Nathaniel J. Jellinek

Longitudinal erythronychia: Suggestions for evaluation and management

Longitudinal erythronychia is a frequent nail presentation with a limited differential diagnosis. This clinical entity may be divided into cases that involve one (localized) or multiple (polydactylous) nails. The different presentations have distinct differential diagnoses and workups yet often share a common pathogenesis. Localized longitudinal erythronychia most commonly represents onychopapilloma, yet malignancies may present identically. Therefore biopsy may be required. Polydactylous longitudinal erythronychia usually coincides with a regional or systemic cause. Occasionally, it may herald an important underlying disease. A thorough understanding of the pathogenesis, clinical presentations, and possible diagnoses is necessary for successful evaluation and management.

Multiple antithrombotic agents increase the risk of postoperative hemorrhage in dermatologic surgery

BACKGROUND Studies show that holding single antithrombotic agents perioperatively increases the risk of acute thrombotic events and does not significantly decrease the risk of bleeding complications in dermatological surgery. Recent data suggest that selected patients may benefit from combination therapy in preventing acute thrombotic events. OBJECTIVE We sought to evaluate postoperative bleeding complications in patients who underwent Mohs micrographic surgery while using multiple agents perioperatively compared with patients using a single agent or none at all. METHODS We conducted a retrospective chart review of patients treated in one academic Mohs micrographic surgery department during 1 year. RESULTS Patients taking two or more agents at the time of surgery were more likely to bleed than those taking one agent or none at all (P = .0016, Fishers exact). LIMITATIONS Small sample size and retrospective nature were limitations. CONCLUSION Perioperative use of more than one antithrombotic agent increases postoperative bleeding risk.

Nail surgery: practical tips and treatment options

ABSTRACT:  This paper provides an introductory overview of nail surgery, including basic principles, anesthesia, wound dressings, and several common nail procedures. In detail, it reviews how to achieve complete anesthesia and hemostasis, perform matrix injection, punch biopsy of the plate, bed, and matrix, and nail fold biopsy, with practical tips and suggested surgical indications.

Alternatives to complete nail plate avulsion

Successful nail surgery requires exposure of the underlying tissues. In many cases, partial nail plate avulsion is preferable compared with traditional total distal and proximal plate avulsions. The techniques described herein include partial distal, lateral, proximal, and window techniques, and two variation of the total plate avulsion termed the trap door and lateral nail plate curl avulsion. By using these methods, the surgeon is able to access the targeted nail unit while minimizing trauma to adjacent, uninvolved tissue.

Onychopapilloma presenting as longitudinal leukonychia

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Melanoma and squamous cell carcinoma on different nails of the same hand

Nail dyschromia, including melanonychia and erythronychia, encompasses a wide range of possible diagnoses. While the majority of these lesions are benign, malignancies of the nail unit represent a sinister, and potentially life-threatening, cause of nail dyschromia. Unfamiliarity with tumors of the nail apparatus can lead to a delay in diagnosis. A case is presented of a patient with two separate and concurrent malignant neoplasms of the nail unit, on different nails on the same hand, each featuring an unusual clinical presentation: amelanotic melanoma presenting as longitudinal erythronychia and squamous cell carcinoma in situ presenting as longitudinal melanonychia. This presentation underscores the need for a low threshold for biopsy in the presence of nail dyschromia of uncertain etiology.

Guidelines for the use of local anesthesia in office-based dermatologic surgery

There are an increasing number and variety of dermatologic surgical procedures performed safely in the office setting. This evidence-based guideline addresses important clinical questions that arise regarding the use and safety of local anesthesia for dermatologic office-based procedures. In addition to recommendations for dermatologists, this guideline also takes into account patient preferences while optimizing their safety and quality of care. The clinical recommendations presented here are based on the best evidence available as well as expert opinion.

Subungual blue nevus with combined phenotypic features

Blue nail dyschromia may represent melanocytic, vascular, or other etiologies. A case of a subungual blue nodule is presented, with a pseudo-clubbed nail. On histopathologic examination, there was a combined subungual blue nevus, with features of a common blue nevus and a pigmented epithelioid melanocytoma. This unusual presentation is reviewed, with a discussion of blue nail dyschromia and subungual blue nevi.

En Bloc Excision of the Nail

The most common malignant nail tumors are squamous cell carcinoma (SCC) and melanoma. Less common nail malignancies are basal cell carcinoma, Merkel cell carcinoma, and aggressive digital papillary adenocarcinoma. The treatment choices for nail SCC and nail melanoma include conservative standard excision, Mohs surgery, staged excision (modified Mohs surgery), en bloc excision, amputation, and radiation therapy (for SCC). Alternative treatments for nail SCC include photodynamic therapy and topical treatment, although long-term data on both are lacking. In the authors’ experience, many cases of nail SCC are amenable to Mohs surgery. The tumors frequently exhibit deep and lateral subclinical spread, particularly in the proximal lateral nail sulci, that could be missed with standard excision and processing, making it ideally suited for treatment with Mohs surgery. There are also reports of successful treatment of invasive nail melanoma using modified and traditional Mohs surgery, the latter ideally complemented by rapid MART-1 immunostaining. En bloc excision, with or without excision of the ungual process of the distal phalanx, has been reported with success for invasive melanoma in Europe, demonstrating no significantly greater patient mortality than with amputation at varying levels. In the United States, the majority of invasive nail melanoma is treated with amputation, although increasing reports in the literature question the validity of this practice, particularly concerning thumb tumors.

Midline/paramedian longitudinal matrix excision with flap reconstruction: alternative surgical techniques for evaluation of longitudinal melanonychia.

BACKGROUND Surgical evaluation of longitudinal melanonychia requires biopsy of the nail matrix. Previous publications have presented detailed surgical approaches to this problem. However, discussion of longitudinal excision with local matrix flap reconstruction is documented sparsely in the literature. OBJECTIVE To describe the indications for and technique of performing a longitudinal, full-thickness excision for longitudinal melanonychia; as this surgery poses a high risk of postoperative split nail, reconstruction is essential. Three local matrix flaps are detailed to maximize functional and cosmetic results. METHODS The authors detail the different procedures, with several illustrations and clinical photographs highlighting the techniques. RESULTS These techniques provide the surgeon with additional approaches to excise lesions of longitudinal melanonychia and reconstruct the surgical defects. LIMITATIONS All surgeries of the nail matrix pose a risk of postoperative nail dystrophy and/or split nail. CONCLUSION The different flaps provide elegant local alternatives to second-intention healing and maximize cosmetic and functional results after matrix excision with narrow margins for longitudinal melanonychia.