Hair & Nails

The importance of early diagnosis and proper treatment for tinea capitis cannot be overstated, given the psychosocial impact of permanent baldness in children and the substantially reduced overall quality of health, reported Aditya K. Gupta, MD, PhD, of Mediprobe Research and the University of Toronto, and his associates.

In a systematic review of both randomized, controlled trials and clinical trials published before June 1, 2017, the authors sought to identify differences between treatment medications and significant adverse side effects, and to evaluate the most effective methods for diagnosis. The study criteria included trials with clinical and mycologic diagnosis of tinea capitis, evaluation of efficacy rates and/or safety measures in participants aged 18 years or younger, yielded a total of 4,190 studies in this article published in Pediatric Dermatology.

Courtesy RegionalDerm.com

Adverse events

Altogether, 295 drug-related adverse effects were reported: 51.2% from terbinafine, 26.8% from griseofulvin, 12.2% from fluconazole, 8.5% from itraconazole, and 1.4% from ketoconazole; all were transient and mild to moderate in severity.

Of the total population observed, just 50 children (1.3% of 3,998) ceased treatment because of adverse effects of the medication.
 

Therapy choices

Of the 75 antifungal treatment combinations identified, cure rates were highest with continuous itraconazole and terbinafine (mycologic), griseofulvin and terbinafine (clinical), and griseofulvin and terbinafine (complete). Griseofulvin was more effective at treating Microsporum than Trichophyton infections, fluconazole was comparably effective in treating both Microsporum and Trichophyton infections, and continuous itraconazole and terbinafine were more effective at curing Trichophyton infections than Microsporum, noted Dr. Gupta and his associates.

Terbinafine treatment for Trichophyton infections was found to be effective at just 4 weeks, however, oral terbinafine was singularly responsible for more than half of adverse events reported. The authors suggested that this might be from its extensive biodistribution. In such cases, the authors recommended baseline monitoring of transaminase.

Although griseofulvin is the most widely prescribed medication for pediatric tinea capitis, primarily because of its cost effectiveness and accessibility, a 2016 Cochrane review found that newer treatments – terbinafine, itraconazole and fluconazole – offer comparative effectiveness in cases of Trichophyton infection. The relatively higher cost of these treatments and the prevalence of tinea capitis in lower socioeconomic populations, however, may render them impractical, the authors noted. As recent clinical trials have suggested significantly larger, weight-normalized doses are required in children to approximate the exposure estimates of adults, this should be of key consideration when choosing appropriate, cost-effective treatments.
 

Diagnostic issues

T. tonsurans cases of tinea capitis are most prevalent in North America, and recent data suggest they are on the rise. The organism typically infects human skin and hair, and can to survive for lengthy periods on inanimate objects, including combs, brushes, sheets, and blankets. Researchers credit the growing number of cases in North America to several factors. Infections from the fungus have become increasingly common in the United States and Canada as a consequence of changing travel and immigration patterns. In addition, many physicians still turn to fluorescence (Wood’s light examination) in diagnosing tinea capitis, but T. tonsurans does not show up with fluorescence and typically does not present with the classic black dots characteristic of other fungal species. As a result, many cases in North America are misdiagnosed as seborrhea, dandruff, and impetigo, and subsequently undertreated, leading to spread of the infection. It was noted that more than half of the included studies used some form of Wood’s light examination.

Of all the techniques addressed, microscopy was found to be the fastest, but not always the most accurate, means of diagnosing tinea capitis. Dr. Gupta and his associates advised that diagnosis confirmation and precise species identification is best obtained with cultured scrapings, but this process can take 3 weeks or longer.

While fomites and hair care practices play a key role in tinea capitis infection, large family size, crowded living conditions, and low socioeconomic status are predisposing factors. Those who come in contact with infected patients should be considered possible asymptomatic carriers and be evaluated accordingly for treatment and to prevent spread of infection, the authors advised. Furthermore, recent studies recognized the impracticality of isolating children recently treated with oral therapy from classrooms since shedding of spores can continue for months.

The researchers had no relevant financial disclosures to report.

SOURCE: Gupta AK et al. Ped Dermatol. 2018 May 24. doi: 10.1111/jdv.15088.

The importance of early diagnosis and proper treatment for tinea capitis cannot be overstated, given the psychosocial impact of permanent baldness in children and the substantially reduced overall quality of health, reported Aditya K. Gupta, MD, PhD, of Mediprobe Research and the University of Toronto, and his associates.

In a systematic review of both randomized, controlled trials and clinical trials published before June 1, 2017, the authors sought to identify differences between treatment medications and significant adverse side effects, and to evaluate the most effective methods for diagnosis. The study criteria included trials with clinical and mycologic diagnosis of tinea capitis, evaluation of efficacy rates and/or safety measures in participants aged 18 years or younger, yielded a total of 4,190 studies in this article published in Pediatric Dermatology.

Courtesy RegionalDerm.com

Adverse events

Altogether, 295 drug-related adverse effects were reported: 51.2% from terbinafine, 26.8% from griseofulvin, 12.2% from fluconazole, 8.5% from itraconazole, and 1.4% from ketoconazole; all were transient and mild to moderate in severity.

Of the total population observed, just 50 children (1.3% of 3,998) ceased treatment because of adverse effects of the medication.
 

Therapy choices

Of the 75 antifungal treatment combinations identified, cure rates were highest with continuous itraconazole and terbinafine (mycologic), griseofulvin and terbinafine (clinical), and griseofulvin and terbinafine (complete). Griseofulvin was more effective at treating Microsporum than Trichophyton infections, fluconazole was comparably effective in treating both Microsporum and Trichophyton infections, and continuous itraconazole and terbinafine were more effective at curing Trichophyton infections than Microsporum, noted Dr. Gupta and his associates.

Terbinafine treatment for Trichophyton infections was found to be effective at just 4 weeks, however, oral terbinafine was singularly responsible for more than half of adverse events reported. The authors suggested that this might be from its extensive biodistribution. In such cases, the authors recommended baseline monitoring of transaminase.

Although griseofulvin is the most widely prescribed medication for pediatric tinea capitis, primarily because of its cost effectiveness and accessibility, a 2016 Cochrane review found that newer treatments – terbinafine, itraconazole and fluconazole – offer comparative effectiveness in cases of Trichophyton infection. The relatively higher cost of these treatments and the prevalence of tinea capitis in lower socioeconomic populations, however, may render them impractical, the authors noted. As recent clinical trials have suggested significantly larger, weight-normalized doses are required in children to approximate the exposure estimates of adults, this should be of key consideration when choosing appropriate, cost-effective treatments.
 

Diagnostic issues

T. tonsurans cases of tinea capitis are most prevalent in North America, and recent data suggest they are on the rise. The organism typically infects human skin and hair, and can to survive for lengthy periods on inanimate objects, including combs, brushes, sheets, and blankets. Researchers credit the growing number of cases in North America to several factors. Infections from the fungus have become increasingly common in the United States and Canada as a consequence of changing travel and immigration patterns. In addition, many physicians still turn to fluorescence (Wood’s light examination) in diagnosing tinea capitis, but T. tonsurans does not show up with fluorescence and typically does not present with the classic black dots characteristic of other fungal species. As a result, many cases in North America are misdiagnosed as seborrhea, dandruff, and impetigo, and subsequently undertreated, leading to spread of the infection. It was noted that more than half of the included studies used some form of Wood’s light examination.

Of all the techniques addressed, microscopy was found to be the fastest, but not always the most accurate, means of diagnosing tinea capitis. Dr. Gupta and his associates advised that diagnosis confirmation and precise species identification is best obtained with cultured scrapings, but this process can take 3 weeks or longer.

While fomites and hair care practices play a key role in tinea capitis infection, large family size, crowded living conditions, and low socioeconomic status are predisposing factors. Those who come in contact with infected patients should be considered possible asymptomatic carriers and be evaluated accordingly for treatment and to prevent spread of infection, the authors advised. Furthermore, recent studies recognized the impracticality of isolating children recently treated with oral therapy from classrooms since shedding of spores can continue for months.

The researchers had no relevant financial disclosures to report.

SOURCE: Gupta AK et al. Ped Dermatol. 2018 May 24. doi: 10.1111/jdv.15088.

The importance of early diagnosis and proper treatment for tinea capitis cannot be overstated, given the psychosocial impact of permanent baldness in children and the substantially reduced overall quality of health, reported Aditya K. Gupta, MD, PhD, of Mediprobe Research and the University of Toronto, and his associates.

In a systematic review of both randomized, controlled trials and clinical trials published before June 1, 2017, the authors sought to identify differences between treatment medications and significant adverse side effects, and to evaluate the most effective methods for diagnosis. The study criteria included trials with clinical and mycologic diagnosis of tinea capitis, evaluation of efficacy rates and/or safety measures in participants aged 18 years or younger, yielded a total of 4,190 studies in this article published in Pediatric Dermatology.

Courtesy RegionalDerm.com

Adverse events

Altogether, 295 drug-related adverse effects were reported: 51.2% from terbinafine, 26.8% from griseofulvin, 12.2% from fluconazole, 8.5% from itraconazole, and 1.4% from ketoconazole; all were transient and mild to moderate in severity.

Of the total population observed, just 50 children (1.3% of 3,998) ceased treatment because of adverse effects of the medication.
 

Therapy choices

Of the 75 antifungal treatment combinations identified, cure rates were highest with continuous itraconazole and terbinafine (mycologic), griseofulvin and terbinafine (clinical), and griseofulvin and terbinafine (complete). Griseofulvin was more effective at treating Microsporum than Trichophyton infections, fluconazole was comparably effective in treating both Microsporum and Trichophyton infections, and continuous itraconazole and terbinafine were more effective at curing Trichophyton infections than Microsporum, noted Dr. Gupta and his associates.

Terbinafine treatment for Trichophyton infections was found to be effective at just 4 weeks, however, oral terbinafine was singularly responsible for more than half of adverse events reported. The authors suggested that this might be from its extensive biodistribution. In such cases, the authors recommended baseline monitoring of transaminase.

Although griseofulvin is the most widely prescribed medication for pediatric tinea capitis, primarily because of its cost effectiveness and accessibility, a 2016 Cochrane review found that newer treatments – terbinafine, itraconazole and fluconazole – offer comparative effectiveness in cases of Trichophyton infection. The relatively higher cost of these treatments and the prevalence of tinea capitis in lower socioeconomic populations, however, may render them impractical, the authors noted. As recent clinical trials have suggested significantly larger, weight-normalized doses are required in children to approximate the exposure estimates of adults, this should be of key consideration when choosing appropriate, cost-effective treatments.
 

Diagnostic issues

T. tonsurans cases of tinea capitis are most prevalent in North America, and recent data suggest they are on the rise. The organism typically infects human skin and hair, and can to survive for lengthy periods on inanimate objects, including combs, brushes, sheets, and blankets. Researchers credit the growing number of cases in North America to several factors. Infections from the fungus have become increasingly common in the United States and Canada as a consequence of changing travel and immigration patterns. In addition, many physicians still turn to fluorescence (Wood’s light examination) in diagnosing tinea capitis, but T. tonsurans does not show up with fluorescence and typically does not present with the classic black dots characteristic of other fungal species. As a result, many cases in North America are misdiagnosed as seborrhea, dandruff, and impetigo, and subsequently undertreated, leading to spread of the infection. It was noted that more than half of the included studies used some form of Wood’s light examination.

Of all the techniques addressed, microscopy was found to be the fastest, but not always the most accurate, means of diagnosing tinea capitis. Dr. Gupta and his associates advised that diagnosis confirmation and precise species identification is best obtained with cultured scrapings, but this process can take 3 weeks or longer.

While fomites and hair care practices play a key role in tinea capitis infection, large family size, crowded living conditions, and low socioeconomic status are predisposing factors. Those who come in contact with infected patients should be considered possible asymptomatic carriers and be evaluated accordingly for treatment and to prevent spread of infection, the authors advised. Furthermore, recent studies recognized the impracticality of isolating children recently treated with oral therapy from classrooms since shedding of spores can continue for months.

The researchers had no relevant financial disclosures to report.

SOURCE: Gupta AK et al. Ped Dermatol. 2018 May 24. doi: 10.1111/jdv.15088.

CHICAGO – Ropivacaine has a fast onset of action, longer duration than either lidocaine or bupivacaine, and it’s the only one of the three that’s inherently vasoconstrictive. For Brienne Cressey, MD, those features make ropivacaine the local anesthetic of choice in performing nail surgery.

“Local anesthesia is really key for nail surgery. If you don’t have good anesthesia it’s not a good experience for either the surgeon or the patient,” she observed at the annual meeting of the American College of Mohs Surgery.

Bruce Jancin/MDedge News

“With lidocaine, you get a lot of blood right after you take off your tourniquet. With ropivacaine, you get really nice reperfusion, but it’s not too much. You take off the tourniquet, check to see you’ve got reperfusion, then you add a little ropivacaine – about 0.5 mL – on either side of the base of the distal phalanx. It stops the bleeding immediately and you can easily put on a pressure dressing. It’s a nice way to get the patient over the hump of those first hours of pain and lets them drive home in comfort,” explained Dr. Cressey, a dermatologist working in a group practice at Dermatology Professionals in East Greenwich, R.I.

Ropivacaine is less cardiotoxic than bupivacaine. And ropivacaine offers an additional advantage: Its pH is such that no buffering is necessary. “Ropivacaine doesn’t require any compounding. You can just use it at 1% straight out of the bottle. That’s what we do in our office, and we’ve had very good experience with it,” according to the dermatologist.

Achieving smooth sailing with local anesthesia

Dr. Cressey delivers ropivacaine slowly through a 30-gauge needle, which makes for a smaller, less painful puncture. She utilizes a topical cold spray, and places a vibrating machine as a distractant proximal to where she is injecting. She keeps the anesthetic at room temperature or warms it to body temperature in a water bath as another means of reducing the pain of injection.

The distal digital block

This is a cross between a traditional proximal digital block and a wing block. It works well for the second, third, and fourth digits, which are mostly volar dominant. The block bathes the volar nerve branch in anesthesia at the midline of the finger or toe.

Dr. Cressey begins by injecting ropivacaine proximal and lateral to the junction of the proximal nail fold and lateral nail fold. After creating a dermal wheal, she directs her needle perpendicularly downward toward the finger or toe pad, injecting 1-4 mL of anesthesia, depending upon digit size. Visible blanching will progress digitally. If resistance is encountered, it suggests the needle has penetrated a ligament or other fibrous tissue. Simply withdraw the needle and continue injecting.

“What’s nice about the distal digital block is you get an immediate effect, and there’s good hemostasis during the procedure as well,” she said.

Dr. Cressey reported no financial conflicts regarding her presentation.

[email protected]

CHICAGO – Ropivacaine has a fast onset of action, longer duration than either lidocaine or bupivacaine, and it’s the only one of the three that’s inherently vasoconstrictive. For Brienne Cressey, MD, those features make ropivacaine the local anesthetic of choice in performing nail surgery.

“Local anesthesia is really key for nail surgery. If you don’t have good anesthesia it’s not a good experience for either the surgeon or the patient,” she observed at the annual meeting of the American College of Mohs Surgery.

Bruce Jancin/MDedge News

“With lidocaine, you get a lot of blood right after you take off your tourniquet. With ropivacaine, you get really nice reperfusion, but it’s not too much. You take off the tourniquet, check to see you’ve got reperfusion, then you add a little ropivacaine – about 0.5 mL – on either side of the base of the distal phalanx. It stops the bleeding immediately and you can easily put on a pressure dressing. It’s a nice way to get the patient over the hump of those first hours of pain and lets them drive home in comfort,” explained Dr. Cressey, a dermatologist working in a group practice at Dermatology Professionals in East Greenwich, R.I.

Ropivacaine is less cardiotoxic than bupivacaine. And ropivacaine offers an additional advantage: Its pH is such that no buffering is necessary. “Ropivacaine doesn’t require any compounding. You can just use it at 1% straight out of the bottle. That’s what we do in our office, and we’ve had very good experience with it,” according to the dermatologist.

Achieving smooth sailing with local anesthesia

Dr. Cressey delivers ropivacaine slowly through a 30-gauge needle, which makes for a smaller, less painful puncture. She utilizes a topical cold spray, and places a vibrating machine as a distractant proximal to where she is injecting. She keeps the anesthetic at room temperature or warms it to body temperature in a water bath as another means of reducing the pain of injection.

The distal digital block

This is a cross between a traditional proximal digital block and a wing block. It works well for the second, third, and fourth digits, which are mostly volar dominant. The block bathes the volar nerve branch in anesthesia at the midline of the finger or toe.

Dr. Cressey begins by injecting ropivacaine proximal and lateral to the junction of the proximal nail fold and lateral nail fold. After creating a dermal wheal, she directs her needle perpendicularly downward toward the finger or toe pad, injecting 1-4 mL of anesthesia, depending upon digit size. Visible blanching will progress digitally. If resistance is encountered, it suggests the needle has penetrated a ligament or other fibrous tissue. Simply withdraw the needle and continue injecting.

“What’s nice about the distal digital block is you get an immediate effect, and there’s good hemostasis during the procedure as well,” she said.

Dr. Cressey reported no financial conflicts regarding her presentation.

[email protected]

CHICAGO – Ropivacaine has a fast onset of action, longer duration than either lidocaine or bupivacaine, and it’s the only one of the three that’s inherently vasoconstrictive. For Brienne Cressey, MD, those features make ropivacaine the local anesthetic of choice in performing nail surgery.

“Local anesthesia is really key for nail surgery. If you don’t have good anesthesia it’s not a good experience for either the surgeon or the patient,” she observed at the annual meeting of the American College of Mohs Surgery.

Bruce Jancin/MDedge News

“With lidocaine, you get a lot of blood right after you take off your tourniquet. With ropivacaine, you get really nice reperfusion, but it’s not too much. You take off the tourniquet, check to see you’ve got reperfusion, then you add a little ropivacaine – about 0.5 mL – on either side of the base of the distal phalanx. It stops the bleeding immediately and you can easily put on a pressure dressing. It’s a nice way to get the patient over the hump of those first hours of pain and lets them drive home in comfort,” explained Dr. Cressey, a dermatologist working in a group practice at Dermatology Professionals in East Greenwich, R.I.

Ropivacaine is less cardiotoxic than bupivacaine. And ropivacaine offers an additional advantage: Its pH is such that no buffering is necessary. “Ropivacaine doesn’t require any compounding. You can just use it at 1% straight out of the bottle. That’s what we do in our office, and we’ve had very good experience with it,” according to the dermatologist.

Achieving smooth sailing with local anesthesia

Dr. Cressey delivers ropivacaine slowly through a 30-gauge needle, which makes for a smaller, less painful puncture. She utilizes a topical cold spray, and places a vibrating machine as a distractant proximal to where she is injecting. She keeps the anesthetic at room temperature or warms it to body temperature in a water bath as another means of reducing the pain of injection.

The distal digital block

This is a cross between a traditional proximal digital block and a wing block. It works well for the second, third, and fourth digits, which are mostly volar dominant. The block bathes the volar nerve branch in anesthesia at the midline of the finger or toe.

Dr. Cressey begins by injecting ropivacaine proximal and lateral to the junction of the proximal nail fold and lateral nail fold. After creating a dermal wheal, she directs her needle perpendicularly downward toward the finger or toe pad, injecting 1-4 mL of anesthesia, depending upon digit size. Visible blanching will progress digitally. If resistance is encountered, it suggests the needle has penetrated a ligament or other fibrous tissue. Simply withdraw the needle and continue injecting.

“What’s nice about the distal digital block is you get an immediate effect, and there’s good hemostasis during the procedure as well,” she said.

Dr. Cressey reported no financial conflicts regarding her presentation.

[email protected]

A new analysis of 18 hair products used by black women finds that they contain 45 endocrine-disrupting or asthma-associated chemicals, a finding that could help explain why this population suffers from higher rates of chemical exposure and hormone-related health conditions.

“We found multiples of our targeted chemicals in all of our products,” said study lead author Jessica S. Helm, PhD, of the Silent Spring Institute, Newton, Mass., in an interview. “We’re concerned about the additive effect of multiple products being used together.”

[email protected]

SOURCE: Helm JS et al. Environ Res. 2018 Apr 25. doi: 10.1016/j.envres.2018.03.030.

A new analysis of 18 hair products used by black women finds that they contain 45 endocrine-disrupting or asthma-associated chemicals, a finding that could help explain why this population suffers from higher rates of chemical exposure and hormone-related health conditions.

“We found multiples of our targeted chemicals in all of our products,” said study lead author Jessica S. Helm, PhD, of the Silent Spring Institute, Newton, Mass., in an interview. “We’re concerned about the additive effect of multiple products being used together.”

[email protected]

SOURCE: Helm JS et al. Environ Res. 2018 Apr 25. doi: 10.1016/j.envres.2018.03.030.

A new analysis of 18 hair products used by black women finds that they contain 45 endocrine-disrupting or asthma-associated chemicals, a finding that could help explain why this population suffers from higher rates of chemical exposure and hormone-related health conditions.

“We found multiples of our targeted chemicals in all of our products,” said study lead author Jessica S. Helm, PhD, of the Silent Spring Institute, Newton, Mass., in an interview. “We’re concerned about the additive effect of multiple products being used together.”

[email protected]

SOURCE: Helm JS et al. Environ Res. 2018 Apr 25. doi: 10.1016/j.envres.2018.03.030.

Case Report

A 62-year-old black man presented for examination of a dark longitudinal streak located adjacent to the lateral nail fold on the third finger of the left hand. The lesion had been present for several months, during which time it had slowly expanded in size. The fingertip had recently become tender, which interfered with the patient’s ability to work. His past medical history was remarkable for end-stage renal disease secondary to glomerulonephritis with nephrotic syndrome of unclear etiology. He initially was treated by an outside physician using peritoneal dialysis for 3 years until he underwent renal transplantation in 2004 with a cadaveric organ. Other remarkable medical conditions included posttransplantation diabetes, hyperlipidemia, and gout. His multidrug regimen included 2 immunosuppressive medications: oral cyclosporine 125 mg twice daily and oral mycophenolate mofetil 250 mg twice daily.

A broad, irregular, black, pigmented, subungual band was noted on the left third finger. The lesion appeared to emanate from below the nail cuticle and traveled along the nail longitudinally toward the distal tip. The band appeared darker at the edge adjacent to the lateral nail fold and grew lighter near the middle of the nail where its free edge was noted to be irregular. A slightly thickened lateral nail fold with an irregular, small, sawtoothlike hyperkeratosis and hyperpigmentation also was noted (Figure 1).

Subungual melanoma, onychomycosis, squamous cell carcinoma (SCC), and a verruca copresenting with onychomycosis were considered in the differential diagnosis. The patient underwent nail avulsion and biopsy of the nail bed as well as the nail matrix. Histopathology was notable for malignant dyskeratosis with a lack of nuclear maturation, occasional mitoses, multinucleation, and individual cell keratinization (Figure 2). Immunostaining for S100 was negative, while staining for cytokeratins AE1/AE3 was positive. Deposition of melanin pigment in the malignant dyskeratotic cells was noted. Periodic acid–Schiff staining identified pseudohyphae without invasion of the nail plate. A diagnosis of pigmented SCC (pSCC) was made. The patient’s nail also was sent for fungal cultures that later grew Candida glabrata and Candida parapsilosis.

The patient underwent Mohs micrographic surgery for removal of the pSCC, which was found to be more extensive than originally suspected and required en bloc excision of the nail repaired with a full-thickness skin graft from the left forearm. The area healed well with some hyperpigmentation (Figure 3).

Comment

Among the various types of skin cancer, an estimated 700,000 patients are diagnosed with SCC annually, making it the second most common form of skin cancer in the United States.¹ Basal cell carcinoma (BCC) is the most common skin cancer among whites in the United States, while in contrast SCC is the most common skin cancer in patients with skin of color.² Only an estimated 2% to 5% of all SCCs are pigmented, and this variant is more commonly seen in patients with skin of color.^3-5 One analysis of 52 cases of pSCC showed that common features included a flat or slightly raised appearance and hyperpigmentation with varying levels of scaling.⁶ Studies have shown an altered presentation of pSCC in black skin with increased melanin production and thickness of the stratum corneum in contrast with cases seen in white patients.⁷ Other potential features include scaling, erosive changes, and sharply demarcated borders. Squamous cell carcinoma typically occurs in sun-exposed areas, reflecting its association with UV light damage; however, SCC in skin of color patients has been noted to occur in sun-protected areas and in areas of chronic scarring.⁸ Pigmented SCC also appears to follow this distribution, as affected areas are not necessarily in direct exposure to the sun. Pigmented SCCs have been associated with pruritus and/or burning pain, which also was seen in our case when our patient complained of tenderness at the site.

We describe the case of a subungual pSCC clinically presenting as longitudinal melanonychia. Pigmented SCC presenting as longitudinal melanonychia was first described by Baran and Simon in 1988.⁹ Since that time, it has been reported that approximately 10% of subungual pSCCs clinically present as longitudinal melanonychia.^10,11 A retrospective study reviewing 35 cases of SCC of the nail apparatus found that 5 (14.3%) cases presented as longitudinal melanonychia.¹⁰ Another retrospective study found that 6 of 51 (11.8%) cases of SCCs affecting the nail unit presented as the warty type of SCC in association with longitudinal melanonychia.¹² Cases of pSCC in situ appearing as longitudinal melanonychia also have been reported.^13,14

Risk factors for the development of pSCC include advanced age, male sex, presence of human papilloma virus, and use of immunosuppressants.¹⁵ Male predominance and advanced age at the time of diagnosis (mean age, 67 years) have been observed in pSCC cases.¹⁶ It is now well established that renal transplant recipients have an increased risk of SCC, with a reported incidence rate of 5% to 6%.¹⁶ When these patients develop an SCC, they typically follow a more aggressive course. Renal transplantation has a higher ratio than cardiac transplantation for SCC development (2.37:1), whereas cardiac transplantation is associated with a higher risk of BCC development.¹⁷ A study of 384 transplant recipients found that 96 (25.0%) had a postsurgical nonmelanoma skin cancer (NMSC), with a ratio of SCC to BCC of 1.2:1.¹⁶ The calculated incidence of NMSC at 10 and 20 years posttransplantation was 24.2% and 54.4%, respectively. Another study also determined that SCC rates (50.0%) in postrenal transplant recipients were approximately twice that of BCC (27.0%).¹⁸

A daily regimen of immunosuppressive medications such as cyclosporine and mycophenolate mofetil showed an increased risk for development of NMSC.¹⁵ Immunosuppressive medications play an important role in the pathogenesis of SCC due to a direct oncogenic effect as well as impairment of the immune system’s ability to fight precancerous developments.¹⁵ A 4-year study of 100 renal transplant recipients using mycophenolate mofetil as part of an immunosuppressive regimen reported 22% NMSC findings among 9 patients.¹⁹ On average, patients developed an NMSC approximately 61 months posttransplantation, with a wide range from 2 to 120 months.

Advanced age was another important risk factor, with each decade of life producing a 60% increase in instantaneous risk of SCC development for transplant recipients.¹⁵ A steady increase in risk was related to the length of time adhering to an immunosuppressive regimen, especially from 2 to 6 years, and then remaining constant in subsequent years. For older patients on immunosuppressant regimens for more than 8 years, the calculated relative risk was noted to be over 200 times greater than the normal population’s development of skin cancers.¹⁸

Conclusion

Although cases of pSCC presenting as longitudinal melanonychia have previously been reported,^9-14,20 our case is unique in that it describes pSCC in a renal transplant recipient. Our patient had many of the known risk factors for the development of pSCC including male sex, advanced age, skin of color, history of renal transplantation, and immunosuppressive therapy. Although regular full-body skin examinations are an accepted part of renal transplantation follow-up due to SCC risk, our case emphasizes the need to remain vigilant due to possible atypical presentations among the immunosuppressed. The nail unit should not be overlooked during the clinical examination of renal transplant recipients as demonstrated by our patient’s rare presentation of pSCC in the nail.

Case Report

A 62-year-old black man presented for examination of a dark longitudinal streak located adjacent to the lateral nail fold on the third finger of the left hand. The lesion had been present for several months, during which time it had slowly expanded in size. The fingertip had recently become tender, which interfered with the patient’s ability to work. His past medical history was remarkable for end-stage renal disease secondary to glomerulonephritis with nephrotic syndrome of unclear etiology. He initially was treated by an outside physician using peritoneal dialysis for 3 years until he underwent renal transplantation in 2004 with a cadaveric organ. Other remarkable medical conditions included posttransplantation diabetes, hyperlipidemia, and gout. His multidrug regimen included 2 immunosuppressive medications: oral cyclosporine 125 mg twice daily and oral mycophenolate mofetil 250 mg twice daily.

A broad, irregular, black, pigmented, subungual band was noted on the left third finger. The lesion appeared to emanate from below the nail cuticle and traveled along the nail longitudinally toward the distal tip. The band appeared darker at the edge adjacent to the lateral nail fold and grew lighter near the middle of the nail where its free edge was noted to be irregular. A slightly thickened lateral nail fold with an irregular, small, sawtoothlike hyperkeratosis and hyperpigmentation also was noted (Figure 1).

Subungual melanoma, onychomycosis, squamous cell carcinoma (SCC), and a verruca copresenting with onychomycosis were considered in the differential diagnosis. The patient underwent nail avulsion and biopsy of the nail bed as well as the nail matrix. Histopathology was notable for malignant dyskeratosis with a lack of nuclear maturation, occasional mitoses, multinucleation, and individual cell keratinization (Figure 2). Immunostaining for S100 was negative, while staining for cytokeratins AE1/AE3 was positive. Deposition of melanin pigment in the malignant dyskeratotic cells was noted. Periodic acid–Schiff staining identified pseudohyphae without invasion of the nail plate. A diagnosis of pigmented SCC (pSCC) was made. The patient’s nail also was sent for fungal cultures that later grew Candida glabrata and Candida parapsilosis.

The patient underwent Mohs micrographic surgery for removal of the pSCC, which was found to be more extensive than originally suspected and required en bloc excision of the nail repaired with a full-thickness skin graft from the left forearm. The area healed well with some hyperpigmentation (Figure 3).

Comment

Among the various types of skin cancer, an estimated 700,000 patients are diagnosed with SCC annually, making it the second most common form of skin cancer in the United States.¹ Basal cell carcinoma (BCC) is the most common skin cancer among whites in the United States, while in contrast SCC is the most common skin cancer in patients with skin of color.² Only an estimated 2% to 5% of all SCCs are pigmented, and this variant is more commonly seen in patients with skin of color.^3-5 One analysis of 52 cases of pSCC showed that common features included a flat or slightly raised appearance and hyperpigmentation with varying levels of scaling.⁶ Studies have shown an altered presentation of pSCC in black skin with increased melanin production and thickness of the stratum corneum in contrast with cases seen in white patients.⁷ Other potential features include scaling, erosive changes, and sharply demarcated borders. Squamous cell carcinoma typically occurs in sun-exposed areas, reflecting its association with UV light damage; however, SCC in skin of color patients has been noted to occur in sun-protected areas and in areas of chronic scarring.⁸ Pigmented SCC also appears to follow this distribution, as affected areas are not necessarily in direct exposure to the sun. Pigmented SCCs have been associated with pruritus and/or burning pain, which also was seen in our case when our patient complained of tenderness at the site.

We describe the case of a subungual pSCC clinically presenting as longitudinal melanonychia. Pigmented SCC presenting as longitudinal melanonychia was first described by Baran and Simon in 1988.⁹ Since that time, it has been reported that approximately 10% of subungual pSCCs clinically present as longitudinal melanonychia.^10,11 A retrospective study reviewing 35 cases of SCC of the nail apparatus found that 5 (14.3%) cases presented as longitudinal melanonychia.¹⁰ Another retrospective study found that 6 of 51 (11.8%) cases of SCCs affecting the nail unit presented as the warty type of SCC in association with longitudinal melanonychia.¹² Cases of pSCC in situ appearing as longitudinal melanonychia also have been reported.^13,14

Risk factors for the development of pSCC include advanced age, male sex, presence of human papilloma virus, and use of immunosuppressants.¹⁵ Male predominance and advanced age at the time of diagnosis (mean age, 67 years) have been observed in pSCC cases.¹⁶ It is now well established that renal transplant recipients have an increased risk of SCC, with a reported incidence rate of 5% to 6%.¹⁶ When these patients develop an SCC, they typically follow a more aggressive course. Renal transplantation has a higher ratio than cardiac transplantation for SCC development (2.37:1), whereas cardiac transplantation is associated with a higher risk of BCC development.¹⁷ A study of 384 transplant recipients found that 96 (25.0%) had a postsurgical nonmelanoma skin cancer (NMSC), with a ratio of SCC to BCC of 1.2:1.¹⁶ The calculated incidence of NMSC at 10 and 20 years posttransplantation was 24.2% and 54.4%, respectively. Another study also determined that SCC rates (50.0%) in postrenal transplant recipients were approximately twice that of BCC (27.0%).¹⁸

A daily regimen of immunosuppressive medications such as cyclosporine and mycophenolate mofetil showed an increased risk for development of NMSC.¹⁵ Immunosuppressive medications play an important role in the pathogenesis of SCC due to a direct oncogenic effect as well as impairment of the immune system’s ability to fight precancerous developments.¹⁵ A 4-year study of 100 renal transplant recipients using mycophenolate mofetil as part of an immunosuppressive regimen reported 22% NMSC findings among 9 patients.¹⁹ On average, patients developed an NMSC approximately 61 months posttransplantation, with a wide range from 2 to 120 months.

Advanced age was another important risk factor, with each decade of life producing a 60% increase in instantaneous risk of SCC development for transplant recipients.¹⁵ A steady increase in risk was related to the length of time adhering to an immunosuppressive regimen, especially from 2 to 6 years, and then remaining constant in subsequent years. For older patients on immunosuppressant regimens for more than 8 years, the calculated relative risk was noted to be over 200 times greater than the normal population’s development of skin cancers.¹⁸

Conclusion

Although cases of pSCC presenting as longitudinal melanonychia have previously been reported,^9-14,20 our case is unique in that it describes pSCC in a renal transplant recipient. Our patient had many of the known risk factors for the development of pSCC including male sex, advanced age, skin of color, history of renal transplantation, and immunosuppressive therapy. Although regular full-body skin examinations are an accepted part of renal transplantation follow-up due to SCC risk, our case emphasizes the need to remain vigilant due to possible atypical presentations among the immunosuppressed. The nail unit should not be overlooked during the clinical examination of renal transplant recipients as demonstrated by our patient’s rare presentation of pSCC in the nail.

Case Report

A 62-year-old black man presented for examination of a dark longitudinal streak located adjacent to the lateral nail fold on the third finger of the left hand. The lesion had been present for several months, during which time it had slowly expanded in size. The fingertip had recently become tender, which interfered with the patient’s ability to work. His past medical history was remarkable for end-stage renal disease secondary to glomerulonephritis with nephrotic syndrome of unclear etiology. He initially was treated by an outside physician using peritoneal dialysis for 3 years until he underwent renal transplantation in 2004 with a cadaveric organ. Other remarkable medical conditions included posttransplantation diabetes, hyperlipidemia, and gout. His multidrug regimen included 2 immunosuppressive medications: oral cyclosporine 125 mg twice daily and oral mycophenolate mofetil 250 mg twice daily.

A broad, irregular, black, pigmented, subungual band was noted on the left third finger. The lesion appeared to emanate from below the nail cuticle and traveled along the nail longitudinally toward the distal tip. The band appeared darker at the edge adjacent to the lateral nail fold and grew lighter near the middle of the nail where its free edge was noted to be irregular. A slightly thickened lateral nail fold with an irregular, small, sawtoothlike hyperkeratosis and hyperpigmentation also was noted (Figure 1).

Subungual melanoma, onychomycosis, squamous cell carcinoma (SCC), and a verruca copresenting with onychomycosis were considered in the differential diagnosis. The patient underwent nail avulsion and biopsy of the nail bed as well as the nail matrix. Histopathology was notable for malignant dyskeratosis with a lack of nuclear maturation, occasional mitoses, multinucleation, and individual cell keratinization (Figure 2). Immunostaining for S100 was negative, while staining for cytokeratins AE1/AE3 was positive. Deposition of melanin pigment in the malignant dyskeratotic cells was noted. Periodic acid–Schiff staining identified pseudohyphae without invasion of the nail plate. A diagnosis of pigmented SCC (pSCC) was made. The patient’s nail also was sent for fungal cultures that later grew Candida glabrata and Candida parapsilosis.

The patient underwent Mohs micrographic surgery for removal of the pSCC, which was found to be more extensive than originally suspected and required en bloc excision of the nail repaired with a full-thickness skin graft from the left forearm. The area healed well with some hyperpigmentation (Figure 3).

Comment

Among the various types of skin cancer, an estimated 700,000 patients are diagnosed with SCC annually, making it the second most common form of skin cancer in the United States.¹ Basal cell carcinoma (BCC) is the most common skin cancer among whites in the United States, while in contrast SCC is the most common skin cancer in patients with skin of color.² Only an estimated 2% to 5% of all SCCs are pigmented, and this variant is more commonly seen in patients with skin of color.^3-5 One analysis of 52 cases of pSCC showed that common features included a flat or slightly raised appearance and hyperpigmentation with varying levels of scaling.⁶ Studies have shown an altered presentation of pSCC in black skin with increased melanin production and thickness of the stratum corneum in contrast with cases seen in white patients.⁷ Other potential features include scaling, erosive changes, and sharply demarcated borders. Squamous cell carcinoma typically occurs in sun-exposed areas, reflecting its association with UV light damage; however, SCC in skin of color patients has been noted to occur in sun-protected areas and in areas of chronic scarring.⁸ Pigmented SCC also appears to follow this distribution, as affected areas are not necessarily in direct exposure to the sun. Pigmented SCCs have been associated with pruritus and/or burning pain, which also was seen in our case when our patient complained of tenderness at the site.

We describe the case of a subungual pSCC clinically presenting as longitudinal melanonychia. Pigmented SCC presenting as longitudinal melanonychia was first described by Baran and Simon in 1988.⁹ Since that time, it has been reported that approximately 10% of subungual pSCCs clinically present as longitudinal melanonychia.^10,11 A retrospective study reviewing 35 cases of SCC of the nail apparatus found that 5 (14.3%) cases presented as longitudinal melanonychia.¹⁰ Another retrospective study found that 6 of 51 (11.8%) cases of SCCs affecting the nail unit presented as the warty type of SCC in association with longitudinal melanonychia.¹² Cases of pSCC in situ appearing as longitudinal melanonychia also have been reported.^13,14

Risk factors for the development of pSCC include advanced age, male sex, presence of human papilloma virus, and use of immunosuppressants.¹⁵ Male predominance and advanced age at the time of diagnosis (mean age, 67 years) have been observed in pSCC cases.¹⁶ It is now well established that renal transplant recipients have an increased risk of SCC, with a reported incidence rate of 5% to 6%.¹⁶ When these patients develop an SCC, they typically follow a more aggressive course. Renal transplantation has a higher ratio than cardiac transplantation for SCC development (2.37:1), whereas cardiac transplantation is associated with a higher risk of BCC development.¹⁷ A study of 384 transplant recipients found that 96 (25.0%) had a postsurgical nonmelanoma skin cancer (NMSC), with a ratio of SCC to BCC of 1.2:1.¹⁶ The calculated incidence of NMSC at 10 and 20 years posttransplantation was 24.2% and 54.4%, respectively. Another study also determined that SCC rates (50.0%) in postrenal transplant recipients were approximately twice that of BCC (27.0%).¹⁸

A daily regimen of immunosuppressive medications such as cyclosporine and mycophenolate mofetil showed an increased risk for development of NMSC.¹⁵ Immunosuppressive medications play an important role in the pathogenesis of SCC due to a direct oncogenic effect as well as impairment of the immune system’s ability to fight precancerous developments.¹⁵ A 4-year study of 100 renal transplant recipients using mycophenolate mofetil as part of an immunosuppressive regimen reported 22% NMSC findings among 9 patients.¹⁹ On average, patients developed an NMSC approximately 61 months posttransplantation, with a wide range from 2 to 120 months.

Advanced age was another important risk factor, with each decade of life producing a 60% increase in instantaneous risk of SCC development for transplant recipients.¹⁵ A steady increase in risk was related to the length of time adhering to an immunosuppressive regimen, especially from 2 to 6 years, and then remaining constant in subsequent years. For older patients on immunosuppressant regimens for more than 8 years, the calculated relative risk was noted to be over 200 times greater than the normal population’s development of skin cancers.¹⁸

Conclusion

Although cases of pSCC presenting as longitudinal melanonychia have previously been reported,^9-14,20 our case is unique in that it describes pSCC in a renal transplant recipient. Our patient had many of the known risk factors for the development of pSCC including male sex, advanced age, skin of color, history of renal transplantation, and immunosuppressive therapy. Although regular full-body skin examinations are an accepted part of renal transplantation follow-up due to SCC risk, our case emphasizes the need to remain vigilant due to possible atypical presentations among the immunosuppressed. The nail unit should not be overlooked during the clinical examination of renal transplant recipients as demonstrated by our patient’s rare presentation of pSCC in the nail.

DALLAS – A picosecond 755-nm laser with focus lens array can serve as a safe, nonsurgical option for neck rejuvenation in patients with Fitzpatrick skin types I-III, especially for those who seek treatments with minimal downtime.

“It’s important to note that response was variable, but many patients were satisfied with the treatment,” Hana Jeon, MD said at the annual conference of the American Society for Laser Medicine and Surgery, Inc. “Further studies are needed to identify the clinical characteristics of neck laxity that would most benefit from this treatment.”

Hana Jeon, MD

Dr. Jeon reported that the average pain score during the procedure was 4.7 on a 10-point scale. Forced-air cooling was used for comfort, and on average, mild redness following the treatment lasted less than 1 day (a mean of 0.6 days, with a range of 0-5 days). Mild pain also lasted less than 1 day (a mean of 0.1 days, with a range of 0-2 days). No swelling, crusting, bruising, bleeding, infection, blistering, scarring, burn, or dyspigmentation occurred.

Hana Jeon, MD

At 3 months, 35% of patients said they would be “somewhat likely” to recommend the procedure, and 30% said they would be “extremely likely” to recommend it.

Dr. Jeon reported having no financial disclosures.

[email protected]

DALLAS – A picosecond 755-nm laser with focus lens array can serve as a safe, nonsurgical option for neck rejuvenation in patients with Fitzpatrick skin types I-III, especially for those who seek treatments with minimal downtime.

“It’s important to note that response was variable, but many patients were satisfied with the treatment,” Hana Jeon, MD said at the annual conference of the American Society for Laser Medicine and Surgery, Inc. “Further studies are needed to identify the clinical characteristics of neck laxity that would most benefit from this treatment.”

Hana Jeon, MD

Dr. Jeon reported that the average pain score during the procedure was 4.7 on a 10-point scale. Forced-air cooling was used for comfort, and on average, mild redness following the treatment lasted less than 1 day (a mean of 0.6 days, with a range of 0-5 days). Mild pain also lasted less than 1 day (a mean of 0.1 days, with a range of 0-2 days). No swelling, crusting, bruising, bleeding, infection, blistering, scarring, burn, or dyspigmentation occurred.

Hana Jeon, MD

At 3 months, 35% of patients said they would be “somewhat likely” to recommend the procedure, and 30% said they would be “extremely likely” to recommend it.

Dr. Jeon reported having no financial disclosures.

[email protected]

DALLAS – A picosecond 755-nm laser with focus lens array can serve as a safe, nonsurgical option for neck rejuvenation in patients with Fitzpatrick skin types I-III, especially for those who seek treatments with minimal downtime.

“It’s important to note that response was variable, but many patients were satisfied with the treatment,” Hana Jeon, MD said at the annual conference of the American Society for Laser Medicine and Surgery, Inc. “Further studies are needed to identify the clinical characteristics of neck laxity that would most benefit from this treatment.”

Hana Jeon, MD

Dr. Jeon reported that the average pain score during the procedure was 4.7 on a 10-point scale. Forced-air cooling was used for comfort, and on average, mild redness following the treatment lasted less than 1 day (a mean of 0.6 days, with a range of 0-5 days). Mild pain also lasted less than 1 day (a mean of 0.1 days, with a range of 0-2 days). No swelling, crusting, bruising, bleeding, infection, blistering, scarring, burn, or dyspigmentation occurred.

Hana Jeon, MD

At 3 months, 35% of patients said they would be “somewhat likely” to recommend the procedure, and 30% said they would be “extremely likely” to recommend it.

Dr. Jeon reported having no financial disclosures.

[email protected]

Hydroxychloroquine could be beneficial as a treatment option for children with alopecia areata (AA), according to Duri Yun, MD, of the University of Chicago Medicine, and associates.

In a retrospective review published in Pediatric Dermatology, nine children aged 6-16 years with AA and diverse ethnicities were treated with hydroxychloroquine between July 1, 2013, and July 1, 2015; all had failed multiple previous treatment modalities. In patient 1, hydroxychloroquine therapy was initiated, fine hair regrowth occurred after 5 months of therapy and was maintained, with dosage tapered to 200 mg once daily after 1 year. After 2 years of therapy, hair had nearly completely regrown. Similar results occurred in patient 2, who had nearly complete hair loss within 2 weeks of initiating hydroxychloroquine. Steady regrowth continued to near-complete regrowth after 1 year of treatment, when dosage was tapered to 200 mg once daily.

Abbassyma/Wikimedia Commons/Public Domain

[email protected]

SOURCE: Yun D et al., Pediatr Dermatol. 2018 Mar 25. doi: 10.1111/pde.13451.

Hydroxychloroquine could be beneficial as a treatment option for children with alopecia areata (AA), according to Duri Yun, MD, of the University of Chicago Medicine, and associates.

In a retrospective review published in Pediatric Dermatology, nine children aged 6-16 years with AA and diverse ethnicities were treated with hydroxychloroquine between July 1, 2013, and July 1, 2015; all had failed multiple previous treatment modalities. In patient 1, hydroxychloroquine therapy was initiated, fine hair regrowth occurred after 5 months of therapy and was maintained, with dosage tapered to 200 mg once daily after 1 year. After 2 years of therapy, hair had nearly completely regrown. Similar results occurred in patient 2, who had nearly complete hair loss within 2 weeks of initiating hydroxychloroquine. Steady regrowth continued to near-complete regrowth after 1 year of treatment, when dosage was tapered to 200 mg once daily.

Abbassyma/Wikimedia Commons/Public Domain

[email protected]

SOURCE: Yun D et al., Pediatr Dermatol. 2018 Mar 25. doi: 10.1111/pde.13451.

Hydroxychloroquine could be beneficial as a treatment option for children with alopecia areata (AA), according to Duri Yun, MD, of the University of Chicago Medicine, and associates.

In a retrospective review published in Pediatric Dermatology, nine children aged 6-16 years with AA and diverse ethnicities were treated with hydroxychloroquine between July 1, 2013, and July 1, 2015; all had failed multiple previous treatment modalities. In patient 1, hydroxychloroquine therapy was initiated, fine hair regrowth occurred after 5 months of therapy and was maintained, with dosage tapered to 200 mg once daily after 1 year. After 2 years of therapy, hair had nearly completely regrown. Similar results occurred in patient 2, who had nearly complete hair loss within 2 weeks of initiating hydroxychloroquine. Steady regrowth continued to near-complete regrowth after 1 year of treatment, when dosage was tapered to 200 mg once daily.

Abbassyma/Wikimedia Commons/Public Domain

[email protected]

SOURCE: Yun D et al., Pediatr Dermatol. 2018 Mar 25. doi: 10.1111/pde.13451.

Pediatric alopecia areata (AA) is more likely to affect girls, but boys are likely to have more severe types of the disorder, reported Iris Wohlmuth-Wieser, MD, of the department of dermatology, MD Anderson Cancer Center, Houston, and her associates, who conducted a large review of U.S. registry data.

Although it is the third most common dermatosis in children, there are not much data on AA in children, so the researchers used information from the National Alopecia Areata Registry, which was established in 2000. First, interested patients and parents were contacted and asked to fill out a web-based screening questionnaire. In the second phase, they were asked to fill out a more extensive survey and visit one of five U.S. sites for a clinical exam by a dermatologist.

Of the 2,218 children and teens who completed the initial questionnaire, the mean age at the time of the survey was 10 years, and their mean age of onset of AA was 6 years. The female to male ratio was 1.5:1; boys were significantly more likely to have severe types of AA (P = .009). Most patients (70%) were white, followed by mixed ethnicity (11%), Hispanic (3%), and then other ethnicities. About 3% of patients said they had a sibling with AA, 14% said that another first-degree relative had AA, and 8% said that at least three first-degree relatives had AA.

In terms of the degree of hair loss, 45% lost all scalp hair, 31% lost all body hair, and 14% lost all nails.

Concomitant diseases were reported by 47% of the responders, with atopic dermatitis, asthma, hay fever, and allergies the most common.

Of the 643 children and teens who completed a more detailed questionnaire and underwent clinical examination, 63% were female; 26% had at least one relative with AA and 8% had at least three first-degree relatives with AA. Almost 4% had congenital AA.

At the physical exam, there were data on the amount of hair loss in 617 children: Of these children, 37% had lost all scalp hair and 19% had lost up to three-quarters of their scalp hair. In 618 children (in whom information on body hair loss was obtained at the physical exam), 72% lost all or some of their body hair. Information on nails was available in 609 children; in this group, 44% had some nail involvement. More detailed information was available in 290 children; in this group, findings included pitting in 86%, dystrophy in 10%, onycholysis in 2%, ridging in 1%, and onychomycosis in 1%.

Commenting on the 25 children who presented with congenital AA, the authors wrote that this is “an extremely rare and infrequently reported form of AA.

“This is an interesting and important finding, because AA has traditionally been described as an acquired disease,” they added.

In their cohort overall, 25% had a family history of AA, with 8% having more than three first-degree relatives with AA. The researchers said that the percentage of children with AA and a positive family history ranges from 8% to 52% in the literature.

“The predominant presentation of AA types in our cohort (61.4%) was severe hair loss (76%-100% of scalp hair loss). This is comparable with a European study reporting a prevalence of 65%. Other studies on childhood AA conducted in Asian and Arab populations observed mainly mild cases,” they wrote.

Nail involvement, often reported with AA, was evident in 39% of patients who completed the questionnaire online and in 44% on physical exam. This agreed with the 26%-40% involvement reported in the literature.

There were no conflicts of interest or funding information reported.

SOURCE: Wohlmuth-Wieser I et al. Pediatr Dermatol. 2018 Jan 15. doi: 10.1111/pde.13387.

Pediatric alopecia areata (AA) is more likely to affect girls, but boys are likely to have more severe types of the disorder, reported Iris Wohlmuth-Wieser, MD, of the department of dermatology, MD Anderson Cancer Center, Houston, and her associates, who conducted a large review of U.S. registry data.

Although it is the third most common dermatosis in children, there are not much data on AA in children, so the researchers used information from the National Alopecia Areata Registry, which was established in 2000. First, interested patients and parents were contacted and asked to fill out a web-based screening questionnaire. In the second phase, they were asked to fill out a more extensive survey and visit one of five U.S. sites for a clinical exam by a dermatologist.

Of the 2,218 children and teens who completed the initial questionnaire, the mean age at the time of the survey was 10 years, and their mean age of onset of AA was 6 years. The female to male ratio was 1.5:1; boys were significantly more likely to have severe types of AA (P = .009). Most patients (70%) were white, followed by mixed ethnicity (11%), Hispanic (3%), and then other ethnicities. About 3% of patients said they had a sibling with AA, 14% said that another first-degree relative had AA, and 8% said that at least three first-degree relatives had AA.

In terms of the degree of hair loss, 45% lost all scalp hair, 31% lost all body hair, and 14% lost all nails.

Concomitant diseases were reported by 47% of the responders, with atopic dermatitis, asthma, hay fever, and allergies the most common.

Of the 643 children and teens who completed a more detailed questionnaire and underwent clinical examination, 63% were female; 26% had at least one relative with AA and 8% had at least three first-degree relatives with AA. Almost 4% had congenital AA.

At the physical exam, there were data on the amount of hair loss in 617 children: Of these children, 37% had lost all scalp hair and 19% had lost up to three-quarters of their scalp hair. In 618 children (in whom information on body hair loss was obtained at the physical exam), 72% lost all or some of their body hair. Information on nails was available in 609 children; in this group, 44% had some nail involvement. More detailed information was available in 290 children; in this group, findings included pitting in 86%, dystrophy in 10%, onycholysis in 2%, ridging in 1%, and onychomycosis in 1%.

Commenting on the 25 children who presented with congenital AA, the authors wrote that this is “an extremely rare and infrequently reported form of AA.

“This is an interesting and important finding, because AA has traditionally been described as an acquired disease,” they added.

In their cohort overall, 25% had a family history of AA, with 8% having more than three first-degree relatives with AA. The researchers said that the percentage of children with AA and a positive family history ranges from 8% to 52% in the literature.

“The predominant presentation of AA types in our cohort (61.4%) was severe hair loss (76%-100% of scalp hair loss). This is comparable with a European study reporting a prevalence of 65%. Other studies on childhood AA conducted in Asian and Arab populations observed mainly mild cases,” they wrote.

Nail involvement, often reported with AA, was evident in 39% of patients who completed the questionnaire online and in 44% on physical exam. This agreed with the 26%-40% involvement reported in the literature.

There were no conflicts of interest or funding information reported.

SOURCE: Wohlmuth-Wieser I et al. Pediatr Dermatol. 2018 Jan 15. doi: 10.1111/pde.13387.

Pediatric alopecia areata (AA) is more likely to affect girls, but boys are likely to have more severe types of the disorder, reported Iris Wohlmuth-Wieser, MD, of the department of dermatology, MD Anderson Cancer Center, Houston, and her associates, who conducted a large review of U.S. registry data.

Although it is the third most common dermatosis in children, there are not much data on AA in children, so the researchers used information from the National Alopecia Areata Registry, which was established in 2000. First, interested patients and parents were contacted and asked to fill out a web-based screening questionnaire. In the second phase, they were asked to fill out a more extensive survey and visit one of five U.S. sites for a clinical exam by a dermatologist.

Of the 2,218 children and teens who completed the initial questionnaire, the mean age at the time of the survey was 10 years, and their mean age of onset of AA was 6 years. The female to male ratio was 1.5:1; boys were significantly more likely to have severe types of AA (P = .009). Most patients (70%) were white, followed by mixed ethnicity (11%), Hispanic (3%), and then other ethnicities. About 3% of patients said they had a sibling with AA, 14% said that another first-degree relative had AA, and 8% said that at least three first-degree relatives had AA.

In terms of the degree of hair loss, 45% lost all scalp hair, 31% lost all body hair, and 14% lost all nails.

Concomitant diseases were reported by 47% of the responders, with atopic dermatitis, asthma, hay fever, and allergies the most common.

Of the 643 children and teens who completed a more detailed questionnaire and underwent clinical examination, 63% were female; 26% had at least one relative with AA and 8% had at least three first-degree relatives with AA. Almost 4% had congenital AA.

At the physical exam, there were data on the amount of hair loss in 617 children: Of these children, 37% had lost all scalp hair and 19% had lost up to three-quarters of their scalp hair. In 618 children (in whom information on body hair loss was obtained at the physical exam), 72% lost all or some of their body hair. Information on nails was available in 609 children; in this group, 44% had some nail involvement. More detailed information was available in 290 children; in this group, findings included pitting in 86%, dystrophy in 10%, onycholysis in 2%, ridging in 1%, and onychomycosis in 1%.

Commenting on the 25 children who presented with congenital AA, the authors wrote that this is “an extremely rare and infrequently reported form of AA.

“This is an interesting and important finding, because AA has traditionally been described as an acquired disease,” they added.

In their cohort overall, 25% had a family history of AA, with 8% having more than three first-degree relatives with AA. The researchers said that the percentage of children with AA and a positive family history ranges from 8% to 52% in the literature.

“The predominant presentation of AA types in our cohort (61.4%) was severe hair loss (76%-100% of scalp hair loss). This is comparable with a European study reporting a prevalence of 65%. Other studies on childhood AA conducted in Asian and Arab populations observed mainly mild cases,” they wrote.

Nail involvement, often reported with AA, was evident in 39% of patients who completed the questionnaire online and in 44% on physical exam. This agreed with the 26%-40% involvement reported in the literature.

There were no conflicts of interest or funding information reported.

SOURCE: Wohlmuth-Wieser I et al. Pediatr Dermatol. 2018 Jan 15. doi: 10.1111/pde.13387.

When longitudinal melanonychia appears as a sharply demarcated pigment band of even width against normal nail in a child, Hutchinson’s sign with longitudinal brushy pigmentation may be a useful clinical pattern suggesting a diagnosis of nail matrix nevus rather than subungual melanoma, said Jae Ho Lee, MD, of Sungkyunkwan University, Seoul, South Korea, and associates.

In a study of biopsy-proven nail matrix nevi (NMN) in 20 children and 8 adults, average melanonychia width was 3.5 times greater in children than in adults, with 14 children having melanonychia greater than 20% the width of the nail, compared with 2 adults. Total melanonychia occurred just twice, in two children. A total of 12 children had nail dystrophy, while none of the adults did; nail dystrophy was more frequent in wider lesions.

Hutchinson’s sign was seen in seven pediatric patients, but no adult patients. In most cases, Hutchinson’s sign had hyponychial pigmentation, and on dermoscopy showed a pigment pattern presenting longitudinally and resembling a brush mark (longitudinal brushy pigmentation or LBP). LBP of nail matrix nevi is different from the Hutchinson’s sign that occurs in subungual melanoma (SUM), where it is typically a “haphazard pigmentation pattern involving periungual skin.

“We propose that Hutchinson’s sign occurs more commonly in pediatric NMN than in adult NMN, and that the presence of the LBP pattern can help distinguish pediatric NMN from SUM,” the investigators said.

Histologically, the biopsies of the NMN in this study showed some important differences from known SUM histology. All the study biopsies “showed a melanocytic proliferation exhibiting a predominantly nested growth pattern, with the nests mostly located at the dermoepithelial junction and with retraction artifact surrounding the nests. There were variable nuclear hyperchromatism, nuclear sizes, and cytologic atypia within the NMN biopsy specimens,” the researchers said. “In contrast, the histology of SUM demonstrates a predominance of atypical single melanocytes over nests, retraction artifacts around individual melanocytes, and uniform atypia of melanocytes throughout the biopsy specimen.”

SOURCE: Lee JH et al. J Am Acad Dermatol. 2018 Mar;78(3):479-89.

When longitudinal melanonychia appears as a sharply demarcated pigment band of even width against normal nail in a child, Hutchinson’s sign with longitudinal brushy pigmentation may be a useful clinical pattern suggesting a diagnosis of nail matrix nevus rather than subungual melanoma, said Jae Ho Lee, MD, of Sungkyunkwan University, Seoul, South Korea, and associates.

In a study of biopsy-proven nail matrix nevi (NMN) in 20 children and 8 adults, average melanonychia width was 3.5 times greater in children than in adults, with 14 children having melanonychia greater than 20% the width of the nail, compared with 2 adults. Total melanonychia occurred just twice, in two children. A total of 12 children had nail dystrophy, while none of the adults did; nail dystrophy was more frequent in wider lesions.

Hutchinson’s sign was seen in seven pediatric patients, but no adult patients. In most cases, Hutchinson’s sign had hyponychial pigmentation, and on dermoscopy showed a pigment pattern presenting longitudinally and resembling a brush mark (longitudinal brushy pigmentation or LBP). LBP of nail matrix nevi is different from the Hutchinson’s sign that occurs in subungual melanoma (SUM), where it is typically a “haphazard pigmentation pattern involving periungual skin.

“We propose that Hutchinson’s sign occurs more commonly in pediatric NMN than in adult NMN, and that the presence of the LBP pattern can help distinguish pediatric NMN from SUM,” the investigators said.

Histologically, the biopsies of the NMN in this study showed some important differences from known SUM histology. All the study biopsies “showed a melanocytic proliferation exhibiting a predominantly nested growth pattern, with the nests mostly located at the dermoepithelial junction and with retraction artifact surrounding the nests. There were variable nuclear hyperchromatism, nuclear sizes, and cytologic atypia within the NMN biopsy specimens,” the researchers said. “In contrast, the histology of SUM demonstrates a predominance of atypical single melanocytes over nests, retraction artifacts around individual melanocytes, and uniform atypia of melanocytes throughout the biopsy specimen.”

SOURCE: Lee JH et al. J Am Acad Dermatol. 2018 Mar;78(3):479-89.

When longitudinal melanonychia appears as a sharply demarcated pigment band of even width against normal nail in a child, Hutchinson’s sign with longitudinal brushy pigmentation may be a useful clinical pattern suggesting a diagnosis of nail matrix nevus rather than subungual melanoma, said Jae Ho Lee, MD, of Sungkyunkwan University, Seoul, South Korea, and associates.

In a study of biopsy-proven nail matrix nevi (NMN) in 20 children and 8 adults, average melanonychia width was 3.5 times greater in children than in adults, with 14 children having melanonychia greater than 20% the width of the nail, compared with 2 adults. Total melanonychia occurred just twice, in two children. A total of 12 children had nail dystrophy, while none of the adults did; nail dystrophy was more frequent in wider lesions.

Hutchinson’s sign was seen in seven pediatric patients, but no adult patients. In most cases, Hutchinson’s sign had hyponychial pigmentation, and on dermoscopy showed a pigment pattern presenting longitudinally and resembling a brush mark (longitudinal brushy pigmentation or LBP). LBP of nail matrix nevi is different from the Hutchinson’s sign that occurs in subungual melanoma (SUM), where it is typically a “haphazard pigmentation pattern involving periungual skin.

“We propose that Hutchinson’s sign occurs more commonly in pediatric NMN than in adult NMN, and that the presence of the LBP pattern can help distinguish pediatric NMN from SUM,” the investigators said.

Histologically, the biopsies of the NMN in this study showed some important differences from known SUM histology. All the study biopsies “showed a melanocytic proliferation exhibiting a predominantly nested growth pattern, with the nests mostly located at the dermoepithelial junction and with retraction artifact surrounding the nests. There were variable nuclear hyperchromatism, nuclear sizes, and cytologic atypia within the NMN biopsy specimens,” the researchers said. “In contrast, the histology of SUM demonstrates a predominance of atypical single melanocytes over nests, retraction artifacts around individual melanocytes, and uniform atypia of melanocytes throughout the biopsy specimen.”

SOURCE: Lee JH et al. J Am Acad Dermatol. 2018 Mar;78(3):479-89.

REPORTING FROM AAD 18

SAN DIEGO – Several device-based therapies are currently being evaluated as treatments for onychomycosis.

These include photodynamic therapy, which has been studied in two clinical trials and case series, Shari Lipner, MD, PhD, said in a video interview at the annual meeting of the American Academy of Dermatology, where she presented on this topic.

“Something that we’re looking at is plasma treatment of onychomycosis basically using ionized gas,” which has been shown to inhibit the growth of Trichophyton rubrum in vitro, added Dr. Lipner of the department of dermatology, Cornell University, New York.

In a pilot study of 19 patients with onychomycosis, she and her associates found that the clinical cure with nonthermal plasma was about 50% and the mycological cure rate was 15%, “and we’re now trying to improve efficacy using this device,” she said (Clin Exp Dermatol. 2017 Apr;42[3]:295-8). With a dielectric insulator, “nonthermal plasma is created by short pulses (about 10 ns) of strong (about 20 kV/mm peak) electric field that ionizes air molecules, creating ions and electrons, as well as ozone, hydroxyl radicals and nitric oxide,” according to the description in the study.

Other device-based therapies include iontophoresis, using electrical currents to increase drug delivery, and creating small punch biopsies or using a device to create “microholes” in the nails to increase delivery of topical medication across the nail, Dr. Lipner said.

Patients often ask about another device-based treatment, laser therapy, which she pointed out is not approved by the Food and Drug Administration for cure, but for a temporary increase in clear nail in patients with onychomycosis, “very different” than the criteria used for topical and systemic medications, making it difficult to compare efficacy data between lasers and medications, she noted.

Dr. Lipner reported receiving grants/research funding from MOE Medical Devices.

[email protected]

REPORTING FROM AAD 18

SAN DIEGO – Several device-based therapies are currently being evaluated as treatments for onychomycosis.

These include photodynamic therapy, which has been studied in two clinical trials and case series, Shari Lipner, MD, PhD, said in a video interview at the annual meeting of the American Academy of Dermatology, where she presented on this topic.

“Something that we’re looking at is plasma treatment of onychomycosis basically using ionized gas,” which has been shown to inhibit the growth of Trichophyton rubrum in vitro, added Dr. Lipner of the department of dermatology, Cornell University, New York.

In a pilot study of 19 patients with onychomycosis, she and her associates found that the clinical cure with nonthermal plasma was about 50% and the mycological cure rate was 15%, “and we’re now trying to improve efficacy using this device,” she said (Clin Exp Dermatol. 2017 Apr;42[3]:295-8). With a dielectric insulator, “nonthermal plasma is created by short pulses (about 10 ns) of strong (about 20 kV/mm peak) electric field that ionizes air molecules, creating ions and electrons, as well as ozone, hydroxyl radicals and nitric oxide,” according to the description in the study.

Other device-based therapies include iontophoresis, using electrical currents to increase drug delivery, and creating small punch biopsies or using a device to create “microholes” in the nails to increase delivery of topical medication across the nail, Dr. Lipner said.

Patients often ask about another device-based treatment, laser therapy, which she pointed out is not approved by the Food and Drug Administration for cure, but for a temporary increase in clear nail in patients with onychomycosis, “very different” than the criteria used for topical and systemic medications, making it difficult to compare efficacy data between lasers and medications, she noted.

Dr. Lipner reported receiving grants/research funding from MOE Medical Devices.

[email protected]

REPORTING FROM AAD 18

SAN DIEGO – Several device-based therapies are currently being evaluated as treatments for onychomycosis.

These include photodynamic therapy, which has been studied in two clinical trials and case series, Shari Lipner, MD, PhD, said in a video interview at the annual meeting of the American Academy of Dermatology, where she presented on this topic.

“Something that we’re looking at is plasma treatment of onychomycosis basically using ionized gas,” which has been shown to inhibit the growth of Trichophyton rubrum in vitro, added Dr. Lipner of the department of dermatology, Cornell University, New York.

In a pilot study of 19 patients with onychomycosis, she and her associates found that the clinical cure with nonthermal plasma was about 50% and the mycological cure rate was 15%, “and we’re now trying to improve efficacy using this device,” she said (Clin Exp Dermatol. 2017 Apr;42[3]:295-8). With a dielectric insulator, “nonthermal plasma is created by short pulses (about 10 ns) of strong (about 20 kV/mm peak) electric field that ionizes air molecules, creating ions and electrons, as well as ozone, hydroxyl radicals and nitric oxide,” according to the description in the study.

Other device-based therapies include iontophoresis, using electrical currents to increase drug delivery, and creating small punch biopsies or using a device to create “microholes” in the nails to increase delivery of topical medication across the nail, Dr. Lipner said.

Patients often ask about another device-based treatment, laser therapy, which she pointed out is not approved by the Food and Drug Administration for cure, but for a temporary increase in clear nail in patients with onychomycosis, “very different” than the criteria used for topical and systemic medications, making it difficult to compare efficacy data between lasers and medications, she noted.

Dr. Lipner reported receiving grants/research funding from MOE Medical Devices.

[email protected]

What does your patient need to know at the first visit?

Risk factors for onychomycosis include prior trauma, history of tinea pedis, sports activities, frequenting gyms and pools, hyperhidrosis, advancing age, diabetes mellitus, immunosuppression, smoking, and family history of onychomycosis. Toenails are involved more frequently than fingernails, and typical physical examination findings are distal and lateral nail plate onycholysis with subungual hyperkeratosis. In more severe cases, there may be nail plate thickening, crumbling, yellowing, and involvement of the nail matrix.

Because other nail conditions may resemble onychomycosis, it is imperative to confirm the diagnosis using histopathology, direct microscopy, fungal culture, and/or polymerase chain reaction on nail plate clippings or subungual debris. 

What are your go-to treatments? What are the side effects?

After laboratory confirmation, assess the patient for the severity of the infection based on the surface area of nail plate affected, nail plate thickness, involvement of the nail matrix, and number of nails affected. United States Food and Drug Administration-approved oral and topical antifungals are used first line for the treatment of onychomycosis. Devices such as lasers are approved by the US Food and Drug Administration for temporary cosmetic improvement in the appearance of the nail without eradicating the fungus.

Oral antifungals such as terbinafine, itraconazole, and fluconazole (off label) are indicated for patients with severe disease. Patients with mild to moderate disease may benefit from oral or topical antifungals such as efinaconazole, tavaborole, or ciclopirox.

I recommend terbinafine to many of my patients due to its high complete and mycological cure rates, short list of drug-drug interactions, and low incidence of side effects. Adverse reactions are uncommon, with the most common being gastrointestinal upset. While liver injury has been reported, it is exceedingly rare. Itraconazole has many important drug interactions and is contraindicated in patients with congestive heart failure. With topical antifungals, side effects are uncommon, but dermatitis, ingrown nails, and vesicles may occur.

How do you keep patients compliant with treatment?

Patients on a 3-month course of daily oral terbinafine or itraconazole for toenail onychomycosis are typically highly compliant. Compliance for patients on oral fluconazole (off label) is generally more challenging because it is dosed weekly until the nail grows out (1-1.5 years for toenails). To circumvent missed fluconazole doses, I recommend that the patient schedule quarterly visits with me and also to set a cell phone alarm as a weekly reminder to take the medication.

Because topical medications are prescribed for the toenails for a year-long course (with avoidance of nail polish during this period), I prescribe topical antifungals only to highly motivated patients. In addition, because topical antifungals are retained in the nail plate for at least several days after a month-long application, I tell my patients that if they have a big event to attend that they can take a vacation from the topical antifungal, get a pedicure, and then resume treatment after the event. 

What do you do if they refuse treatment?

In 2018, we have many options to treat onychomycosis effectively, and therapy is individualized based on the patient's severity of disease, infecting organism(s), comorbidities, concomitant medications, and preferences. If the patient's fungal nail infection is asymptomatic and not aesthetically bothersome, he/she may opt for observation rather than treatment. If the decision is observation, I recommend use of a topical antifungal on the feet and web spaces to prevent worsening of onychomycosis. 

Suggested Readings

Gupta AK, Versteeg SG. A critical review of improvement rates for laser therapy used to treat toenail onychomycosis. J Eur Acad Dermatol Venereol. 2017;31:1111-1118.

Lipner SR, Scher RK. Long-standing onychodystrophy in a young woman. JAMA. 2016;316:1915-1916.

Lipner SR, Scher RK. Onychomycosis--a small step for quality of care. Curr Med Res Opin. 2016;32:865-867.

Lipner SR, Scher RK. Onychomycosis: current and investigational therapies. Cutis. 2014;94:E21-E24.

What does your patient need to know at the first visit?

Risk factors for onychomycosis include prior trauma, history of tinea pedis, sports activities, frequenting gyms and pools, hyperhidrosis, advancing age, diabetes mellitus, immunosuppression, smoking, and family history of onychomycosis. Toenails are involved more frequently than fingernails, and typical physical examination findings are distal and lateral nail plate onycholysis with subungual hyperkeratosis. In more severe cases, there may be nail plate thickening, crumbling, yellowing, and involvement of the nail matrix.

Because other nail conditions may resemble onychomycosis, it is imperative to confirm the diagnosis using histopathology, direct microscopy, fungal culture, and/or polymerase chain reaction on nail plate clippings or subungual debris. 

What are your go-to treatments? What are the side effects?

After laboratory confirmation, assess the patient for the severity of the infection based on the surface area of nail plate affected, nail plate thickness, involvement of the nail matrix, and number of nails affected. United States Food and Drug Administration-approved oral and topical antifungals are used first line for the treatment of onychomycosis. Devices such as lasers are approved by the US Food and Drug Administration for temporary cosmetic improvement in the appearance of the nail without eradicating the fungus.

Oral antifungals such as terbinafine, itraconazole, and fluconazole (off label) are indicated for patients with severe disease. Patients with mild to moderate disease may benefit from oral or topical antifungals such as efinaconazole, tavaborole, or ciclopirox.

I recommend terbinafine to many of my patients due to its high complete and mycological cure rates, short list of drug-drug interactions, and low incidence of side effects. Adverse reactions are uncommon, with the most common being gastrointestinal upset. While liver injury has been reported, it is exceedingly rare. Itraconazole has many important drug interactions and is contraindicated in patients with congestive heart failure. With topical antifungals, side effects are uncommon, but dermatitis, ingrown nails, and vesicles may occur.

How do you keep patients compliant with treatment?

Patients on a 3-month course of daily oral terbinafine or itraconazole for toenail onychomycosis are typically highly compliant. Compliance for patients on oral fluconazole (off label) is generally more challenging because it is dosed weekly until the nail grows out (1-1.5 years for toenails). To circumvent missed fluconazole doses, I recommend that the patient schedule quarterly visits with me and also to set a cell phone alarm as a weekly reminder to take the medication.

Because topical medications are prescribed for the toenails for a year-long course (with avoidance of nail polish during this period), I prescribe topical antifungals only to highly motivated patients. In addition, because topical antifungals are retained in the nail plate for at least several days after a month-long application, I tell my patients that if they have a big event to attend that they can take a vacation from the topical antifungal, get a pedicure, and then resume treatment after the event. 

What do you do if they refuse treatment?

In 2018, we have many options to treat onychomycosis effectively, and therapy is individualized based on the patient's severity of disease, infecting organism(s), comorbidities, concomitant medications, and preferences. If the patient's fungal nail infection is asymptomatic and not aesthetically bothersome, he/she may opt for observation rather than treatment. If the decision is observation, I recommend use of a topical antifungal on the feet and web spaces to prevent worsening of onychomycosis. 

Suggested Readings

Gupta AK, Versteeg SG. A critical review of improvement rates for laser therapy used to treat toenail onychomycosis. J Eur Acad Dermatol Venereol. 2017;31:1111-1118.

Lipner SR, Scher RK. Long-standing onychodystrophy in a young woman. JAMA. 2016;316:1915-1916.

Lipner SR, Scher RK. Onychomycosis--a small step for quality of care. Curr Med Res Opin. 2016;32:865-867.

Lipner SR, Scher RK. Onychomycosis: current and investigational therapies. Cutis. 2014;94:E21-E24.

What does your patient need to know at the first visit?

Risk factors for onychomycosis include prior trauma, history of tinea pedis, sports activities, frequenting gyms and pools, hyperhidrosis, advancing age, diabetes mellitus, immunosuppression, smoking, and family history of onychomycosis. Toenails are involved more frequently than fingernails, and typical physical examination findings are distal and lateral nail plate onycholysis with subungual hyperkeratosis. In more severe cases, there may be nail plate thickening, crumbling, yellowing, and involvement of the nail matrix.

Because other nail conditions may resemble onychomycosis, it is imperative to confirm the diagnosis using histopathology, direct microscopy, fungal culture, and/or polymerase chain reaction on nail plate clippings or subungual debris. 

What are your go-to treatments? What are the side effects?

After laboratory confirmation, assess the patient for the severity of the infection based on the surface area of nail plate affected, nail plate thickness, involvement of the nail matrix, and number of nails affected. United States Food and Drug Administration-approved oral and topical antifungals are used first line for the treatment of onychomycosis. Devices such as lasers are approved by the US Food and Drug Administration for temporary cosmetic improvement in the appearance of the nail without eradicating the fungus.

Oral antifungals such as terbinafine, itraconazole, and fluconazole (off label) are indicated for patients with severe disease. Patients with mild to moderate disease may benefit from oral or topical antifungals such as efinaconazole, tavaborole, or ciclopirox.

I recommend terbinafine to many of my patients due to its high complete and mycological cure rates, short list of drug-drug interactions, and low incidence of side effects. Adverse reactions are uncommon, with the most common being gastrointestinal upset. While liver injury has been reported, it is exceedingly rare. Itraconazole has many important drug interactions and is contraindicated in patients with congestive heart failure. With topical antifungals, side effects are uncommon, but dermatitis, ingrown nails, and vesicles may occur.

How do you keep patients compliant with treatment?

Patients on a 3-month course of daily oral terbinafine or itraconazole for toenail onychomycosis are typically highly compliant. Compliance for patients on oral fluconazole (off label) is generally more challenging because it is dosed weekly until the nail grows out (1-1.5 years for toenails). To circumvent missed fluconazole doses, I recommend that the patient schedule quarterly visits with me and also to set a cell phone alarm as a weekly reminder to take the medication.

Because topical medications are prescribed for the toenails for a year-long course (with avoidance of nail polish during this period), I prescribe topical antifungals only to highly motivated patients. In addition, because topical antifungals are retained in the nail plate for at least several days after a month-long application, I tell my patients that if they have a big event to attend that they can take a vacation from the topical antifungal, get a pedicure, and then resume treatment after the event. 

What do you do if they refuse treatment?

In 2018, we have many options to treat onychomycosis effectively, and therapy is individualized based on the patient's severity of disease, infecting organism(s), comorbidities, concomitant medications, and preferences. If the patient's fungal nail infection is asymptomatic and not aesthetically bothersome, he/she may opt for observation rather than treatment. If the decision is observation, I recommend use of a topical antifungal on the feet and web spaces to prevent worsening of onychomycosis. 

Suggested Readings

Gupta AK, Versteeg SG. A critical review of improvement rates for laser therapy used to treat toenail onychomycosis. J Eur Acad Dermatol Venereol. 2017;31:1111-1118.

Lipner SR, Scher RK. Long-standing onychodystrophy in a young woman. JAMA. 2016;316:1915-1916.

Lipner SR, Scher RK. Onychomycosis--a small step for quality of care. Curr Med Res Opin. 2016;32:865-867.

Lipner SR, Scher RK. Onychomycosis: current and investigational therapies. Cutis. 2014;94:E21-E24.