1. CASE CONFERENCE: Nail Disorders KAREN ESTRELLA 05/12/2010

2. Do you check the nails of your patients?

3. History 3y/o M seen at SBC for 1 st WCC -no acute concerns except for: changes in nail bed of left 2 nd nail for 1 year

4. Normal nail EMBRIOLOGY: – starts to develop at 10-11 wks – keratinizes from 15 wk – fully formed by birth

5. Normal nail ANATOMY:

6. Consult DERMATOLOGY: Dark linear, uniform, well demarcated linear ban along the nail bed, involving proximal nail fold Melanonichia striata

7. What is melanonychia? Tan, brown or black pigmentation from the proximal nail fold and cuticle to the free distal end of the nail plate – Usually affects 1 or 2 digits Due to: melanocyte activation (physiologic), benign melanocyte hyperplasia (nevi), or melanoma. Most common in african-american or hispanics

8. Melanonychia etiology: benign LOCAL – Trauma – Radiation – Nail bitting – Foreign body – Infection Single bands SYSTEMIC – Addison, Cushing, Hyperthyroidism, – Hemosiderosis – Alcaptonuria – Psoriasis – LES, scleroderma – Malnutrition Multiple bands

9. Melanonychia etiology: iatrogenic CHEMOTHERAPY – Metotrexatem – Bleomycin – Doxorubicin – Ciclophosphamide – 5-fluoruracil OTHERS – Steroids, – Ibuprofen – Phenytoin – Zidovudine, lamivudine – Ketokonazole, fluconazole

10. Melanonychia etiology: malignancy Age: adults Brown-black band greater than 3 mm Change in nail band morphology despite treatment Digit involved: The thumb is more likely to be affected by subungual melanoma than the great toe; the great toe is more likely than the index finger to be affected by subungual melanoma. Extension onto the adjacent cuticle and proximal and/or lateral nail folds (Hutchinson sign) Family or personal history of dysplastic nevus or melanoma

11. Melanonychia work-up Dermatoscopic evaluation: – Of the free edge of nail bed

12. Melanonychia: Dermatoscopic evaluation continued

13. Melanonychia: work-up continued Nail bed Sampling: – Punch bx: 3mm, from proximal matrix Risk of permanent nail dystrophy – Nail-shave bx : 4-6mm, central portion of nail bed – lateral-longitudinal – If suspicion for subungueal melanoma: full thickness

14. Melanonychia Treatment Tx of underlying condition Removal of agent If melanoma: complete removal of hyperpigmented section

15. OTHER NAIL DISORDERS

16. Congenital disorders: ( Ectodermal defects) ANONYCHIA – Associated with nail-patella sd., deafness PACHONYCHIA – Associated with: hyperhidrosis, leukokeratosis: TM, cornea, mucosas

17. Congenital disorders continued HYPOPLASTIC – Phenytoin – Warfarin – Fetal alcohol syndrome

18. Associated with systemic disorders CLUBBING – hypoxic stages KOILONYCHIA (spoon nails) – Iron deficiency

19. Associated with systemic disorders HALF & HALF NAILS – liver, kidney failure SPLINTER HEMORRHAGES – endocarditis RIDGING-TRANSVERSE LINES - malnourishment

20. Acquired nail disorders: infection PARONYCHIA – Red, tender, swelling of prox or lateral fold Acute: S. aureus Chronic: Candida albincans ONYCHOMYCOSIS -yellowish, brittle -Unusual before puberty - Systemic antifungal tx

21. Acquired nail disorders: dystrophy (distortion, discoloration) TRAUMA – Subungual hematoma PSORIASIS

22. Acquired nail disorders: dystrophy continued TRACHYONYCHIA (Twenty nail dystrophy) – School children – Yellow or gray color nails, (+) pitting, friable – Progresses in 6-18 months, self-limited – Some cases associated with alopecia areata, atopic dermatitis

23. Thank you : )

24. References Cohen, B. pediatric Dermatology. Mosby LTD, Spain: 1999. pg 201-208 www.dermaimaging.com/?cat=39 http://www.ncbi.nlm.nih.gov/pubmed/10411404 http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0365- 05962009000200013&lng=en&nrm=iso>. ISSN 0365-0596. doi: 10.1590/S0365-05962009000200013. http://emedicine.medscape.com/article/1375850-overview http://www.medscape.com/viewarticle/718695_7