Interesting nail cases from Miami

Antonella TostiFredric Brandt Endowed Professor of

Dermatology&Cutaneous Surgery Miller School of Medicine, University of Miami

Antonella Tosti, MDF091 Interesting nail cases from Miami

DISCLOSURES

Fotofinder :Consultant, Erconia Laser : PI, Springer & Verlag, Taylor&Francis: Author-Royalties , Karger : Editor in chief

DISCLOSURE OF RELATIONSHIPS WITH INDUSTRY

65 year old woman

Diabetes and chronic kidneydisease in dialysis

Nail “infection” since a few months, recently worsened

Complains of paresthesia of the fingertips

Carpal tunnel syndrome

Treatment: nitroglycerin transdermal patch

Nerve conduction study

Patient referred to hand surgeon

Carpal tunnel syndrome

After 2 weeks of treatment with nitroglycerin transdermal patch

Diagnosis confirmed by nerve conduction study

Carpal tunnel syndromeDiagnostic clues

Nail abnormalitiesrestricted to theanatomical distributionof the median nerve

Neurological symptoms

Take Home MessageThink of carpal tunnel syndrome in patients with nail abnormalities involving first three fingers.Fingertip paresthesia is typically associated. Depending on the severity of nerve damage, nail changes vary from Beau’s lines to onychomadesis and necrosis. Neurological examination and electromyography confirm the diagnosis. Treatment : nail lesions are cured by surgery in most cases

62 -year old lady

Bending of her 3°, 4° and 5° fingernails

No evidence of pulp atrophy, sclerosis or digital ulceration.

Parrot beak nails

The nails straighten whenimmersed in water for 30 min

Parrot beak nails

Primary as in this case

Secondary to conditions causingfinger pulp atrophy

Scleroderma

Cocaine abuse

Desai T, Magdum A, Patel T, Loghdey S. Parrot-beak nails. Clin Exp Dermatol.2011 Mar;36(2):208-9.

74 year oldwoman

nail discolorationsince 2 years

Convex proximalborder

Superficial scaling

Exogeneous nail discoloration

Exogeneous nail discoloration

Patient was regularlyapplying a self tanninglotion to her legs

Herskovitz I, Nolan BV, Tosti A. Orange chromonychia due to dihydroxyacetone. Dermatitis. 2014 Jan-Feb;25(1):43-4.

74 year old womanNail discoloration of all fingernails for 5 years

Endogeneous nail discoloration

Concave proximal border

More marked around lunula

Daily intake of colloidal silver to treat occasional sore throats for twenty years

No skin or mucosal pigmentation

Argyria

Fox J, D, Baker J, A, Tosti A, Chromonychia in an Asymptomatic Vitamin Consumer. Skin Appendage Disord 2015;1:131-133

There are no known chelating agents or other treatments for argyria.

1064-nm Q-switched Nd:YAG laser has been used in cutaneous argyria.

Argyria

Nail discoloration : look at the shape of proximal border!

Exogenous : convex proximal border Endogenous : concave proximal border

61 year-old man

Milia and hemorrhagic bullaeon the dorsum of the hands

Nail abnormalities

Progressive alopecia

Thinning

Longitudinalridging

Onychorrexis

Nail abnormalities

Longitudinal incisional nail biopsy demonstrating striking amorphous pink deposits (arrowheads) in the nail matrix, dermis and vessels.

Systemic amyloidosis

Systemic amyloidosis

A bone marrow biopsy revealed multiple myeloma

The patient underwent four rounds of chemotherapy with cyclophosphamide-bortezomib-dexamethasone (CyBorD) before undergoing an autologous stem cell transplant, followed by maintenance bortezomibtherapy

Systemic amyloidosisPatient was cured and is still symptom free after 3 years, his skin and nail changes resolved 1 year after treatment

First case showing resolution of nail amyloidosis after successful bone marrow transplantation

Oberlin KE, Wei EX, Cho-Vega JH, Tosti A. Resolution of Nail Changes of Systemic Amyloidosis After Bone-Marrow Transplantation in a Patient With Multiple Myeloma. JAMA Dermatol. 2016 Dec 1;152(12):1395-1396

Thank you!

atosti@med.miami.edu