What's New in Nail Disorders Antonella Tosti

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1 What's New in Nail Disorders Antonella Tosti Fredric Brandt Endowed Professor of Dermatology&Cutaneous Surgery Miller School of Medicine, University of Miami

2 DISCLOSURE OF RELATIONSHIPS WITH INDUSTRY Antonella Tosti, MD S030 What's New in Nail Disorders DISCLOSURES Fotofinder :Consultant, Erconia Laser : PI, Springer & Verlag, CRC Press: Author-Royalties, Karger : Editor in chief

3 What s new in nail disorders Nail psoriasis Psoriasiform nail reactions Brittle nails Onychotillomania Traumas Trachyonychia Pyogenic granulomas Yellow nail syndrome Melanonychia

4 Nail psoriasis Biologics All very effective Response is slow, mostly noticeable after approximately 12 weeks Pasch MC. Nail Psoriasis: A Review of Treatment Options. Drugs Apr;76(6):

5 Nail psoriasis Biologics : don t really know what s the best for nails Anti-TNFα Anti-Interleukin (IL)-17 Anti-IL-12/23 Studies difficult to compare due to different outcome measures

6 Nail psoriasis Apremilast : effective, improvement noticed at week 16 and continued through week 32 and maintained through week 52

7 Allergic psoriasiform reactions from gel polish manicure Onycholysis and subungual hyperkeratosis of all fingernails Mattos Simoes Mendonca M, LaSenna C, Tosti A. Severe Onychodystrophy due to Allergic Contact Dermatitis from Acrylic Nails. Skin Appendage Disord Sep;1(2):91-4.

8 Allergic psoriasiform reactions from gel polish manicure 2HEMA and 2HPMA most commonly positive Patch tests with acrylates!

9 Treatment Allergic psoriasiform reactions Short course of systemic steroids Topical steroids

10 Brittle nails What to do beside prescribing biotin? Consider glycolic acid chemical peels!

11 Chemical peeling for dry dull nails Protect the cuticle and PNF with petrolatum. Apply glycolic acid 70% with a cotton tip. Wash with plain water after 45 minutes. Banga G, Patel K. Glycolic Acid peels for nail rejuvenation. J Cutan Aesthet Surg Oct-Dec;7(4): Grover C. Role of chemical peeling in nail disorders. J Cutan Aesthet Surg Oct-Dec;7(4):201-2.

12 Chemical peeling for nail plate surface abnormalities 8% phenol with 15% TCA (ph 0.5) 70% GA peel (ph < 1)

13 Brittle nails Biotin 10 mg day Always tell patients to discontinue treatment 1 week before having lab tests Biotin treatment can potentially interferes with streptavidin biotin immunoassays Lipner SR, Scher RK. Biotin for the treatment of nail disease: what is the evidence? J Dermatolog Treat Nov 9:1-4.

14 Brittle nails FDA approved for brittle nails Hydroxypropyl-chitosan (HPCH) nail laquer Poly-ureaurethane (16%) nail solution Avoid tangential filing and buffering!

15 Onychotillomania Diagnostic features Absence of cuticle Absence of the nail plate Crusts and hemorrhages Melanonychia Patients usually admit to use instruments to clean the nails

16 Onychotillomania Treatments N acetylcysteine 1200/1800 mg day Manicuring/pedicuring Behavioral modification (habit reversal) Rieder EA, Tosti A. Onychotillomania: An underrecognized disorder. J Am Acad Dermatol. 2016;75(6):

17 Traumas Patients ask for a treatment! Transitory changes Permanent nail changes

18 Traumas Transitory changes Treatment:silicone toe separator

19 Traumas Permanent changes Tattooing Same technology utilized for nipple tattoing Renzoni A, Pirrera A, Lepri A et al Medical tattooing, the new frontiers: a case of nail bed treatment. Ann Ist Super Sanita Oct-Dec;53(4):

20 Brittle thin nails with excessive longitudinal ridging Most commonly associated with alopecia areata Nail changes might regress spontaneously Trachyonychia

21 Patients with severe nail disease can seek for treatment Efficacy of tofacitinib recently reported Trachyonychia

22 1: Jaller et al. Recovery of nail dystrophy potential new therapeutic indication of tofacitinib. Clin Rheumatol Feb : Ferreira al Remarkable Improvement of Nail Changes in Alopecia Areata Universalis with 10 Months of Treatment with Tofacitinib: A Case Report. Case Rep Dermatol Oct 4;8(3): : Dhayalan A, King BA. Tofacitinib Citrate for the Treatment of Nail Dystrophy Associated With Alopecia Universalis. JAMA Dermatol Apr;152(4): Trachyonychia

23 Trachyonychia Six patients published until now All of them also had alopecia areata Two required more than 5 mg twice a day Nail improved even in patients who did nor regrow hair

24 Trachyonychia No information on long term benefit Alopecia areata relapses after drug discontinuation and even during treatment Seems aggressive approach for a benign disease.

25 Pyogenic granulomas Topical propanolol Photodynamic therapy

26 Pyogenic granulomas Topical propanolol 1% cream Small open study 10 patients once a day under occlusion PG due to chemotherapy 3 PG due to ingrowing toenails 5 PG due to friction 2 Piraccini et al Topical propranolol 1% cream for pyogenic granulomas of the nail: open-label study in 10 patients. J Eur Acad Dermatol Venereol Feb 23.

27 Pyogenic granulomas Topical propanolol 1% cream PG due to chemotherapy cured in fingernails only PG due to ingrowing toenails no response PG due to friction cured Piraccini BM, Alessandrini A, Dika E, Starace M, Patrizi A, Neri I. Topical propranolol 1% cream for pyogenic granulomas of the nail: open-label study in 10 patients. J Eur Acad Dermatol Venereol Feb 23.

28 Pyogenic granulomas Photodynamic therapy 16% 5-methyl aminolevulinate acid for 2 hours Irradiation with LED 635 nm. 3 sessions (every 20 days) Fabbrocini et al Photodynamic therapy for periungual pyogenic granuloma-like during chemotherapy: our preliminary results. Supportive Care in Cancer in press

29 Nail Changes Growth arrest Nail overcurvature Loss of the cuticle Yellow nail syndrome Respiratory disorders Bronchiectasias Chronic bronchitis Sinusitis Lymphedema

30 Yellow Nail Syndrome Possible treatments Vitamin E 1200 UI/day Itraconazole (400 mg/day 1 week/month) Fluconazole 150/300 mg weekly Topical Minoxidil? Treatment of underlying disorders

31 Topical minoxidil for nail growth 5% topical minoxidil twice a day Aiempanakit K, Geater A, Limtong P, Nicoletti K. The use of topical minoxidil to accelerate nail growth: a pilot study. Int J Dermatol Jul;56(7):

32 Yellow Nail Syndrome Treatment of underlying disorders Hosokawa Y, Kuboki A, Mori A, Kanaya H, Nakayama T, Haruna S. Yellow Nail Syndrome With Dramatic Improvement of Nail Manifestations After Endoscopic Sinus Surgery. Clin Med Insights Ear Nose Throat Jul 5

33 Yellow Nail Syndrome Treatment of underlying disorders Simmons BJ, Baker JA, Zaiac M, Cho-Vega JH, Tosti A. Subungual Keratoacanthoma in a Patient With Yellow Nail Syndrome. Dermatol Surg Jul;42(7):900-2.

34 Longitudinal melanonychia First presentation of nail melanoma Moon et al. Heterogeneous spectrum of acral melanoma: A clinicoprognostic study of 213 acral melanomas according to tumor site. J Am Acad Dermatol Jan;78(1): e3.

35 Longitudinal melanonychia Should we biopsy or excise? An excisional biopsy is recommended for pathological evaluation of the whole lesion Several cases of delay in treatment of nail matrix melanoma due to false negative incisional biopsies are reported in the literature

36 Longitudinal melanonychia Excisional biopsy Small lesions ( < 3mm) can be removed with a punch Larger lesions can be removed with a tangential biopsy of the nail matrix

37 Longitudinal melanonychia Punch biopsy Punch should be obtained from the nail matrix after removal of the nail plate

38 Longitudinal melanonychia Pathological diagnosis was made in all cases No post op dystrophy 74% Tangential shave biopsy Richert B, Theunis A, Norrenberg S, André J. Tangential excision of pigmented nail matrix lesions responsible for longitudinal melanonychia: evaluation of the technique on a series of 30 patients. J Am Acad Dermatol Jul;69(1):96-104

39 Thank you!

Nail diseases This page outlines the terms used by dermatologists to describe diseases of the fingernails and toenails.

Nail diseases This page outlines the terms used by dermatologists to describe diseases of the fingernails and toenails. Abnormalities of the nail plate surface Nail discolouration Abnormalities of the