2011 64, 167.e1-167.e11DOI: (10.1016/j.jaad.2009.10.047) Copyright © 2010 American Academy of Dermatology, Inc. Terms and Conditions

Fig 14 Systemic amyloidosis with PLE, splinter hemorrhages, onychorrhexis, onychoschizia, hyperkeratosis of the cuticle, and a flaccid vesicle on dorsal aspect of one finger. Journal of the American Academy of Dermatology 2011 64, 167.e1-167.e11DOI: (10.1016/j.jaad.2009.10.047) Copyright © 2010 American Academy of Dermatology, Inc. Terms and Conditions

Fig 15 Nails with classic Darier's disease, with “candy-cane” PLE, distal onycholysis, splinter hemorrhages, and hyperkeratosis of hyponychium distal to red bands. Journal of the American Academy of Dermatology 2011 64, 167.e1-167.e11DOI: (10.1016/j.jaad.2009.10.047) Copyright © 2010 American Academy of Dermatology, Inc. Terms and Conditions

Fig 16 Nail lichen planus, with PLE, nail plate thinning, onychorrhexis, and mild onycholysis. Journal of the American Academy of Dermatology 2011 64, 167.e1-167.e11DOI: (10.1016/j.jaad.2009.10.047) Copyright © 2010 American Academy of Dermatology, Inc. Terms and Conditions

Fig 17 Graft-versus-host disease with PLE, distal onycholysis, nail plate atrophy, and onychorrhexis. (Courtesy of Bianca Maria Piraccini, MD.) Journal of the American Academy of Dermatology 2011 64, 167.e1-167.e11DOI: (10.1016/j.jaad.2009.10.047) Copyright © 2010 American Academy of Dermatology, Inc. Terms and Conditions

Fig 18 Pathogenesis of longitudinal erythronychia, as proposed by de Berker. Distal matrix disease process results in production of a thinned ventral nail plate. Nail bed swells to fill the concave nail plate, is pinched by the sides. causing splinter hemorrhages, and cracks and splits distally with activities of daily living (ADL). Secondary reactive hyperkeratosis of distal nail bed and hyponychium results. Journal of the American Academy of Dermatology 2011 64, 167.e1-167.e11DOI: (10.1016/j.jaad.2009.10.047) Copyright © 2010 American Academy of Dermatology, Inc. Terms and Conditions

Fig 19 Nail bed biopsy in setting of onychopapilloma. Epithelium shows maturation with development of keratogenous zone, indicative of matrix metaplasia of nail bed. This is a histologic hallmark of onychopapilloma. Journal of the American Academy of Dermatology 2011 64, 167.e1-167.e11DOI: (10.1016/j.jaad.2009.10.047) Copyright © 2010 American Academy of Dermatology, Inc. Terms and Conditions

Fig 20 Proposed algorithm for evaluation of LLE. Journal of the American Academy of Dermatology 2011 64, 167.e1-167.e11DOI: (10.1016/j.jaad.2009.10.047) Copyright © 2010 American Academy of Dermatology, Inc. Terms and Conditions

Fig 21 Proposed algorithm for evaluation of PLE. Journal of the American Academy of Dermatology 2011 64, 167.e1-167.e11DOI: (10.1016/j.jaad.2009.10.047) Copyright © 2010 American Academy of Dermatology, Inc. Terms and Conditions