NAI A L I TI T P I S FO F R THE

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1 NAIL TIPS FOR THE PRACTICING DERMATOLOGIST Boni E. Elewski, MD James Elder, MD Endowed Professor of Dermatology University of Alabama Conflict of Interests Clinical Research: Amgen, Abbvie, Lilly, Merck, Novartis, Pfizer Consultant: Anacor, Novartis, Pfizer, Valeant OBJECTIVES: TIPS ON. COMMON NAIL DISORDERS INFECTION INFLAMMATORY TUMOR COSMETIC ISSUES NAIL TIPS #1 INFECTION Green Nail- Pseudomonas 1

2 Green Nail- Pseudomonas TIP.. Pseudomonas favors moist wet spaces Vinegar soaks Half white vinegar and half water Clorox bleach soaks Tablespoon bleach in cup water Half white vinegar/half isopropyl alcohol drops under nail Ciprofloxacin otic drops Oral antibiotics KEEP AFFECTED AREA DRY OBTAIN FUNGAL CULTURE WHEN INFECTION IS RESOLVED OBTAIN X-RAYS IN DIGITS WITH CHRONIC INFECTION TO R/O OSTEOMYELITIS DERMATOPHYTES POTENTIATE GROWTH OF PSEUDOMONAS IN NAIL ARCH DERM 2005; 141: Foster et al BONE DIRECTLY BENEATH NAIL UNIT WITHOUT SUBCUTANEOUS TISSUE TIP # 1: Nail Infections PEARL ONYCHOMYCOSIS SELECT BEST THERAPEUTIC PLAN FOR ONYCHOMYCOSIS Systemic antifungal therapy Terbinafine Itraconazole Fluconazole Verses.. New topical therapeutics Efinaconazole 10%, 5% Tavaborole 2

3 Onychomycosis: Fluconazole Onychomycosis: Fluconazole LONG TREATMENT DURATION MATCHES SLOW GROWTH OF NAILS Month 1 Month 2 Month 3 Month 4 Month 1 Month 2 Month 3 Month 4 Wk1 Wk2 Wk3 Wk4 Wk1 Wk2 Wk3 Wk4 Wk1 Wk2 Wk3 Wk4 Wk1 Wk2 Wk3 Wk4 Key: = one day Dose 150 mg/d 300 mg/d 450 mg/d Not FDA approved for indication I use mg once weekly Toenail/Fingernail TREAT UNTIL NAIL IS CLEAR Scher et al JAAD,1998 Wk1 Wk2 Wk3 Wk4 Wk1 Wk2 Wk3 Wk4 Wk1 Wk2 Wk3 Wk4 Wk1 Wk2 Wk3 Wk4 Key: = one day Dose 150 mg/d 300 mg/d 450 mg/d Not FDA approved for indication I use mg once weekly Toenail/Fingernail BEST CURE RATE Scher et al JAAD,1998 FLUCONAZOLE:WHAT YOU NEED TO KNOW In FDA study clinical cure 48% 450 mg/week 46% 300 mg/week 37% 150 mg/week FLUCONAZOLE- Broad spectrum- activity against yeasts, certain molds and dermatophytes Best antifungal for Candida spp JAAD 1998; 38:S77-86 Scher R.et al Onychomycosis: Itraconazole Month 1 Month 2 Month 3 Month 4 Wk1 Wk2 Wk3 Wk4 Wk1 Wk2 Wk3 Wk4 Wk1 Wk2 Wk3 Wk4 Wk1 Wk2 Wk3 Wk4 400 mg/d 400 mg/d 400 mg/d 400 mg/d OR Month 1 Month 2 Month 3 Month 4 Wk1 Wk2 Wk3 Wk4 Wk1 Wk2 Wk3 Wk4 Wk1 Wk2 Wk3 Wk4 Wk1 Wk2 Wk3 Wk4 200 mg/d 200 mg/d 200 mg/d 200 mg/d Toenail/Fingernail *Pulse dosage not approved for toenails Onychomycosis: Terbinafine NEW TOPICAL DRUGS APPROVED FOR ONYCHOMYCOSIS Month 1 Month 2 Month 3 Month 4 Wk1 Wk2 Wk3 Wk4 Wk1 Wk2 Wk3 Wk4 Wk1 Wk2 Wk3 Wk4 Wk1 Wk2 Wk3 Wk4 250 mg/d 250 mg/d 250 mg/d Topical antifungal solutions 10% efinaconazole solution 5% tavaborole solution Toenail-12 weeks Fingernail- 6 weeks 38% Complete cure rate, PDR BOTH SOLUTIONS SO CAN BE APPLIED ON, UNDER, AROUND NAIL 3

4 Complete and Mycologic Cure Rates: Topical Agents BASELINE FAILED ORAL TERBINAFINE CULTURED T.RUBRUM DERMATOPHYTOMA PRESENT SO NOT ELIGIBLE FOR TOPICAL STUDY Elewski BE et al JAAD. 2013;68(4): Elewski BE et al. Presented at: Desert Foot 2013; Nov , 2013; Phoenix, AZ. Penlac (ciclopirox) [package insert]. Dermik Laboratories, Bridgwater, NJ; BASELINE After three months TOPICAL EFINACONAZOLE UNDER AND AROUND THE NAIL NAIL TIPS AFTER 5 MONTHS OF THERAPY- SHOULD SHORTLY BE CURED WITH CONTINUED TREATMENT #2 NAIL PSORIASIS INFLAMMATORY NAIL DISEASE 4

5 Overview of Nail Psoriasis Occurs in up to 78% of patients with psoriasis More common in those with psoriatic arthritis (about 80%) Usually involves several nails Fingernails not toenails have the typical findings May be the only sign of psoriasis in 5% May affect quality of life TIP Features Most Indicative of Nail Psoriasis Irregular pitting of the nail plate Salmon-colored patches or oil spots on the nail bed Onycholysis with erythematous borders These signs are more common on fingernails NAIL PLATE PITTING: OIL SPOTS ONYCHOLYSIS AND RED BORDER NAIL PSORIASIS ONYCHOLYSIS WITHOUT RED BORDER Trauma Runners toe Onychomycosis Contact dermatitis Nail glue Nail polish Drugs Tetracyclines psoralens Internal disease Anemia (iron def) Thyroid disorders Yellow nail syndrome Foreign body Congenital onycholysis 5

6 RUNNERS TOE- ONYCHOLYSIS OFTEN WITH HEMATOMA, ONE NAIL INVOLVED Other Less Specific Clinical Features of Nail Psoriasis: Nail bed hyperkeratosis (resembles onychomycosis) Onychorrhexis of fingernails Splinter hemorrhages Nail plate thickening and crumbling Paronychia Rarely: erythema or spotting of lunula, leukonychia These findings may also occur with other inflammatory or infectious conditions NAIL PLATE CRUMBLING NAIL PLATE CRUMBLING NONSPECIFIC FOR NAIL PSORIASIS NONSPECIFIC FOR NAIL PSORIASIS NONSPECIFIC NAIL FINDINGS OTHER TIPS... When approaching dystrophic toenails look at fingernails Findings of nail psoriasis more common in fingernails COMPLETE DYSTROPHY OF THE NAIL PLATE 6

7 TIP Look for manifestation of PSA in patients with fingernail dystrophy PSORIATIC NAIL DISEASE PSORIATIC NAILS MAY BE INDICATIVE OF PSORIATIC ARTHRITIS Jones SM, Armas JB, Cohen MG et al. Psoriatic arthritis: outcome of disease subsets and relationship of joint disease to nail and skin disease. Br J Rheumatol 1994;33: Scarpa R, Soscia E, Peluso R et al Nail and distal interphalangeal joint in psoriatic arthritis. J Rheumatol 2006;33: BEFORE TREATING PSORIASIS- MAY NEED TO RULE OUT ONYCHOMYCOSIS TIP NAIL PSORIASIS MAY BE HIDDEN nnail ABOUT ONE-THIRD OF ABNORMAL TOENAILS IN PSORIATIC PATIENTS HAVE ONYCHOMYCOSIS PSORIASIS OF NAIL OR ONYCHOMYCOSIS OR BOTH? ONYCHOMYCOSIS Gupta AK, Lynde CW, Jain HC et al. A higher prevalence of onychomycosis in psoriatics compared with non psoriatics. Br J Dermatol 1997;136: (27%) Sanchez Regana M, Videla S, Villoria J et al. Prevalence of fungal involvement in a series of patients with nail psoriasis. Clin Exp Dermatol 2007;33: (30%) TIP # 2: MORE TIPS ON Nail Psoriasis PEARL TREATMENT TIPS TOPICAL MEDICATIONS FIRST LINE Corticosteroids Calcitriol Calcipotriol Tazarotene SECOND LINE Urea Anthralin 5-FU 10% cyclosporine solution 7

8 IS PROLONGED USAGE OF TOPICAL STEROIDS IN THE NAIL SAFE? TOPICAL STEROIDS Use over 4 months may lead to skin atrophy Use for years may lead to atrophy of the underlying phalanx Wolf R, Tur E, Brenner S; Corticosteroid-induced «disappearing digit». Arch Dermatol 1990,23: Deffer TA,Goette DK. Distal phalangeal atrophy secondary to topical steroid therapy. Arch Dermatol 1987;123: Distal Phalangeal Atrophy: Disappearing Digit First report in a 62 yo woman who applied.05% fluocinonide ointment 4x per day for one month Fingertip resembled sharpened pencil No Hx of Raynauds or collagen vascular disorders X-Ray confirmed digit atrophy Deffer,T. et al. Arch Dermatol 1987;123:571-2 DISAPPEARING DIGIT Courtesy J. André, Brussels DISAPPEARING DIGIT TIP TREATMENT NAIL PSORIASIS AVOID PROLONGED APPLICATION OF TOPICAL STEROIDS TO THE NAIL UNIT 12 year old girl with parakeratosis pustulosa on clobetasol 8

9 Courtesy Tosti & Piraccini, Italy NAIL TIPS Vitamin D Ointment #3 NAIL TUMORS COLORFUL PEARL #2 RED NAILS RED NAILS:ERYTHRONYCHIA RED NAILS: ERYTHRONYCHIA LONGITUDINAL ERYTHRONYCHIA 9

10 DIFFERENTIAL DIAGNOSIS ONYCHOPAPILLOMA LOCALIZED TO ONE NAIL- TUMOR POLYDACTYLOUS- INFLAMMATORY PROCESS Idiopathic benign tumor Questionable role of HPV Typically presents as classic band of LLE with prominent distal hyperkeratosis that may resemble a papule at hyponchium Dermoscopic findings highlight erythema and telangectasia and splinter hemorrhages TUMORS- ERYTHRONYCHIA Onychopapilloma- most common Other benign: Glomus tumor, verrucae, warty dyskeratoma, and isolated lichen planus Cancerous- BCC, Bowens, melanoma in situ POLYDACTYLOUS ERYTHRONYCHIA Lichen planus GVH disease Drug- AZT Darier s disease Idiopathic Primary amyloid Acantholytic epidermolysis bullosa ONYCHOPAPILLOMA Mechanism of clinical findings Idiopathic benign tumor Questionable role of HPV Typically presents as classic band of LLE with prominent distal hyperkeratosis that may resemble a papule at hyponchium Dermoscopic findings highlight erythema and telangectasia and splinter hemorrhages de Berker, et al. Arch Dermatol 2004;140:

11 BLACK NAILS LONGITUDINAL MELANONYCHIA MELANONYCHIA STRIATA Pigmented linear band in nail unit longitudinal melanonychia More common in darkly pigmented individuals- 77% of African Americans older than 20 years, and close to 100% older than 50 years Hutchinson s sign- periungual extension of pigmentation MULTIPLE STRIATA OK ONE NAIL INVOLVED- MAY REQUIRE BIOPSY MELANONYCHIA STRIATA Biopsy nail matrix TIP. ACQUIRED MELANOCHYIA DIFFUSE PIGMENT NOT STREAKS 11

12 BLACK FINGERNAILS.BUT NAIL STAINING HYDROQUINONE AND VITAMIN C IN COSMETICS NORMAL TOENAILS WHY HYDROQUINONE? NAIL PIGMENTATION Hydroquinone is oxidized to quinone, a yellow compound, which is then oxidized to hydroxyquinone, a yellow compound, but this polymerizes to dark brown compounds. The process is a photosensitive reaction. NAIL PIGMENTATION Hydroxyurea Cyclophosphamide Doxorubicin Minocycline Zidovudine MELANONYCHIA 12

13 NAIL PIGMENTATION HYDROXYUREA IN A PATIENT WITH SICKLE CELL SYNDROME MELANONYCHIA IN ALL NAILS Hydroxyurea Cyclophosphamide Doxorubicin Minocycline Zidovudine THUMB IS MOST COMMONLY AFFECTED EXTERNAL ETIOLOGY LIKELY IF 1. If pigment easily scrapes off with 15 blade Melanonychia- fooler PSEUDOMONAS AND CANDIDA 2. Normal toenails THUMB IS MOST COMMONLY AFFECTED IN SYSTEMIC CAUSE GREENISH VS BLACKISH NAIL TIPS #4 COSMETIC ISSUES DRY BRITTLE NAILS Biotin 3 to 5 mg daily Soak nails in olive oil at least once daily Frequent usage of emollients 13

14 DRY BRITTLE NAILS Colloidal silicic acid (Silicol) 10 ml daily Topical tazarotene cream Nail Lacquer with chitin - FDA approved as Device for brittle nails Poly-ureaurethane solution also a Device TIPS ON POLYUREAURETHANE SOLUTION 16% Can be used as topical onychomycosis treatment????? Best usage is for treating onychoschizia or brittle nails Water-proof MAY DRY OUT CUTICLE CHITIN CONTAINING LACQUER Indicated to protect intact or damaged nails from effects of moisture, friction and splitting, fragility Hydrosoluble Hydrosoluble, so apply after nail washing and drying Can be applied under polish TIPS # 4- COSMETIC ISSUES ONYCHOGRYPHOSIS DIFFERENTIATE FROM ONYCHOMYCOSIS ONYCHOMYCOSIS FOOLER ONYCHOGRYPHOSIS ABNORMAL NAILS NORMAL PLANTAR SURFACE ONYCHOGRYPHOSIS 14

15 ONYCHOGRYPHOSIS ONYCHOGRYPHOSIS 40-50% UREA CREAMS UNDER OCCLUSION TREAT WITH 40% UREA CREAM KEY TIPS INFECTION Pseudomonas Pseudomonas- R/O dermatophytosis, cellulitis Onychomycosis- effective topical antifungals INFLAMMATORY Nail psoriasis- onycholysis with red border, pits and oil spots Avoid long standing topical steroids TUMOR One red or black streak may require biopsy COSMETIC Topical formulations, urea containing creams THE END 15