Francesca Bruni

Dermoscopy of non-skin cancer nail disorders.

Nail dermoscopy is becoming more and more frequently utilized for the diagnosis of nail disorders. It can be performed with handy dermoscope or with a video dermoscope, which allows magnifications of up to 200. Nail dermoscopy requires a good knowledge of nail anatomy and physiology and the pathogenesis of nail diseases: we have to know which part of the nail we have to look at! The nail is in fact not visible as a whole at one time, but its different parts should be observed, moving the lens back and forth and transversally. All nail disorders can be observed by dermoscopy. However, except for some diseases in which the technique really adds a lot to clinical examination, in most of the cases, nail dermoscopy only permits a better visualization of symptoms already evident to the naked eye. Dermoscopic features of nail signs are always very interesting and surprising, and may help in our understanding of nails.

Erosive pustular dermatosis of the scalp: Clinical, trichoscopic, and histopathologic features of 20 cases

Background Erosive pustular dermatosis of the scalp is a chronic eruption that leads to scarring alopecia. Objective The clinical, dermoscopic, and histopathological features and the course of the disease in 20 patients were reviewed and compared with the reports in the literature. Methods Gender, age at diagnosis, age at onset, duration, topography, predisposing factors, concomitant diseases, trichoscopy, histology, treatment, and outcome were taken into consideration. Results The mean age was 59.4 years. Androgenetic alopecia was present in 12 patients, 6 of whom showed actinic damage. Trauma was reported in 9 patients. Four patients were affected by autoimmune disorders. The vertex was the most common location. In all 20 patients trichoscopy showed an absence of follicular ostia with skin atrophy. Histopathology revealed 3 different features, depending on the disease duration. A reduction of inflammatory signs was observed in 14 patients treated with topical steroids and in all 3 patients treated with topical tacrolimus 0.1%. Limitations The rarity of this disease is a limitation. Conclusions The relatively high number of patients allowed us to identify a better diagnostic approach, using trichoscopy, and a more effective therapeutic strategy, with high‐potency steroids or tacrolimus, which should be considered as first‐line treatment.

Nail apparatus melanoma: dermoscopic and histopathologic correlations on a series of 23 patients from a single centre

Nail apparatus melanoma (NAM) is an uncommon tumour, and there are few studies focused on its dermoscopic features.

Acute periungueal dermatitis induced by application of urea-containing cream under occlusion.

BACKGROUND Urea containing topical products are extensively marked for treatment of nail diseases. Side effects are rare and mainly include irritation of the periungual skin, when topicals with high urea concentration are applied too widely on the digit, or covered by tape. MAIN OBSERVATION We report a case of a 84-year-old man with an erosive-bullous eruption of the 1st and the 2nd left toes due to application of an urea-containing cream, that he had regularly applied every night covering the digit with a plastic bandage. Suspecting an allergic contact dermatitis, we performed patch test with the Italian Standard series called SIDAPA and the product (Xérial 50 Extrême cream®) itself. Patch test readings showed a positive reaction to colophony contained in the plastic band and to the cream. CONCLUSION Our case is the first report of allergic contact dermatitis to a cream containing a high concentration urea utilized for treatment of nail thickening under occlusion.

Platelet-rich plasma on female androgenetic alopecia: Tested on 10 patients

Recently, platelet‐rich plasma (PRP) injection has been proposed as a potential adjuvant therapy to treat androgenetic alopecia.

Treatment of nail psoriasis with topical application of clobetasol propionate 0.05% solution: a pilot study

Nail psoriasis more commonly affects fingernails than toenails and can involve both the nail bed and the nail matrix. In general, given the difficulty of topical agents to penetrate to the nail matrix, the involvement of the nail bed is associated with better therapeutic results [1, 2]. One of the main goals for successful therapy is the cosmetic acceptability of the most common topical products, which can lead to improved patient adherence to treatment and efficacy. Current topical therapies include drugs vehicled in creams and ointments that are often scarcely liked by patients, because they are greasy and difficult to apply on nail bed and periungueal tissues. The aim of our study was to evaluate the efficacy, tolerability, and patient compliance of topical therapy with clobetasol propionate 0.05%, vehicled in a solution for nail psoriasis. In total, 15 psoriatic patients (seven males and eight females, aged 18-50 years) with nail involvement were included in this clinical open pilot study. For all patients, the diagnosis of nail psoriasis was established on clinical grounds, as well as their medical history. The only study inclusion criterion was the presence of any macroscopic lesion in the nail unit typical of the disease, such as oil-drop discolouration, splinter haemorrhages, subungual hyperkeratosis, onycholysis, irregular pitting, leukonychia, red spots of the lunula, and nail plate crumbling. All the patients were affected by isolated nail psoriasis of one to three digits; eight patients presented nail bed involvement with onycholysis and subungual hyperkeratosis, while seven patients also had signs of matrix disease, namely pitting and nail plate surface abnormalities. Onychomycosis was excluded by direct microscopy and culture. All patients were evaluated according to the Nail Psoriasis Severity Index (NAPSI) [3], both at the beginning and at the end of the study. Patients underwent periodic clinical evaluation every two months and the treatment efficacy was assessed by iconography. At the end of treatment, patients were asked to give their opinion on tolerability and ease of application. None of the patients was receiving additional systemic and/or topical treatment. The product was applied once daily for four to six months on the periungual tissues and nail bed using a small eyeshadow brush. Each of the enrolled patients completed the study. Ten of 15 patients showed a marked improvement of the nail lesions and five of 15 achieved complete resolution of the PATIENT NUMBER

Efficacious and safe management of thick scales, redness and flaky scalp condition using a specific shampoo containing urea, glycolic acid, salicylic acid, icthyol pale and laureth 9

Abstract Dandruff is a common condition, generally due to seborrheic dermatitis (SD) and occasionally to scalp psoriasis (SP), which is characterized by accumulation of scales, oily, red and flaky scalp, often accompanied by itch. The aim of our study was to evaluate the cleansing efficacy and tolerability of a new shampoo (Psorisdin Shampoo®) containing urea, glycolic acid, salicylic acid, ichthyol pale and laureth 9 compared to a nonspecific shampoo. A total of 10 subjects (4 males and 6 females, 18–60 years) with mild–moderate scalp inflammation with redness, itching and flaking, due to SP and/or SD, were included in this open clinical study. The treatment efficacy was assessed by comparison of global photography and trichoscopy pictures, evaluating the presence of scales and erythema on the scalp, the number and morphology of capillaries and verifying disease evolution, severity of symptoms and presence of scalp irritation/itch. The use of this medicated shampoo resulted in an important improvement of patient’s scalp and hair clinical appearance and was well tolerated, with disappearance of scalp irritation and itching in almost all patients, showing higher cleansing and soothing property than a nonspecific shampoo. The effect of the tested shampoo was maintained over time, even after 5 days since the last wash.

The doll hairline: A clue for the diagnosis of frontal fibrosing alopecia

CLINICAL CHALLENGE Frontal fibrosing alopecia (FFA) is a variant of lichen planopilaris, which predominantly affects postmenopausal women and the incidence of which is constantly increasing all over the world. FFA is characterized by a band of scarring alopecia localized in the frontal, temporal and parietal hairline and is often associated with a partial or complete loss of eyebrows. The clinical manifestations of FFA, once established, are very characteristic; however, differential diagnosis with other types of alopecia may be complex when the disease is in its initial stages. The early detection of its peculiar hairline recessionwill enable diagnosis and treatment at an earlier stage (before involvement of the entire scalp), thus improving therapeutic outcomes.

Subungual myiasis: An unusual complication of taxane chemotherapy

A 68-year-old woman was referred to us by her oncologist for the presence of peculiar whitish substances under the right great toenail. The patient had been diagnosed with a breast carcinoma 6 months prior to presentation and had been treated with surgery and six cycles of paclitaxel, with optimal outcome and tolerability. She was concluding the last cycle when she noticed a black nail discoloration of the right great toenail and mild pain. No fever or other systemic symptoms were reported. Aware of the possible side-effects of chemotherapy, the patient had preferred to keep the nail long for aesthetic reasons rather than clip it. On the morning of our observation the patient noticed the presence of many whitish, subungual moving masses. A clinical examination showed an onycholytic nail plate under which white larvae were emerging. Removal of the nail plate disclosed an eroded nail bed (Fig. 1a) and we were able to extract 11 larvae, all approximately 10 mm in length. The presence of posterior spiracles lying within a hollow (Fig. 1b) represents a typical feature of Sarcophagidae. In the interview with the patient no psychiatric disorders or other predisposing ectoparasitic infestation factors emerged. She had high socioeconomic status and took great hygienic care of her person. She denied having had recent trips to subtropical and tropical countries but that summer had been particularly hot and humid in Italy. Laboratory investigations were normal. We performed a diagnosis of taxane-induced acute onycholysis due to nail bed toxicity, infested by sarcophagid larvae. The patient was treated with daily footbaths with an antiseptic solution followed by medication with topical antibiotics and oral amoxicillin (2 g/day) for 5 days. At follow up, after 10 days, the nail bed was free from larvae and the erosion was partly epithelialised. Topical antibiotics were continued until complete healing. Acute, painful onycholysis is a well-known side effect of taxanes, affecting up to 44% of patients. Nail changes are especially due to docetaxel, and are dose-dependent and vary in severity, manifesting after 2–3 treatment cycles. The pathogenesis is thought to be a selective toxic effect of taxanes on the nail bed epithelium, which is typically acutely damaged with erosions. Taxane-induced peripheral neuropathy may also be a cofactor responsible for distal ischaemic changes, leading to nail bed epithelium damage. Frequent complications of taxane-induced onycholysis include haemorrhages, thrombocytopenia and bacterial infections. Myiasis is an ectoparasitic infestation of living tissues sustained by maggots, the immature form of flies (Diptera), which are responsible for a semi-specific or opportunistic infestation. It is rare in Europe but is reported mostly during the summer or in predisposed individuals who have exposed skin wounds and usually in poor hygienic conditions. A subungual location is a very rare occurrence of myiasis. The maintenance of the detached nail plate produced a niche and the haemorrhagic and necrotic debris ofthe nail bed provided a suitable environment for fly maggots. This case underlines the necessity to remove the onycholytic nail plate in all cases of nail detachment, especially when nail bed erosion is associated. Removing, cleaning and disinfecting the wound area is helpful in avoiding inflammation as well as maggot infestation.

Periungual Pyogenic Granuloma: The Importance of the Medical History

Pyogenic granuloma (PG) is a common, benign vascular proliferation that can arise on the skin or subcutaneous tissue. It is more frequent in the early decades of life, and the most common locations are the digits of both hands and feet. The most common cause of periungual PG is drug intake, but many other trigger factors have been described in the literature. Treatment should be chosen according to the cause. We describe 2 particular cases of periungual PG in which the clinical history has been fundamental. In the first case, there was an underlying hand eczema, and in the second case, a foreign body was present.