Hair & Nails

To the Editor:

Onychomycosis is a common nail disease that frequently is caused by dermatophytes and is diagnosed by direct microscopy. Conventional diagnostic methods are often time consuming and can produce false-positive or false-negative results. We report a case of onychomycosis diagnosed by confocal microscopy and confirmed with routine potassium hydroxide (KOH) examination and fungal culture. Confocal microscopy is a reliable, practical, and noninvasive technique in the diagnosis of onychomycosis.

A 46-year-old woman presented with yellow-brown discoloration and dystrophy of the toenails (Figure 1) that had become worse over a 5-year period. She was otherwise healthy and had no other dermatologic problems. Examination revealed yellow-brown discoloration, subungual hyperkeratosis, and onycholysis of the toenails. Clinically, a diagnosis of onychomycosis was made. Potassium hydroxide examination of a scraping from the subungual region showed fungal elements. Trichophyton rubrum on Sabouraud dextrose agar was determined.

Figure 1. Onycholysis and onychodystrophy affecting the toes. Figure 2. In vivo confocal image of hyphae (arrows).

We performed both in vivo and in vitro confocal laser scanning microscopic examination of the nail of the right great toe (Figure 2). For the diagnosis of onychomycosis in our case, we used a multilaser reflectance confocal microscope (RCM) with a wavelength of 786 nm. In vivo confocal microscopy of the nail revealed branching hyphae just below the surface of the nail plate. Hyphae were seen as refractile, bright, linear structures along the laminates of the nail.

Onychomycosis is a common condition affecting 5.5% of the population worldwide and representing 20% to 40% of all onychopathies and approximately 30% of cutaneous mycotic infections.^1,2 There are many methods available to confirm the clinical diagnosis of onychomycosis by detecting the causative organisms. Direct microscopic examination of the scraping with a KOH culture, histopathologic assessment with periodic acid–Schiff staining, immunofluorescence analysis with calcofluor white staining, enzyme analysis, and polymerase chain reaction can be used for diagnosis of fungal infections. The most frequently used diagnostic method for onychomycosis is KOH examination of the scraping; however, fungal culture and histopathologic examination also can be used in cases having diagnostic difficulties.^1,3,4 There are many studies comparing the efficacies of these methods in the literature.^5-9

The causative fungal agent should be determined with at least 1 laboratory method due to the high cost, long duration, and serious potential adverse effects of systemic antifungal treatment. Direct microscopic examination with KOH in the diagnosis of onychomycosis is simple, fast, and inexpensive. However, inadequate material, using crystallized KOH for hydrolysis, insufficient or too much hydrolysis of scrapings, inappropriate staining, and not scanning all areas in the microscopy produce false-negative results. Similarly, secondary contamination of hair, cotton, yarn, or air bubbles mimicking fungal structures can cause false-positive results.^9,10

Fungal culture is another diagnostic method that is accepted as the gold standard for diagnosis of onychomycosis.⁹ However, fungal cultures were positive in only 43% to 50% of all cases of onychomycosis that were diagnosed with other methods,^11,12 which may be due to the loss of viability and ability of the fungi to grow in culture media during the transport. A major advantage of fungal culture is that the fungal agent can be classified as dermatophyte, nondermatophyte, mold, or yeast. However, culture does determine if the growing fungi is contamination or the real pathogen. Moreover, it is necessary to wait 3 to 4 weeks for culture results. For nondermatophyte fungi this time may be much longer.¹²

In vivo RCM is a noninvasive imaging method that allows optical en face sectioning of the living tissue with high resolution. Currently, RCM has a wide range of applications, such as the evaluation of both benign and malignant skin lesions in clinical dermatology.¹³

In vivo RCM was used first by Hongcharu et al.¹⁴ The diagnoses of onychomycosis and fungal hyphae were shown both in vivo and in vitro.¹⁴ The sensitivity and specificity of confocal examination in the diagnosis of onychomycosis is not known yet. Large clinical trials are needed to assess the sensitivity and specificity of this method in diagnosing fungal infections.

Onychomycosis is a contagious infectious disease characterized by hyphae proliferation in the nail plate. Definitive diagnosis is necessary before treatment because onychomycosis can be mistaken for many infectious or noninfectious skin diseases with nail involvement. Conventional methods are time consuming, laborious, and less reliable. Instead of high-cost procedures, in vivo confocal microscopic examination can be a rapid and reliable diagnostic method for onychomycosis in the near future.

To the Editor:

Onychomycosis is a common nail disease that frequently is caused by dermatophytes and is diagnosed by direct microscopy. Conventional diagnostic methods are often time consuming and can produce false-positive or false-negative results. We report a case of onychomycosis diagnosed by confocal microscopy and confirmed with routine potassium hydroxide (KOH) examination and fungal culture. Confocal microscopy is a reliable, practical, and noninvasive technique in the diagnosis of onychomycosis.

A 46-year-old woman presented with yellow-brown discoloration and dystrophy of the toenails (Figure 1) that had become worse over a 5-year period. She was otherwise healthy and had no other dermatologic problems. Examination revealed yellow-brown discoloration, subungual hyperkeratosis, and onycholysis of the toenails. Clinically, a diagnosis of onychomycosis was made. Potassium hydroxide examination of a scraping from the subungual region showed fungal elements. Trichophyton rubrum on Sabouraud dextrose agar was determined.

Figure 1. Onycholysis and onychodystrophy affecting the toes. Figure 2. In vivo confocal image of hyphae (arrows).

We performed both in vivo and in vitro confocal laser scanning microscopic examination of the nail of the right great toe (Figure 2). For the diagnosis of onychomycosis in our case, we used a multilaser reflectance confocal microscope (RCM) with a wavelength of 786 nm. In vivo confocal microscopy of the nail revealed branching hyphae just below the surface of the nail plate. Hyphae were seen as refractile, bright, linear structures along the laminates of the nail.

Onychomycosis is a common condition affecting 5.5% of the population worldwide and representing 20% to 40% of all onychopathies and approximately 30% of cutaneous mycotic infections.^1,2 There are many methods available to confirm the clinical diagnosis of onychomycosis by detecting the causative organisms. Direct microscopic examination of the scraping with a KOH culture, histopathologic assessment with periodic acid–Schiff staining, immunofluorescence analysis with calcofluor white staining, enzyme analysis, and polymerase chain reaction can be used for diagnosis of fungal infections. The most frequently used diagnostic method for onychomycosis is KOH examination of the scraping; however, fungal culture and histopathologic examination also can be used in cases having diagnostic difficulties.^1,3,4 There are many studies comparing the efficacies of these methods in the literature.^5-9

The causative fungal agent should be determined with at least 1 laboratory method due to the high cost, long duration, and serious potential adverse effects of systemic antifungal treatment. Direct microscopic examination with KOH in the diagnosis of onychomycosis is simple, fast, and inexpensive. However, inadequate material, using crystallized KOH for hydrolysis, insufficient or too much hydrolysis of scrapings, inappropriate staining, and not scanning all areas in the microscopy produce false-negative results. Similarly, secondary contamination of hair, cotton, yarn, or air bubbles mimicking fungal structures can cause false-positive results.^9,10

Fungal culture is another diagnostic method that is accepted as the gold standard for diagnosis of onychomycosis.⁹ However, fungal cultures were positive in only 43% to 50% of all cases of onychomycosis that were diagnosed with other methods,^11,12 which may be due to the loss of viability and ability of the fungi to grow in culture media during the transport. A major advantage of fungal culture is that the fungal agent can be classified as dermatophyte, nondermatophyte, mold, or yeast. However, culture does determine if the growing fungi is contamination or the real pathogen. Moreover, it is necessary to wait 3 to 4 weeks for culture results. For nondermatophyte fungi this time may be much longer.¹²

In vivo RCM is a noninvasive imaging method that allows optical en face sectioning of the living tissue with high resolution. Currently, RCM has a wide range of applications, such as the evaluation of both benign and malignant skin lesions in clinical dermatology.¹³

In vivo RCM was used first by Hongcharu et al.¹⁴ The diagnoses of onychomycosis and fungal hyphae were shown both in vivo and in vitro.¹⁴ The sensitivity and specificity of confocal examination in the diagnosis of onychomycosis is not known yet. Large clinical trials are needed to assess the sensitivity and specificity of this method in diagnosing fungal infections.

Onychomycosis is a contagious infectious disease characterized by hyphae proliferation in the nail plate. Definitive diagnosis is necessary before treatment because onychomycosis can be mistaken for many infectious or noninfectious skin diseases with nail involvement. Conventional methods are time consuming, laborious, and less reliable. Instead of high-cost procedures, in vivo confocal microscopic examination can be a rapid and reliable diagnostic method for onychomycosis in the near future.

To the Editor:

Onychomycosis is a common nail disease that frequently is caused by dermatophytes and is diagnosed by direct microscopy. Conventional diagnostic methods are often time consuming and can produce false-positive or false-negative results. We report a case of onychomycosis diagnosed by confocal microscopy and confirmed with routine potassium hydroxide (KOH) examination and fungal culture. Confocal microscopy is a reliable, practical, and noninvasive technique in the diagnosis of onychomycosis.

A 46-year-old woman presented with yellow-brown discoloration and dystrophy of the toenails (Figure 1) that had become worse over a 5-year period. She was otherwise healthy and had no other dermatologic problems. Examination revealed yellow-brown discoloration, subungual hyperkeratosis, and onycholysis of the toenails. Clinically, a diagnosis of onychomycosis was made. Potassium hydroxide examination of a scraping from the subungual region showed fungal elements. Trichophyton rubrum on Sabouraud dextrose agar was determined.

Figure 1. Onycholysis and onychodystrophy affecting the toes. Figure 2. In vivo confocal image of hyphae (arrows).

We performed both in vivo and in vitro confocal laser scanning microscopic examination of the nail of the right great toe (Figure 2). For the diagnosis of onychomycosis in our case, we used a multilaser reflectance confocal microscope (RCM) with a wavelength of 786 nm. In vivo confocal microscopy of the nail revealed branching hyphae just below the surface of the nail plate. Hyphae were seen as refractile, bright, linear structures along the laminates of the nail.

Onychomycosis is a common condition affecting 5.5% of the population worldwide and representing 20% to 40% of all onychopathies and approximately 30% of cutaneous mycotic infections.^1,2 There are many methods available to confirm the clinical diagnosis of onychomycosis by detecting the causative organisms. Direct microscopic examination of the scraping with a KOH culture, histopathologic assessment with periodic acid–Schiff staining, immunofluorescence analysis with calcofluor white staining, enzyme analysis, and polymerase chain reaction can be used for diagnosis of fungal infections. The most frequently used diagnostic method for onychomycosis is KOH examination of the scraping; however, fungal culture and histopathologic examination also can be used in cases having diagnostic difficulties.^1,3,4 There are many studies comparing the efficacies of these methods in the literature.^5-9

The causative fungal agent should be determined with at least 1 laboratory method due to the high cost, long duration, and serious potential adverse effects of systemic antifungal treatment. Direct microscopic examination with KOH in the diagnosis of onychomycosis is simple, fast, and inexpensive. However, inadequate material, using crystallized KOH for hydrolysis, insufficient or too much hydrolysis of scrapings, inappropriate staining, and not scanning all areas in the microscopy produce false-negative results. Similarly, secondary contamination of hair, cotton, yarn, or air bubbles mimicking fungal structures can cause false-positive results.^9,10

Fungal culture is another diagnostic method that is accepted as the gold standard for diagnosis of onychomycosis.⁹ However, fungal cultures were positive in only 43% to 50% of all cases of onychomycosis that were diagnosed with other methods,^11,12 which may be due to the loss of viability and ability of the fungi to grow in culture media during the transport. A major advantage of fungal culture is that the fungal agent can be classified as dermatophyte, nondermatophyte, mold, or yeast. However, culture does determine if the growing fungi is contamination or the real pathogen. Moreover, it is necessary to wait 3 to 4 weeks for culture results. For nondermatophyte fungi this time may be much longer.¹²

In vivo RCM is a noninvasive imaging method that allows optical en face sectioning of the living tissue with high resolution. Currently, RCM has a wide range of applications, such as the evaluation of both benign and malignant skin lesions in clinical dermatology.¹³

In vivo RCM was used first by Hongcharu et al.¹⁴ The diagnoses of onychomycosis and fungal hyphae were shown both in vivo and in vitro.¹⁴ The sensitivity and specificity of confocal examination in the diagnosis of onychomycosis is not known yet. Large clinical trials are needed to assess the sensitivity and specificity of this method in diagnosing fungal infections.

Onychomycosis is a contagious infectious disease characterized by hyphae proliferation in the nail plate. Definitive diagnosis is necessary before treatment because onychomycosis can be mistaken for many infectious or noninfectious skin diseases with nail involvement. Conventional methods are time consuming, laborious, and less reliable. Instead of high-cost procedures, in vivo confocal microscopic examination can be a rapid and reliable diagnostic method for onychomycosis in the near future.

Nail matrix biopsies are performed to confirm a diagnosis or surgically remove a skin lesion that is affecting the growth of the nail plate. The procedure may be used to identify:

Nail biopsy can lead to complications such as bleeding, infection, or scarring. Postoperative scarring can cause permanent nail splitting, dystrophy, or both.

In a Cosmetic Dermatology article, “Matrix Biopsy of Longitudinal Melanonychia and Longitudinal Erythronychia: A Step-by-Step Approach,” Drs. Siobhan C. Collins and Nathaniel J. Jellinek review 6 techniques used to biopsy the nail matrix.

Techniques used to biopsy the nail matrix. From Cosmet Dermatol. 2009;22:130-136.

In the setting of longitudinal melanonychia (to diagnose nail melanoma or SCC) and longitudinal erythronychia (to diagnose SCC and rarely amelanotic melanoma or basal cell carcinoma), the techniques they describe accomplish 3 fundamental goals of nail surgery:

Dermatologists must be confident when performing nail biopsies and the techniques discussed by the authors will help approach nail surgery with more certainty.

At the 73rd Annual Meeting of the American Academy of Dermatology, Dr. Jellinek provides a hands-on approach to nail surgery. On Saturday, March 21, he will provide tips for nail surgeries at the “Medical and Surgical Management of Nail Disorders” lecture.

For more information, read the Collins and Jellinek article from Cosmetic Dermatology.

Nail matrix biopsies are performed to confirm a diagnosis or surgically remove a skin lesion that is affecting the growth of the nail plate. The procedure may be used to identify:

Nail biopsy can lead to complications such as bleeding, infection, or scarring. Postoperative scarring can cause permanent nail splitting, dystrophy, or both.

In a Cosmetic Dermatology article, “Matrix Biopsy of Longitudinal Melanonychia and Longitudinal Erythronychia: A Step-by-Step Approach,” Drs. Siobhan C. Collins and Nathaniel J. Jellinek review 6 techniques used to biopsy the nail matrix.

Techniques used to biopsy the nail matrix. From Cosmet Dermatol. 2009;22:130-136.

In the setting of longitudinal melanonychia (to diagnose nail melanoma or SCC) and longitudinal erythronychia (to diagnose SCC and rarely amelanotic melanoma or basal cell carcinoma), the techniques they describe accomplish 3 fundamental goals of nail surgery:

Dermatologists must be confident when performing nail biopsies and the techniques discussed by the authors will help approach nail surgery with more certainty.

At the 73rd Annual Meeting of the American Academy of Dermatology, Dr. Jellinek provides a hands-on approach to nail surgery. On Saturday, March 21, he will provide tips for nail surgeries at the “Medical and Surgical Management of Nail Disorders” lecture.

For more information, read the Collins and Jellinek article from Cosmetic Dermatology.

Nail matrix biopsies are performed to confirm a diagnosis or surgically remove a skin lesion that is affecting the growth of the nail plate. The procedure may be used to identify:

Nail biopsy can lead to complications such as bleeding, infection, or scarring. Postoperative scarring can cause permanent nail splitting, dystrophy, or both.

In a Cosmetic Dermatology article, “Matrix Biopsy of Longitudinal Melanonychia and Longitudinal Erythronychia: A Step-by-Step Approach,” Drs. Siobhan C. Collins and Nathaniel J. Jellinek review 6 techniques used to biopsy the nail matrix.

Techniques used to biopsy the nail matrix. From Cosmet Dermatol. 2009;22:130-136.

In the setting of longitudinal melanonychia (to diagnose nail melanoma or SCC) and longitudinal erythronychia (to diagnose SCC and rarely amelanotic melanoma or basal cell carcinoma), the techniques they describe accomplish 3 fundamental goals of nail surgery:

Dermatologists must be confident when performing nail biopsies and the techniques discussed by the authors will help approach nail surgery with more certainty.

At the 73rd Annual Meeting of the American Academy of Dermatology, Dr. Jellinek provides a hands-on approach to nail surgery. On Saturday, March 21, he will provide tips for nail surgeries at the “Medical and Surgical Management of Nail Disorders” lecture.

For more information, read the Collins and Jellinek article from Cosmetic Dermatology.

To the Editor:

First identified by Samuel Wilks in 1852, trichorrhexis nodosa (TN) is a congenital or acquired hair shaft disorder that is characterized by fragile and easily broken hair.¹ Congenital TN is rare and can occur in syndromes such as pseudomonilethrix, Netherton syndrome, pili annulati,² argininosuccinic aciduria,³ trichothiodystrophy,⁴ Menkes syndrome,⁵ and trichohepatoenteric syndrome.⁶ The primary congenital form of TN is inherited as an autosomal-dominant trait in some families. Acquired TN is the most common hair shaft abnormality and often is overlooked. It is provoked by hair injury, usually mechanical or physical, or chemical trauma.^7,8

Chemical trauma is caused by the use of permanent hair liquids or dyes. Mechanical injuries are the result of frequent brushing, scalp massage, or lengthy backcombing, and physical damage includes excessive UV exposure or repeated application of heat. Habit tics, trichotillomania, and the scratching and pulling associated with pruritic dermatoses also can result in sufficient damage to provoke TN. Furthermore, this acquired disorder may develop from malnutrition, particularly iron deficiency, or endocrinopathy such as hypothyroidism.⁹ Seasonal recurrence of TN has been reported from the cumulative effect of repeated soaking in salt water and exposure to UV light. Macroscopically, hair shafts affected by TN contain small white nodes at irregular intervals throughout the length of the hair shaft. These nodes represent areas of cuticular cell disruption, which allows the underlying cortical fibers to separate and fray and gives the node the microscopic appearance of 2 brooms or paintbrushes thrusting together end-to-end by the bristles. The classic description is known as paintbrush fracture.¹⁰ Generally, complete breakage occurs at these nodes.

A 21-year-old white woman presented to our clinic with hair fragility and inability to grow long hair of 2 years’ duration. The hair was lusterless and dry. Dermoscopic examination revealed broken blunt-ended hair of uneven length with minute pinpoint grayish white nodules (Figure 1). Small fragments could be easily broken off with gentle tugging on the distal ends. She reported a history of severe sunlight and seawater exposure during the last 2 summers and the continuous use of a flat iron in the last year. Microscopic examination of hair samples with a scanning electron microscope showed the characteristic paintbrush fracture (Figure 2). She had no history of diseases, and blood examinations including complete blood cell count, thyroid function test, and iron levels were within reference range.

Figure 1. Dermoscopy revealed broken blunt-ended hair of uneven length with minute pinpoint grayish white nodules (original magnification ×30). Figure 2. Scanning electron microscopy showed characteristic paintbrush fracture of the hair shaft (original magnification ×748).

We hypothesize that the seasonal damage caused by exposure to UV light and salt water with repeated trauma from the heat of the flat iron caused distal TN. The patient was given an explanation about the diagnosis of TN and was instructed to avoid the practices that were suspected causes of the condition. Use of a gentle shampoo and conditioner also was recommended. At 6-month follow-up, we noticed an improvement of the quality of hair with a reduction in the whitish nodules and a revival of hair growth.

Acquired TN has been classified into 3 clinical forms: proximal, distal, and localized.¹ Proximal TN is common in black individuals who use caustic chemicals when styling the hair. The involved hairs develop the characteristic nodes that break within a few centimeters from the scalp, especially in areas subject to friction from combing or sleeping. Distal TN primarily occurs in white or Asian individuals. In this disorder, nodes and breakage occur near the ends of the hairs that appear dull, dry, and uneven. Breakage commonly is associated with trichoptilosis, or longitudinal splitting, commonly referred to as split ends. This breakage may reflect frequent use of shampoo or heat treatments. The distal acquired form may simulate dandruff or pediculosis and the detection of this hair defect often is casual.

Localized TN, described by Raymond Sabouraud in 1921, is a rare disorder. It occurs in a patch that is usually a few centimeters long. It generally is accompanied by a pruritic dermatosis, such as circumscribed neurodermatitis, contact dermatitis, or atopic dermatitis. Scratching and rubbing most likely are the ultimate causes.

Trichorrhexis nodosa can spontaneously resolve. In all cases, diagnosis depends on careful microscopy examination and, if possible, scanning electron microscopy. Treatment is aimed at minimizing mechanical and physical injury, and chemical trauma. Excessive brushing, hot-combing, permanent waving, and other harsh hair treatments should be avoided. If the hair is long and the damage is distal, it may be sufficient to cut the distal fraction and to change cosmetic practices to prevent relapse.

Dermatologists who see patients with hair fragility and inability to grow long hair should consider the diagnosis of TN. Acquired TN often is reversible. Complete resolution may take 2 to 4 years depending on the growth of new anagen hairs. All patients with a history of white flecking on the scalp, abnormal fragility of the hair, and failure to attain normal hair length should be questioned about their routine hair care habits as well as environmental or chemical exposures to determine and remove the source of physical or chemical trauma.

To the Editor:

First identified by Samuel Wilks in 1852, trichorrhexis nodosa (TN) is a congenital or acquired hair shaft disorder that is characterized by fragile and easily broken hair.¹ Congenital TN is rare and can occur in syndromes such as pseudomonilethrix, Netherton syndrome, pili annulati,² argininosuccinic aciduria,³ trichothiodystrophy,⁴ Menkes syndrome,⁵ and trichohepatoenteric syndrome.⁶ The primary congenital form of TN is inherited as an autosomal-dominant trait in some families. Acquired TN is the most common hair shaft abnormality and often is overlooked. It is provoked by hair injury, usually mechanical or physical, or chemical trauma.^7,8

Chemical trauma is caused by the use of permanent hair liquids or dyes. Mechanical injuries are the result of frequent brushing, scalp massage, or lengthy backcombing, and physical damage includes excessive UV exposure or repeated application of heat. Habit tics, trichotillomania, and the scratching and pulling associated with pruritic dermatoses also can result in sufficient damage to provoke TN. Furthermore, this acquired disorder may develop from malnutrition, particularly iron deficiency, or endocrinopathy such as hypothyroidism.⁹ Seasonal recurrence of TN has been reported from the cumulative effect of repeated soaking in salt water and exposure to UV light. Macroscopically, hair shafts affected by TN contain small white nodes at irregular intervals throughout the length of the hair shaft. These nodes represent areas of cuticular cell disruption, which allows the underlying cortical fibers to separate and fray and gives the node the microscopic appearance of 2 brooms or paintbrushes thrusting together end-to-end by the bristles. The classic description is known as paintbrush fracture.¹⁰ Generally, complete breakage occurs at these nodes.

A 21-year-old white woman presented to our clinic with hair fragility and inability to grow long hair of 2 years’ duration. The hair was lusterless and dry. Dermoscopic examination revealed broken blunt-ended hair of uneven length with minute pinpoint grayish white nodules (Figure 1). Small fragments could be easily broken off with gentle tugging on the distal ends. She reported a history of severe sunlight and seawater exposure during the last 2 summers and the continuous use of a flat iron in the last year. Microscopic examination of hair samples with a scanning electron microscope showed the characteristic paintbrush fracture (Figure 2). She had no history of diseases, and blood examinations including complete blood cell count, thyroid function test, and iron levels were within reference range.

Figure 1. Dermoscopy revealed broken blunt-ended hair of uneven length with minute pinpoint grayish white nodules (original magnification ×30). Figure 2. Scanning electron microscopy showed characteristic paintbrush fracture of the hair shaft (original magnification ×748).

We hypothesize that the seasonal damage caused by exposure to UV light and salt water with repeated trauma from the heat of the flat iron caused distal TN. The patient was given an explanation about the diagnosis of TN and was instructed to avoid the practices that were suspected causes of the condition. Use of a gentle shampoo and conditioner also was recommended. At 6-month follow-up, we noticed an improvement of the quality of hair with a reduction in the whitish nodules and a revival of hair growth.

Acquired TN has been classified into 3 clinical forms: proximal, distal, and localized.¹ Proximal TN is common in black individuals who use caustic chemicals when styling the hair. The involved hairs develop the characteristic nodes that break within a few centimeters from the scalp, especially in areas subject to friction from combing or sleeping. Distal TN primarily occurs in white or Asian individuals. In this disorder, nodes and breakage occur near the ends of the hairs that appear dull, dry, and uneven. Breakage commonly is associated with trichoptilosis, or longitudinal splitting, commonly referred to as split ends. This breakage may reflect frequent use of shampoo or heat treatments. The distal acquired form may simulate dandruff or pediculosis and the detection of this hair defect often is casual.

Localized TN, described by Raymond Sabouraud in 1921, is a rare disorder. It occurs in a patch that is usually a few centimeters long. It generally is accompanied by a pruritic dermatosis, such as circumscribed neurodermatitis, contact dermatitis, or atopic dermatitis. Scratching and rubbing most likely are the ultimate causes.

Trichorrhexis nodosa can spontaneously resolve. In all cases, diagnosis depends on careful microscopy examination and, if possible, scanning electron microscopy. Treatment is aimed at minimizing mechanical and physical injury, and chemical trauma. Excessive brushing, hot-combing, permanent waving, and other harsh hair treatments should be avoided. If the hair is long and the damage is distal, it may be sufficient to cut the distal fraction and to change cosmetic practices to prevent relapse.

Dermatologists who see patients with hair fragility and inability to grow long hair should consider the diagnosis of TN. Acquired TN often is reversible. Complete resolution may take 2 to 4 years depending on the growth of new anagen hairs. All patients with a history of white flecking on the scalp, abnormal fragility of the hair, and failure to attain normal hair length should be questioned about their routine hair care habits as well as environmental or chemical exposures to determine and remove the source of physical or chemical trauma.

To the Editor:

First identified by Samuel Wilks in 1852, trichorrhexis nodosa (TN) is a congenital or acquired hair shaft disorder that is characterized by fragile and easily broken hair.¹ Congenital TN is rare and can occur in syndromes such as pseudomonilethrix, Netherton syndrome, pili annulati,² argininosuccinic aciduria,³ trichothiodystrophy,⁴ Menkes syndrome,⁵ and trichohepatoenteric syndrome.⁶ The primary congenital form of TN is inherited as an autosomal-dominant trait in some families. Acquired TN is the most common hair shaft abnormality and often is overlooked. It is provoked by hair injury, usually mechanical or physical, or chemical trauma.^7,8

Chemical trauma is caused by the use of permanent hair liquids or dyes. Mechanical injuries are the result of frequent brushing, scalp massage, or lengthy backcombing, and physical damage includes excessive UV exposure or repeated application of heat. Habit tics, trichotillomania, and the scratching and pulling associated with pruritic dermatoses also can result in sufficient damage to provoke TN. Furthermore, this acquired disorder may develop from malnutrition, particularly iron deficiency, or endocrinopathy such as hypothyroidism.⁹ Seasonal recurrence of TN has been reported from the cumulative effect of repeated soaking in salt water and exposure to UV light. Macroscopically, hair shafts affected by TN contain small white nodes at irregular intervals throughout the length of the hair shaft. These nodes represent areas of cuticular cell disruption, which allows the underlying cortical fibers to separate and fray and gives the node the microscopic appearance of 2 brooms or paintbrushes thrusting together end-to-end by the bristles. The classic description is known as paintbrush fracture.¹⁰ Generally, complete breakage occurs at these nodes.

A 21-year-old white woman presented to our clinic with hair fragility and inability to grow long hair of 2 years’ duration. The hair was lusterless and dry. Dermoscopic examination revealed broken blunt-ended hair of uneven length with minute pinpoint grayish white nodules (Figure 1). Small fragments could be easily broken off with gentle tugging on the distal ends. She reported a history of severe sunlight and seawater exposure during the last 2 summers and the continuous use of a flat iron in the last year. Microscopic examination of hair samples with a scanning electron microscope showed the characteristic paintbrush fracture (Figure 2). She had no history of diseases, and blood examinations including complete blood cell count, thyroid function test, and iron levels were within reference range.

Figure 1. Dermoscopy revealed broken blunt-ended hair of uneven length with minute pinpoint grayish white nodules (original magnification ×30). Figure 2. Scanning electron microscopy showed characteristic paintbrush fracture of the hair shaft (original magnification ×748).

We hypothesize that the seasonal damage caused by exposure to UV light and salt water with repeated trauma from the heat of the flat iron caused distal TN. The patient was given an explanation about the diagnosis of TN and was instructed to avoid the practices that were suspected causes of the condition. Use of a gentle shampoo and conditioner also was recommended. At 6-month follow-up, we noticed an improvement of the quality of hair with a reduction in the whitish nodules and a revival of hair growth.

Acquired TN has been classified into 3 clinical forms: proximal, distal, and localized.¹ Proximal TN is common in black individuals who use caustic chemicals when styling the hair. The involved hairs develop the characteristic nodes that break within a few centimeters from the scalp, especially in areas subject to friction from combing or sleeping. Distal TN primarily occurs in white or Asian individuals. In this disorder, nodes and breakage occur near the ends of the hairs that appear dull, dry, and uneven. Breakage commonly is associated with trichoptilosis, or longitudinal splitting, commonly referred to as split ends. This breakage may reflect frequent use of shampoo or heat treatments. The distal acquired form may simulate dandruff or pediculosis and the detection of this hair defect often is casual.

Localized TN, described by Raymond Sabouraud in 1921, is a rare disorder. It occurs in a patch that is usually a few centimeters long. It generally is accompanied by a pruritic dermatosis, such as circumscribed neurodermatitis, contact dermatitis, or atopic dermatitis. Scratching and rubbing most likely are the ultimate causes.

Trichorrhexis nodosa can spontaneously resolve. In all cases, diagnosis depends on careful microscopy examination and, if possible, scanning electron microscopy. Treatment is aimed at minimizing mechanical and physical injury, and chemical trauma. Excessive brushing, hot-combing, permanent waving, and other harsh hair treatments should be avoided. If the hair is long and the damage is distal, it may be sufficient to cut the distal fraction and to change cosmetic practices to prevent relapse.

Dermatologists who see patients with hair fragility and inability to grow long hair should consider the diagnosis of TN. Acquired TN often is reversible. Complete resolution may take 2 to 4 years depending on the growth of new anagen hairs. All patients with a history of white flecking on the scalp, abnormal fragility of the hair, and failure to attain normal hair length should be questioned about their routine hair care habits as well as environmental or chemical exposures to determine and remove the source of physical or chemical trauma.

A 30-year-old woman cuts her finger on a glass jar. She goes to the clinic and needs to have sutures on her right ring finger. What would you recommend for anesthesia to prepare the patient for repair?

A. 1% lidocaine.

B. 1% lidocaine with epinephrine.

C. Bupivacaine.

Myth: You should not use lidocaine with epinephrine on a digit.

Many of us were taught to avoid the use of epinephrine on digits because of the concern of precipitating digital ischemia. This was a common warning in emergency and surgical textbooks (J.C. Vance. Anesthesia. R.K. Roenigk, H.H. Roenigk [Eds.], Dermatologic Surgery, Principles and Practice [2nd ed.], Marcel Decker, New York, N.Y. [1996], pp. 31-52.).

Over the past 20 years, there has been a growing body of evidence that the concern is unwarranted and that there may be benefit to the addition of epinephrine.

Dr. Bradon J. Wilhelmi and his colleagues performed a randomized, double-blind trial comparing lidocaine with epinephrine (31 patients) and lidocaine (29 patients) in patients with traumatic injuries or elective procedures (Plast. Reconstr. Surg. 2001;107:393-7). The need for control of bleeding required digital tourniquet use in 20 of 29 block procedures with plain lidocaine and in 9 of 31 procedures using lidocaine with epinephrine (P < .002). There were no complications in the patients who received lidocaine with epinephrine.

A retrospective study was done by Dr. Saeed Chowdhry and his colleagues of 1,111 patients who had hand surgery and received digital blocks (Plast. Reconstr. Surg. 2010;126:2031-4). A total of 611 patients received lidocaine with epinephrine, and 500 patients received lidocaine alone. The concentration of lidocaine with epinephrine was 1:100,000, with an average dose of 4.33 cc.

There were no cases of digital gangrene or other complications because of the use of epinephrine in this retrospective study.

In a large, retrospective study of nine hand surgeons’ practices, looking at 3,110 cases of elective injection of low-dose epinephrine in hands and fingers, there were no cases of digital tissue loss or need for phentolamine rescue (J. Hand Surg. Am. 2005;30:1061-7).

Several studies have been done using epinephrine digital injections of the toes. In a prospective, randomized, controlled trial, 44 patients undergoing phenolization matricectomy involving digital block injection of 70 toes received either anesthetic and epinephrine or anesthetic and digital tourniquet (J. Eur. Acad. Dermatol. Venereol. 2014 [doi:10.1111/jdv.12746]). The outcome measures were rate of recurrence, bleeding, pain, and duration of anesthetic effect.

There was no difference in recurrence rates, but postoperative bleeding was higher in the procedures done with digital tourniquet and no epinephrine (P = .001). Anesthetic effect as measured by less pain and duration of effect was superior in the patients receiving digital block with epinephrine (P = .001).

In another study looking at chemical matricectomy, Dr. Cevdet Altinyazar and his colleagues randomized patients to receive either 2% lidocaine or lidocaine with epinephrine for anesthesia for chemical matricectomy of ingrown toenails of the great toe (Dermatol. Surg. 2010;36:1568-71). There was less anesthetic needed in the patients who received lidocaine with epinephrine, and a statistically significant reduction in days of drainage following procedure in the lidocaine with epinephrine group (11.1 days +/- 2.5 days), compared with the lidocaine-only group (19.0 days +/- 3.8 days). There were no complications because of the use of epinephrine.

The belief in this myth is still quite common, despite the evidence from randomized, controlled trials and the experience of more than 3,500 patients who have received epinephrine in the fingers without any complications. The evidence from the podiatry literature on safety in use in the toes mirrors the evidence of safety in the fingers.

Dr. Paauw is a professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington Medical School. He is the Rathmann Family Foundation Chair in Patient-Centered Clinical Education. Contact Dr. Paauw at [email protected].

A 30-year-old woman cuts her finger on a glass jar. She goes to the clinic and needs to have sutures on her right ring finger. What would you recommend for anesthesia to prepare the patient for repair?

A. 1% lidocaine.

B. 1% lidocaine with epinephrine.

C. Bupivacaine.

Myth: You should not use lidocaine with epinephrine on a digit.

Many of us were taught to avoid the use of epinephrine on digits because of the concern of precipitating digital ischemia. This was a common warning in emergency and surgical textbooks (J.C. Vance. Anesthesia. R.K. Roenigk, H.H. Roenigk [Eds.], Dermatologic Surgery, Principles and Practice [2nd ed.], Marcel Decker, New York, N.Y. [1996], pp. 31-52.).

Over the past 20 years, there has been a growing body of evidence that the concern is unwarranted and that there may be benefit to the addition of epinephrine.

Dr. Bradon J. Wilhelmi and his colleagues performed a randomized, double-blind trial comparing lidocaine with epinephrine (31 patients) and lidocaine (29 patients) in patients with traumatic injuries or elective procedures (Plast. Reconstr. Surg. 2001;107:393-7). The need for control of bleeding required digital tourniquet use in 20 of 29 block procedures with plain lidocaine and in 9 of 31 procedures using lidocaine with epinephrine (P < .002). There were no complications in the patients who received lidocaine with epinephrine.

A retrospective study was done by Dr. Saeed Chowdhry and his colleagues of 1,111 patients who had hand surgery and received digital blocks (Plast. Reconstr. Surg. 2010;126:2031-4). A total of 611 patients received lidocaine with epinephrine, and 500 patients received lidocaine alone. The concentration of lidocaine with epinephrine was 1:100,000, with an average dose of 4.33 cc.

There were no cases of digital gangrene or other complications because of the use of epinephrine in this retrospective study.

In a large, retrospective study of nine hand surgeons’ practices, looking at 3,110 cases of elective injection of low-dose epinephrine in hands and fingers, there were no cases of digital tissue loss or need for phentolamine rescue (J. Hand Surg. Am. 2005;30:1061-7).

Several studies have been done using epinephrine digital injections of the toes. In a prospective, randomized, controlled trial, 44 patients undergoing phenolization matricectomy involving digital block injection of 70 toes received either anesthetic and epinephrine or anesthetic and digital tourniquet (J. Eur. Acad. Dermatol. Venereol. 2014 [doi:10.1111/jdv.12746]). The outcome measures were rate of recurrence, bleeding, pain, and duration of anesthetic effect.

There was no difference in recurrence rates, but postoperative bleeding was higher in the procedures done with digital tourniquet and no epinephrine (P = .001). Anesthetic effect as measured by less pain and duration of effect was superior in the patients receiving digital block with epinephrine (P = .001).

In another study looking at chemical matricectomy, Dr. Cevdet Altinyazar and his colleagues randomized patients to receive either 2% lidocaine or lidocaine with epinephrine for anesthesia for chemical matricectomy of ingrown toenails of the great toe (Dermatol. Surg. 2010;36:1568-71). There was less anesthetic needed in the patients who received lidocaine with epinephrine, and a statistically significant reduction in days of drainage following procedure in the lidocaine with epinephrine group (11.1 days +/- 2.5 days), compared with the lidocaine-only group (19.0 days +/- 3.8 days). There were no complications because of the use of epinephrine.

The belief in this myth is still quite common, despite the evidence from randomized, controlled trials and the experience of more than 3,500 patients who have received epinephrine in the fingers without any complications. The evidence from the podiatry literature on safety in use in the toes mirrors the evidence of safety in the fingers.

Dr. Paauw is a professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington Medical School. He is the Rathmann Family Foundation Chair in Patient-Centered Clinical Education. Contact Dr. Paauw at [email protected].

A 30-year-old woman cuts her finger on a glass jar. She goes to the clinic and needs to have sutures on her right ring finger. What would you recommend for anesthesia to prepare the patient for repair?

A. 1% lidocaine.

B. 1% lidocaine with epinephrine.

C. Bupivacaine.

Myth: You should not use lidocaine with epinephrine on a digit.

Many of us were taught to avoid the use of epinephrine on digits because of the concern of precipitating digital ischemia. This was a common warning in emergency and surgical textbooks (J.C. Vance. Anesthesia. R.K. Roenigk, H.H. Roenigk [Eds.], Dermatologic Surgery, Principles and Practice [2nd ed.], Marcel Decker, New York, N.Y. [1996], pp. 31-52.).

Over the past 20 years, there has been a growing body of evidence that the concern is unwarranted and that there may be benefit to the addition of epinephrine.

Dr. Bradon J. Wilhelmi and his colleagues performed a randomized, double-blind trial comparing lidocaine with epinephrine (31 patients) and lidocaine (29 patients) in patients with traumatic injuries or elective procedures (Plast. Reconstr. Surg. 2001;107:393-7). The need for control of bleeding required digital tourniquet use in 20 of 29 block procedures with plain lidocaine and in 9 of 31 procedures using lidocaine with epinephrine (P < .002). There were no complications in the patients who received lidocaine with epinephrine.

A retrospective study was done by Dr. Saeed Chowdhry and his colleagues of 1,111 patients who had hand surgery and received digital blocks (Plast. Reconstr. Surg. 2010;126:2031-4). A total of 611 patients received lidocaine with epinephrine, and 500 patients received lidocaine alone. The concentration of lidocaine with epinephrine was 1:100,000, with an average dose of 4.33 cc.

There were no cases of digital gangrene or other complications because of the use of epinephrine in this retrospective study.

In a large, retrospective study of nine hand surgeons’ practices, looking at 3,110 cases of elective injection of low-dose epinephrine in hands and fingers, there were no cases of digital tissue loss or need for phentolamine rescue (J. Hand Surg. Am. 2005;30:1061-7).

Several studies have been done using epinephrine digital injections of the toes. In a prospective, randomized, controlled trial, 44 patients undergoing phenolization matricectomy involving digital block injection of 70 toes received either anesthetic and epinephrine or anesthetic and digital tourniquet (J. Eur. Acad. Dermatol. Venereol. 2014 [doi:10.1111/jdv.12746]). The outcome measures were rate of recurrence, bleeding, pain, and duration of anesthetic effect.

There was no difference in recurrence rates, but postoperative bleeding was higher in the procedures done with digital tourniquet and no epinephrine (P = .001). Anesthetic effect as measured by less pain and duration of effect was superior in the patients receiving digital block with epinephrine (P = .001).

In another study looking at chemical matricectomy, Dr. Cevdet Altinyazar and his colleagues randomized patients to receive either 2% lidocaine or lidocaine with epinephrine for anesthesia for chemical matricectomy of ingrown toenails of the great toe (Dermatol. Surg. 2010;36:1568-71). There was less anesthetic needed in the patients who received lidocaine with epinephrine, and a statistically significant reduction in days of drainage following procedure in the lidocaine with epinephrine group (11.1 days +/- 2.5 days), compared with the lidocaine-only group (19.0 days +/- 3.8 days). There were no complications because of the use of epinephrine.

The belief in this myth is still quite common, despite the evidence from randomized, controlled trials and the experience of more than 3,500 patients who have received epinephrine in the fingers without any complications. The evidence from the podiatry literature on safety in use in the toes mirrors the evidence of safety in the fingers.

Dr. Paauw is a professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington Medical School. He is the Rathmann Family Foundation Chair in Patient-Centered Clinical Education. Contact Dr. Paauw at [email protected].

First described by Fetsch et al¹ in 2001, superficial acral fibromyxoma (SAFM) is a rare fibromyxoid mesenchymal tumor that typically affects the fingers and toes with frequent involvement of the nail unit. It is not widely recognized and remains poorly understood. We describe a series of 3 cases of SAFM encountered at our institution and provide a review of the literature on this unique tumor.

Case Reports

Patient 1

A 35-year-old man presented for treatment of a “wart” on the right fifth toe that had increased in size over the last year. He reported that the lesion was mildly painful and occasionally bled or drained clear fluid. He also noted cracking of the nail plate on the same toe. Physical examination revealed a firm, flesh-colored, 3-mm dermal papule on the proximal nail fold of the right fifth toe with subtle flattening of the underlying nail plate (Figure 1). The patient underwent biopsy of the involved proximal nail fold. Histopathology revealed a proliferation of small oval and spindle cells arranged in fascicles and bundles in the dermis (Figure 2). There was extensive mucin deposition associated with the spindle cell proliferation. Additionally, spindle cells and mucin surrounded and entrapped collagen bundles on the periphery of the lesion. Lesional cells were diffusely positive for CD34 and extended to the deep surgical margin (Figure 3). S-100 and factor XIIIa stains were negative. The diagnosis of SAFM was made based on the acral location, histopathologic appearance, and immunohistochemical profile of the tumor.

Figure 1. Firm dermal papule on the proximal nail fold of the right fifth toe with associated nail plate dystrophy. Figure 2. Small oval and spindle cells arranged in fascicles and bundles in the dermis, with extensive mucin deposition and collagen trapping (H&E, original magnification ×100). Figure 3. Tumor cells were positive on CD34 staining (original magnification ×40). Figure 4. Dermal stellate spindle cells arranged in a loose fascicular pattern with marked mucin deposition (H&E, original magnification ×400).

Patient 2

A 47-year-old man presented with an asymptomatic growth on the left fourth toe that had increased in size over the last year. Physical examination revealed an 8-mm, firm, fleshy, flesh-colored, smooth and slightly pedunculated papule on the distal aspect of the left fourth toe. The nail plate and periungual region were not involved. A shave biopsy of the papule was obtained. Histopathology demonstrated dermal stellate spindle cells arranged in a loose fascicular pattern with marked mucin deposition throughout the dermis (Figure 4). Lesional cells were positive for CD34. An S-100 stain highlighted dermal dendritic cells, but lesional cells were negative. No further excision was undertaken, and there was no evidence of recurrence at 1-year follow-up. The diagnosis of SAFM was made based on the acral location, histopathologic appearance, and immunohistochemical profile of the tumor.

Patient 3

A 45-year-old woman presented with asymptomatic distal onycholysis of the right thumbnail of 1 year’s duration. She denied any history of trauma, and no bleeding or pigmentary changes were noted. Physical examination revealed a 5-mm flesh-colored papule on the hyponychium of the right thumb with focal onycholysis (Figure 5). A wedge biopsy of the lesion was performed. Histopathology showed an intradermal nodular proliferation of bland spindle cells arranged in loose fascicles and bundles and embedded in a myxoid stroma (Figure 6). CD34 staining strongly highlighted lesional cells. S-100 and neurofilament stains were negative. The diagnosis of SAFM was made based on the acral location, histopathologic appearance, and immunohistochemical profile of the tumor.

Comment

Clinically, SAFM typically presents as a slow-growing solitary nodule on the distal fingers or toes. The great toe is the most commonly affected digit, and the tumor may be subungual in up to two-thirds of cases.¹ Unusual locations, such as the heel, also have been reported.² Onset typically occurs in the fifth or sixth decade, and there is an approximately 2-fold higher incidence in men than women.^1-3

Histopathologically, SAFM is a characteristically well-circumscribed but unencapsulated dermal tumor composed of spindle and stellate cells in a loose storiform or fascicular arrangement embedded in a myxoid, myxocollagenous, or collagenous stroma.⁴ The tumor often occupies the entire dermis and may extend into the subcutis or occasionally the underlying fascia and bone.^4,5 Mast cells often are prominent, and microvascular accentuation also may be seen. Inflammatory infiltrates and multinucleated giant cells typically are not seen.⁶ Although 2 cases of atypical SAFM have been described,² cellular atypia is not a characteristic feature of SAFM.

The immunohistochemical profile of SAFM is characterized by diffuse or focal expression of CD34, focal expression of epithelial membrane antigen (EMA), CD99 expression, and varying numbers of factor XIIIa–positive histiocytes.^2,3 Positive staining for vimentin also is common. Staining typically is negative for S-100, human melanoma black 45, keratin, smooth muscle actin, and desmin.

The standard treatment of SAFM is complete local resection of the tumor, though some patients have been treated with partial excision or biopsy and partial or complete digital amputation.¹ Local recurrence may occur in up to 20% of cases; however, approximately two-thirds of the reported recurrences in the literature occurred after incomplete tumor excision.^1,2 It may be more appropriate to consider these cases as persistent rather than recurrent tumors. Superficial acral fibromyxoma is considered a benign tumor, with no known cases of metastases.⁴

Figure 5. A firm flesh-colored papule on the hyponychium of the right thumb prior to biopsy. Figure 6. Intradermal nodular proliferation of bland spindle cells arranged in loose fascicles and bundles and embedded in a myxoid stroma (H&E, original magnification ×40).

A broad differential diagnosis exists for SAFM and it can be difficult to differentiate it from a wide variety of benign and malignant tumors that may be seen on the nail unit and distal extremities (Table). Myxoid neurofibromas typically present as solitary lesions on the hands and feet. Similar to SAFM, myxoid neurofibromas are unencapsulated dermal tumors composed of spindle-shaped cells in which mast cells often are conspicuous.^2,7 However, tumor cells in myxoid neurofibromas are S-100 positive, and the lesions typically do not show vasculature accentuation.^4,7

Sclerosing perineuriomas are benign fibrous tumors of the fingers and palms. Histopathologically, bland spindle cells arranged in fascicles and whorls are observed in a hyalinized collagen matrix.⁸ Immunohistochemically, sclerosing perineuriomas are positive for EMA and negative for S-100, but unlike SAFM, these tumors usually are CD34 negative.⁸

Superficial angiomyxomas typically are located on the head and neck but also may be found in other locations such as the trunk. They present as cutaneous papules or polypoid lesions. Histopathologically, superficial angiomyxomas are poorly circumscribed with a lobular pattern. Spindle-shaped fibroblasts exist in a myxoid matrix with neutrophils and thin-walled capillaries. The fibroblasts are variably positive for CD34 but also are S-100 positive.^1,9

Myxoid dermatofibrosarcoma protuberans is a rare, locally aggressive, mesenchymal tumor of the skin and subcutis² that typically presents on the trunk, proximal extremities, or head and neck; occurrence on the fingers or toes is exceedingly rare.^2,10 Histopathologically, a myxoid stroma contains sheets of bland spindle-shaped cells with minimal to no atypia, sometimes arranged in a storiform pattern. The tumor characteristically invades deeply into the subcutaneous tissues. CD34 is characteristically positive and S-100 is negative.^2,10

Low-grade myxofibrosarcoma is a soft tissue sarcoma easily confused with other spindle cell tumors. It is one of the most common sarcomas in adults but rarely arises in acral areas.² It is characterized by a nodular growth pattern with marked nuclear atypia and perivascular clustering of tumor cells. CD34 staining may be positive in some cases.¹¹

Similar to SAFM, myxoinflammatory fibroblastic sarcoma has a predilection for the extremities.⁴ However, it typically presents as a subcutaneous mass and has no documented tendency for nail bed involvement. Also unlike SAFM, it has a remarkable inflammatory infiltrate and characteristic virocyte or Reed-Sternberg cells.¹²

Acquired digital fibrokeratomas are benign neoplasms that occur on fingers and toes; the classic clinical presentation is a solitary smooth nodule or dome, often with a characteristic projecting configuration and horn shape.¹ Histopathologically, these tumors are paucicellular with thick, vertically oriented, interwoven collagen bundles; cells may be positive for CD34 but are negative for EMA.^1,13 Related to acquired digital fibrokeratomas are Koenen tumors, which share a similar histology but are distinguished by their clinical characteristics. For example, Koenen tumors tend to be multifocal and are strongly associated with tuberous sclerosis. These tumors also have a tendency to recur.¹

Conclusion

Our report of 3 typical cases of SAFM highlights the need to keep this increasingly recognized and well-defined clinicopathological entity in the differential for slow-growing tumors in acral locations, particularly those in the periungual and subungual regions.

First described by Fetsch et al¹ in 2001, superficial acral fibromyxoma (SAFM) is a rare fibromyxoid mesenchymal tumor that typically affects the fingers and toes with frequent involvement of the nail unit. It is not widely recognized and remains poorly understood. We describe a series of 3 cases of SAFM encountered at our institution and provide a review of the literature on this unique tumor.

Case Reports

Patient 1

A 35-year-old man presented for treatment of a “wart” on the right fifth toe that had increased in size over the last year. He reported that the lesion was mildly painful and occasionally bled or drained clear fluid. He also noted cracking of the nail plate on the same toe. Physical examination revealed a firm, flesh-colored, 3-mm dermal papule on the proximal nail fold of the right fifth toe with subtle flattening of the underlying nail plate (Figure 1). The patient underwent biopsy of the involved proximal nail fold. Histopathology revealed a proliferation of small oval and spindle cells arranged in fascicles and bundles in the dermis (Figure 2). There was extensive mucin deposition associated with the spindle cell proliferation. Additionally, spindle cells and mucin surrounded and entrapped collagen bundles on the periphery of the lesion. Lesional cells were diffusely positive for CD34 and extended to the deep surgical margin (Figure 3). S-100 and factor XIIIa stains were negative. The diagnosis of SAFM was made based on the acral location, histopathologic appearance, and immunohistochemical profile of the tumor.

Figure 1. Firm dermal papule on the proximal nail fold of the right fifth toe with associated nail plate dystrophy. Figure 2. Small oval and spindle cells arranged in fascicles and bundles in the dermis, with extensive mucin deposition and collagen trapping (H&E, original magnification ×100). Figure 3. Tumor cells were positive on CD34 staining (original magnification ×40). Figure 4. Dermal stellate spindle cells arranged in a loose fascicular pattern with marked mucin deposition (H&E, original magnification ×400).

Patient 2

A 47-year-old man presented with an asymptomatic growth on the left fourth toe that had increased in size over the last year. Physical examination revealed an 8-mm, firm, fleshy, flesh-colored, smooth and slightly pedunculated papule on the distal aspect of the left fourth toe. The nail plate and periungual region were not involved. A shave biopsy of the papule was obtained. Histopathology demonstrated dermal stellate spindle cells arranged in a loose fascicular pattern with marked mucin deposition throughout the dermis (Figure 4). Lesional cells were positive for CD34. An S-100 stain highlighted dermal dendritic cells, but lesional cells were negative. No further excision was undertaken, and there was no evidence of recurrence at 1-year follow-up. The diagnosis of SAFM was made based on the acral location, histopathologic appearance, and immunohistochemical profile of the tumor.

Patient 3

A 45-year-old woman presented with asymptomatic distal onycholysis of the right thumbnail of 1 year’s duration. She denied any history of trauma, and no bleeding or pigmentary changes were noted. Physical examination revealed a 5-mm flesh-colored papule on the hyponychium of the right thumb with focal onycholysis (Figure 5). A wedge biopsy of the lesion was performed. Histopathology showed an intradermal nodular proliferation of bland spindle cells arranged in loose fascicles and bundles and embedded in a myxoid stroma (Figure 6). CD34 staining strongly highlighted lesional cells. S-100 and neurofilament stains were negative. The diagnosis of SAFM was made based on the acral location, histopathologic appearance, and immunohistochemical profile of the tumor.

Comment

Clinically, SAFM typically presents as a slow-growing solitary nodule on the distal fingers or toes. The great toe is the most commonly affected digit, and the tumor may be subungual in up to two-thirds of cases.¹ Unusual locations, such as the heel, also have been reported.² Onset typically occurs in the fifth or sixth decade, and there is an approximately 2-fold higher incidence in men than women.^1-3

Histopathologically, SAFM is a characteristically well-circumscribed but unencapsulated dermal tumor composed of spindle and stellate cells in a loose storiform or fascicular arrangement embedded in a myxoid, myxocollagenous, or collagenous stroma.⁴ The tumor often occupies the entire dermis and may extend into the subcutis or occasionally the underlying fascia and bone.^4,5 Mast cells often are prominent, and microvascular accentuation also may be seen. Inflammatory infiltrates and multinucleated giant cells typically are not seen.⁶ Although 2 cases of atypical SAFM have been described,² cellular atypia is not a characteristic feature of SAFM.

The immunohistochemical profile of SAFM is characterized by diffuse or focal expression of CD34, focal expression of epithelial membrane antigen (EMA), CD99 expression, and varying numbers of factor XIIIa–positive histiocytes.^2,3 Positive staining for vimentin also is common. Staining typically is negative for S-100, human melanoma black 45, keratin, smooth muscle actin, and desmin.

The standard treatment of SAFM is complete local resection of the tumor, though some patients have been treated with partial excision or biopsy and partial or complete digital amputation.¹ Local recurrence may occur in up to 20% of cases; however, approximately two-thirds of the reported recurrences in the literature occurred after incomplete tumor excision.^1,2 It may be more appropriate to consider these cases as persistent rather than recurrent tumors. Superficial acral fibromyxoma is considered a benign tumor, with no known cases of metastases.⁴

Figure 5. A firm flesh-colored papule on the hyponychium of the right thumb prior to biopsy. Figure 6. Intradermal nodular proliferation of bland spindle cells arranged in loose fascicles and bundles and embedded in a myxoid stroma (H&E, original magnification ×40).

A broad differential diagnosis exists for SAFM and it can be difficult to differentiate it from a wide variety of benign and malignant tumors that may be seen on the nail unit and distal extremities (Table). Myxoid neurofibromas typically present as solitary lesions on the hands and feet. Similar to SAFM, myxoid neurofibromas are unencapsulated dermal tumors composed of spindle-shaped cells in which mast cells often are conspicuous.^2,7 However, tumor cells in myxoid neurofibromas are S-100 positive, and the lesions typically do not show vasculature accentuation.^4,7

Sclerosing perineuriomas are benign fibrous tumors of the fingers and palms. Histopathologically, bland spindle cells arranged in fascicles and whorls are observed in a hyalinized collagen matrix.⁸ Immunohistochemically, sclerosing perineuriomas are positive for EMA and negative for S-100, but unlike SAFM, these tumors usually are CD34 negative.⁸

Superficial angiomyxomas typically are located on the head and neck but also may be found in other locations such as the trunk. They present as cutaneous papules or polypoid lesions. Histopathologically, superficial angiomyxomas are poorly circumscribed with a lobular pattern. Spindle-shaped fibroblasts exist in a myxoid matrix with neutrophils and thin-walled capillaries. The fibroblasts are variably positive for CD34 but also are S-100 positive.^1,9

Myxoid dermatofibrosarcoma protuberans is a rare, locally aggressive, mesenchymal tumor of the skin and subcutis² that typically presents on the trunk, proximal extremities, or head and neck; occurrence on the fingers or toes is exceedingly rare.^2,10 Histopathologically, a myxoid stroma contains sheets of bland spindle-shaped cells with minimal to no atypia, sometimes arranged in a storiform pattern. The tumor characteristically invades deeply into the subcutaneous tissues. CD34 is characteristically positive and S-100 is negative.^2,10

Low-grade myxofibrosarcoma is a soft tissue sarcoma easily confused with other spindle cell tumors. It is one of the most common sarcomas in adults but rarely arises in acral areas.² It is characterized by a nodular growth pattern with marked nuclear atypia and perivascular clustering of tumor cells. CD34 staining may be positive in some cases.¹¹

Similar to SAFM, myxoinflammatory fibroblastic sarcoma has a predilection for the extremities.⁴ However, it typically presents as a subcutaneous mass and has no documented tendency for nail bed involvement. Also unlike SAFM, it has a remarkable inflammatory infiltrate and characteristic virocyte or Reed-Sternberg cells.¹²

Acquired digital fibrokeratomas are benign neoplasms that occur on fingers and toes; the classic clinical presentation is a solitary smooth nodule or dome, often with a characteristic projecting configuration and horn shape.¹ Histopathologically, these tumors are paucicellular with thick, vertically oriented, interwoven collagen bundles; cells may be positive for CD34 but are negative for EMA.^1,13 Related to acquired digital fibrokeratomas are Koenen tumors, which share a similar histology but are distinguished by their clinical characteristics. For example, Koenen tumors tend to be multifocal and are strongly associated with tuberous sclerosis. These tumors also have a tendency to recur.¹

Conclusion

Our report of 3 typical cases of SAFM highlights the need to keep this increasingly recognized and well-defined clinicopathological entity in the differential for slow-growing tumors in acral locations, particularly those in the periungual and subungual regions.

First described by Fetsch et al¹ in 2001, superficial acral fibromyxoma (SAFM) is a rare fibromyxoid mesenchymal tumor that typically affects the fingers and toes with frequent involvement of the nail unit. It is not widely recognized and remains poorly understood. We describe a series of 3 cases of SAFM encountered at our institution and provide a review of the literature on this unique tumor.

Case Reports

Patient 1

A 35-year-old man presented for treatment of a “wart” on the right fifth toe that had increased in size over the last year. He reported that the lesion was mildly painful and occasionally bled or drained clear fluid. He also noted cracking of the nail plate on the same toe. Physical examination revealed a firm, flesh-colored, 3-mm dermal papule on the proximal nail fold of the right fifth toe with subtle flattening of the underlying nail plate (Figure 1). The patient underwent biopsy of the involved proximal nail fold. Histopathology revealed a proliferation of small oval and spindle cells arranged in fascicles and bundles in the dermis (Figure 2). There was extensive mucin deposition associated with the spindle cell proliferation. Additionally, spindle cells and mucin surrounded and entrapped collagen bundles on the periphery of the lesion. Lesional cells were diffusely positive for CD34 and extended to the deep surgical margin (Figure 3). S-100 and factor XIIIa stains were negative. The diagnosis of SAFM was made based on the acral location, histopathologic appearance, and immunohistochemical profile of the tumor.

Figure 1. Firm dermal papule on the proximal nail fold of the right fifth toe with associated nail plate dystrophy. Figure 2. Small oval and spindle cells arranged in fascicles and bundles in the dermis, with extensive mucin deposition and collagen trapping (H&E, original magnification ×100). Figure 3. Tumor cells were positive on CD34 staining (original magnification ×40). Figure 4. Dermal stellate spindle cells arranged in a loose fascicular pattern with marked mucin deposition (H&E, original magnification ×400).

Patient 2

A 47-year-old man presented with an asymptomatic growth on the left fourth toe that had increased in size over the last year. Physical examination revealed an 8-mm, firm, fleshy, flesh-colored, smooth and slightly pedunculated papule on the distal aspect of the left fourth toe. The nail plate and periungual region were not involved. A shave biopsy of the papule was obtained. Histopathology demonstrated dermal stellate spindle cells arranged in a loose fascicular pattern with marked mucin deposition throughout the dermis (Figure 4). Lesional cells were positive for CD34. An S-100 stain highlighted dermal dendritic cells, but lesional cells were negative. No further excision was undertaken, and there was no evidence of recurrence at 1-year follow-up. The diagnosis of SAFM was made based on the acral location, histopathologic appearance, and immunohistochemical profile of the tumor.

Patient 3

A 45-year-old woman presented with asymptomatic distal onycholysis of the right thumbnail of 1 year’s duration. She denied any history of trauma, and no bleeding or pigmentary changes were noted. Physical examination revealed a 5-mm flesh-colored papule on the hyponychium of the right thumb with focal onycholysis (Figure 5). A wedge biopsy of the lesion was performed. Histopathology showed an intradermal nodular proliferation of bland spindle cells arranged in loose fascicles and bundles and embedded in a myxoid stroma (Figure 6). CD34 staining strongly highlighted lesional cells. S-100 and neurofilament stains were negative. The diagnosis of SAFM was made based on the acral location, histopathologic appearance, and immunohistochemical profile of the tumor.

Comment

Clinically, SAFM typically presents as a slow-growing solitary nodule on the distal fingers or toes. The great toe is the most commonly affected digit, and the tumor may be subungual in up to two-thirds of cases.¹ Unusual locations, such as the heel, also have been reported.² Onset typically occurs in the fifth or sixth decade, and there is an approximately 2-fold higher incidence in men than women.^1-3

Histopathologically, SAFM is a characteristically well-circumscribed but unencapsulated dermal tumor composed of spindle and stellate cells in a loose storiform or fascicular arrangement embedded in a myxoid, myxocollagenous, or collagenous stroma.⁴ The tumor often occupies the entire dermis and may extend into the subcutis or occasionally the underlying fascia and bone.^4,5 Mast cells often are prominent, and microvascular accentuation also may be seen. Inflammatory infiltrates and multinucleated giant cells typically are not seen.⁶ Although 2 cases of atypical SAFM have been described,² cellular atypia is not a characteristic feature of SAFM.

The immunohistochemical profile of SAFM is characterized by diffuse or focal expression of CD34, focal expression of epithelial membrane antigen (EMA), CD99 expression, and varying numbers of factor XIIIa–positive histiocytes.^2,3 Positive staining for vimentin also is common. Staining typically is negative for S-100, human melanoma black 45, keratin, smooth muscle actin, and desmin.

The standard treatment of SAFM is complete local resection of the tumor, though some patients have been treated with partial excision or biopsy and partial or complete digital amputation.¹ Local recurrence may occur in up to 20% of cases; however, approximately two-thirds of the reported recurrences in the literature occurred after incomplete tumor excision.^1,2 It may be more appropriate to consider these cases as persistent rather than recurrent tumors. Superficial acral fibromyxoma is considered a benign tumor, with no known cases of metastases.⁴

Figure 5. A firm flesh-colored papule on the hyponychium of the right thumb prior to biopsy. Figure 6. Intradermal nodular proliferation of bland spindle cells arranged in loose fascicles and bundles and embedded in a myxoid stroma (H&E, original magnification ×40).

A broad differential diagnosis exists for SAFM and it can be difficult to differentiate it from a wide variety of benign and malignant tumors that may be seen on the nail unit and distal extremities (Table). Myxoid neurofibromas typically present as solitary lesions on the hands and feet. Similar to SAFM, myxoid neurofibromas are unencapsulated dermal tumors composed of spindle-shaped cells in which mast cells often are conspicuous.^2,7 However, tumor cells in myxoid neurofibromas are S-100 positive, and the lesions typically do not show vasculature accentuation.^4,7

Sclerosing perineuriomas are benign fibrous tumors of the fingers and palms. Histopathologically, bland spindle cells arranged in fascicles and whorls are observed in a hyalinized collagen matrix.⁸ Immunohistochemically, sclerosing perineuriomas are positive for EMA and negative for S-100, but unlike SAFM, these tumors usually are CD34 negative.⁸

Superficial angiomyxomas typically are located on the head and neck but also may be found in other locations such as the trunk. They present as cutaneous papules or polypoid lesions. Histopathologically, superficial angiomyxomas are poorly circumscribed with a lobular pattern. Spindle-shaped fibroblasts exist in a myxoid matrix with neutrophils and thin-walled capillaries. The fibroblasts are variably positive for CD34 but also are S-100 positive.^1,9

Myxoid dermatofibrosarcoma protuberans is a rare, locally aggressive, mesenchymal tumor of the skin and subcutis² that typically presents on the trunk, proximal extremities, or head and neck; occurrence on the fingers or toes is exceedingly rare.^2,10 Histopathologically, a myxoid stroma contains sheets of bland spindle-shaped cells with minimal to no atypia, sometimes arranged in a storiform pattern. The tumor characteristically invades deeply into the subcutaneous tissues. CD34 is characteristically positive and S-100 is negative.^2,10

Low-grade myxofibrosarcoma is a soft tissue sarcoma easily confused with other spindle cell tumors. It is one of the most common sarcomas in adults but rarely arises in acral areas.² It is characterized by a nodular growth pattern with marked nuclear atypia and perivascular clustering of tumor cells. CD34 staining may be positive in some cases.¹¹

Similar to SAFM, myxoinflammatory fibroblastic sarcoma has a predilection for the extremities.⁴ However, it typically presents as a subcutaneous mass and has no documented tendency for nail bed involvement. Also unlike SAFM, it has a remarkable inflammatory infiltrate and characteristic virocyte or Reed-Sternberg cells.¹²

Acquired digital fibrokeratomas are benign neoplasms that occur on fingers and toes; the classic clinical presentation is a solitary smooth nodule or dome, often with a characteristic projecting configuration and horn shape.¹ Histopathologically, these tumors are paucicellular with thick, vertically oriented, interwoven collagen bundles; cells may be positive for CD34 but are negative for EMA.^1,13 Related to acquired digital fibrokeratomas are Koenen tumors, which share a similar histology but are distinguished by their clinical characteristics. For example, Koenen tumors tend to be multifocal and are strongly associated with tuberous sclerosis. These tumors also have a tendency to recur.¹

Conclusion

Our report of 3 typical cases of SAFM highlights the need to keep this increasingly recognized and well-defined clinicopathological entity in the differential for slow-growing tumors in acral locations, particularly those in the periungual and subungual regions.

ORLANDO – In a patient presenting with a tender, firm lesion under the nail, think subungual exostosis, Dr. Phoebe Rich advised.

Subungual exostosis is a benign bony growth that can cause discomfort by pressing up from the nail bed. It can be mistaken for onychomycosis, but keep in mind that only 50% of those presenting with nail disorders will have onychomycosis, so it is important to consider other diagnoses, Dr. Rich, director of the Nail Disorder Center at Oregon Health and Science University, Portland, said at the Orlando Dermatology Aesthetic and Clinical Conference.

She described a teenager who presented with a growth under her nail, which the patient thought was nail fungus. The lesion developed after an injury experienced during a touch football game 2 months earlier.

An X-ray will aid in the diagnosis of such lesions, Dr. Rich said.

“You want to know that’s what it is … because you don’t want to just cut into it for a biopsy if you don’t know that it’s bone,” she said.

The diagnosis can be confirmed by removing the nail to take a look at the tumor.

“They are pretty characteristic. They are a bony growth. They’re actually composed of bone with a fibro-cartilaginous cap,” she said noting that tenderness is an important clue to the diagnosis.

Subungual exostosis occurs more often in toes than fingers, more often in girls than boys, and more often in children and young adults than older individuals, Dr. Rich noted.

Surgical removal is typically successful; the recurrence rate is about 10%, and recurrence is more common in children.

Presentation varies; some lesions can be quite obvious, with the growth protruding from under the nail, while others are more subtle. Dr. Rich described one young college student who presented with slight white spotting of the nail, and slight onycholysis. The patient had tenderness of the nail area when pressed, and the tumor peeked out from under the nail.

“If you see something like this, get an X-ray,” she said, adding: “You can be a hero and make the diagnosis. Don’t just treat it as though it’s a fungus.”

“If you’re very comfortable and expert at nails, great. Otherwise, make the diagnosis and send them to someone else, but you can really help these patients a lot,” she said.

Dr. Rich has participated in clinical trials with companies with antifungal/onychomycosis drugs, including Anacor, Merz, and Valeant.

ORLANDO – In a patient presenting with a tender, firm lesion under the nail, think subungual exostosis, Dr. Phoebe Rich advised.

Subungual exostosis is a benign bony growth that can cause discomfort by pressing up from the nail bed. It can be mistaken for onychomycosis, but keep in mind that only 50% of those presenting with nail disorders will have onychomycosis, so it is important to consider other diagnoses, Dr. Rich, director of the Nail Disorder Center at Oregon Health and Science University, Portland, said at the Orlando Dermatology Aesthetic and Clinical Conference.

She described a teenager who presented with a growth under her nail, which the patient thought was nail fungus. The lesion developed after an injury experienced during a touch football game 2 months earlier.

An X-ray will aid in the diagnosis of such lesions, Dr. Rich said.

“You want to know that’s what it is … because you don’t want to just cut into it for a biopsy if you don’t know that it’s bone,” she said.

The diagnosis can be confirmed by removing the nail to take a look at the tumor.

“They are pretty characteristic. They are a bony growth. They’re actually composed of bone with a fibro-cartilaginous cap,” she said noting that tenderness is an important clue to the diagnosis.

Subungual exostosis occurs more often in toes than fingers, more often in girls than boys, and more often in children and young adults than older individuals, Dr. Rich noted.

Surgical removal is typically successful; the recurrence rate is about 10%, and recurrence is more common in children.

Presentation varies; some lesions can be quite obvious, with the growth protruding from under the nail, while others are more subtle. Dr. Rich described one young college student who presented with slight white spotting of the nail, and slight onycholysis. The patient had tenderness of the nail area when pressed, and the tumor peeked out from under the nail.

“If you see something like this, get an X-ray,” she said, adding: “You can be a hero and make the diagnosis. Don’t just treat it as though it’s a fungus.”

“If you’re very comfortable and expert at nails, great. Otherwise, make the diagnosis and send them to someone else, but you can really help these patients a lot,” she said.

Dr. Rich has participated in clinical trials with companies with antifungal/onychomycosis drugs, including Anacor, Merz, and Valeant.

ORLANDO – In a patient presenting with a tender, firm lesion under the nail, think subungual exostosis, Dr. Phoebe Rich advised.

Subungual exostosis is a benign bony growth that can cause discomfort by pressing up from the nail bed. It can be mistaken for onychomycosis, but keep in mind that only 50% of those presenting with nail disorders will have onychomycosis, so it is important to consider other diagnoses, Dr. Rich, director of the Nail Disorder Center at Oregon Health and Science University, Portland, said at the Orlando Dermatology Aesthetic and Clinical Conference.

She described a teenager who presented with a growth under her nail, which the patient thought was nail fungus. The lesion developed after an injury experienced during a touch football game 2 months earlier.

An X-ray will aid in the diagnosis of such lesions, Dr. Rich said.

“You want to know that’s what it is … because you don’t want to just cut into it for a biopsy if you don’t know that it’s bone,” she said.

The diagnosis can be confirmed by removing the nail to take a look at the tumor.

“They are pretty characteristic. They are a bony growth. They’re actually composed of bone with a fibro-cartilaginous cap,” she said noting that tenderness is an important clue to the diagnosis.

Subungual exostosis occurs more often in toes than fingers, more often in girls than boys, and more often in children and young adults than older individuals, Dr. Rich noted.

Surgical removal is typically successful; the recurrence rate is about 10%, and recurrence is more common in children.

Presentation varies; some lesions can be quite obvious, with the growth protruding from under the nail, while others are more subtle. Dr. Rich described one young college student who presented with slight white spotting of the nail, and slight onycholysis. The patient had tenderness of the nail area when pressed, and the tumor peeked out from under the nail.

“If you see something like this, get an X-ray,” she said, adding: “You can be a hero and make the diagnosis. Don’t just treat it as though it’s a fungus.”

“If you’re very comfortable and expert at nails, great. Otherwise, make the diagnosis and send them to someone else, but you can really help these patients a lot,” she said.

Dr. Rich has participated in clinical trials with companies with antifungal/onychomycosis drugs, including Anacor, Merz, and Valeant.

Topical treatment of toenail onychomycosis is effective with several antifungals, Dr. Aditya Gupta of the University of Toronto and his associates reported in an evidence-based review.

The researchers identified 28 relevant studies, 13 of which were of high quality. Four antifungals were an effective cure for mild to moderate toenail onychomycosis: amorolfine, ciclopirox, tavaborole, and efinaconazole. Efinaconazole was the most effective, but in all cases, outcomes were improved with longer treatment times and follow-ups.

Oral treatments are usually more effective for toenail onychomycosis, but are not always possible because of drug interactions, so topical treatments are important in certain patient populations, the investigators noted in the article abstract.

The article abstract can be found online in the American Journal of Clinical Dermatology (doi:10.1007/s40257-014-0096-2).

Topical treatment of toenail onychomycosis is effective with several antifungals, Dr. Aditya Gupta of the University of Toronto and his associates reported in an evidence-based review.

The researchers identified 28 relevant studies, 13 of which were of high quality. Four antifungals were an effective cure for mild to moderate toenail onychomycosis: amorolfine, ciclopirox, tavaborole, and efinaconazole. Efinaconazole was the most effective, but in all cases, outcomes were improved with longer treatment times and follow-ups.

Oral treatments are usually more effective for toenail onychomycosis, but are not always possible because of drug interactions, so topical treatments are important in certain patient populations, the investigators noted in the article abstract.

The article abstract can be found online in the American Journal of Clinical Dermatology (doi:10.1007/s40257-014-0096-2).

Topical treatment of toenail onychomycosis is effective with several antifungals, Dr. Aditya Gupta of the University of Toronto and his associates reported in an evidence-based review.

The researchers identified 28 relevant studies, 13 of which were of high quality. Four antifungals were an effective cure for mild to moderate toenail onychomycosis: amorolfine, ciclopirox, tavaborole, and efinaconazole. Efinaconazole was the most effective, but in all cases, outcomes were improved with longer treatment times and follow-ups.

Oral treatments are usually more effective for toenail onychomycosis, but are not always possible because of drug interactions, so topical treatments are important in certain patient populations, the investigators noted in the article abstract.

The article abstract can be found online in the American Journal of Clinical Dermatology (doi:10.1007/s40257-014-0096-2).

Photodynamic antimicrobial chemotherapy is an effective option for treatment of in vitro onychomycosis, according to Dr. Tarun Mehra of Eberhard Karls University, Tübingen, Germany, and his associates.

In both a microdilution assay and a onychomycosis model, photodynamic antimicrobial chemotherapy (PACT) was effective in suppressing Trichophyton rubrum in conjunction with toluidine blue O (TBO) and LED irradiation. In another test, a patient diagnosed with distolateral onychomycosis was treated with TBO and PACT and experienced a significant improvement in nail health over the next 6 months while receiving no other treatments.

The long-term normalization of the patients’ nails suggests that PACT is a persistent cure, but patients with more than 50% of the nail affected may be more difficult to treat with PACT, the researchers said.

Read the full article online in the Journal of the European Academy of Dermatology and Venereology (doi:10:1111/jdv.12467).

Photodynamic antimicrobial chemotherapy is an effective option for treatment of in vitro onychomycosis, according to Dr. Tarun Mehra of Eberhard Karls University, Tübingen, Germany, and his associates.

In both a microdilution assay and a onychomycosis model, photodynamic antimicrobial chemotherapy (PACT) was effective in suppressing Trichophyton rubrum in conjunction with toluidine blue O (TBO) and LED irradiation. In another test, a patient diagnosed with distolateral onychomycosis was treated with TBO and PACT and experienced a significant improvement in nail health over the next 6 months while receiving no other treatments.

The long-term normalization of the patients’ nails suggests that PACT is a persistent cure, but patients with more than 50% of the nail affected may be more difficult to treat with PACT, the researchers said.

Read the full article online in the Journal of the European Academy of Dermatology and Venereology (doi:10:1111/jdv.12467).

Photodynamic antimicrobial chemotherapy is an effective option for treatment of in vitro onychomycosis, according to Dr. Tarun Mehra of Eberhard Karls University, Tübingen, Germany, and his associates.

In both a microdilution assay and a onychomycosis model, photodynamic antimicrobial chemotherapy (PACT) was effective in suppressing Trichophyton rubrum in conjunction with toluidine blue O (TBO) and LED irradiation. In another test, a patient diagnosed with distolateral onychomycosis was treated with TBO and PACT and experienced a significant improvement in nail health over the next 6 months while receiving no other treatments.

The long-term normalization of the patients’ nails suggests that PACT is a persistent cure, but patients with more than 50% of the nail affected may be more difficult to treat with PACT, the researchers said.

Read the full article online in the Journal of the European Academy of Dermatology and Venereology (doi:10:1111/jdv.12467).