Saturday, March 18, 2006

“NAILING DOWN A DIAGNOSIS”



Presented by
Brian T. Maurer, Enfield, Connecticut


D.S. is a 72-year-old left-handed male with a three-year history of periungual inflammation coupled with periodic cracking, separation and nail loss on the 3rd, 4th and 5th fingers of the left hand. The pads of these fingers also appear erythematous and swollen with dry cracked skin.

Initially, a local dermatologist prescribed topical Lamisil without effect. A subsequent month-long course of oral griseofulvin likewise did nothing. The periungual inflammation seemed to respond to topical erythromycin; the patient reports that all symptoms subsided over the summer months, only to return with the cold autumn weather.

An amateur gardener and golfer, D.S. wears a golf glove on his left hand during summer golfing season (when the condition seems to subside). He reports that his left hand usually feels colder than the right in winter time.

With the exception of one discolored nail of the left great toe, the nails of his remaining fingers and toes appear normal; he exhibits no other form of dermatitis.

Questions: Given the history and clinical course, what is the diagnosis? Suggestions for treatment?

5 comments:

  1. Given the seasonal variation and asymmetry, I think the condition is of vascular origin.
    Is the patient a smoker? Does he have any other vascular disease symtoms like claudication, discolouration, etc.
    Needs a complete work-up I guess.

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  2. As far as i can see in the first photo, the color of the mentioned fingers of the left hand are different from the rest and looks to be mildly cyanotic. Therefore, it seems that the nail changes are secondary to an underlying asymmetical neurovascular disease. Work up should be oriented to find this primary disease. cheers, omid

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  3. Agree with above comments re neurovascular compromise. Also, any symptoms of Raynaud's? Any periungual nailfold vascular abnormalities grossly or at 10x magnification?
    -Rick Sontheimer

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  4. I do not think this vascular in origin.It is contact dermatitis with fissuring of the fingers of the left hand only with related nails deformity.There some incriminated allergens like wearing golf gloves on the left hand in summer time will initiate dermatitis in early winter.patch testing is essential confirmatory test.Management is by exclusion the allergen plus clobetasole ointment.

    khalifa sharquie

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  5. Abbas AlshammariMarch 21, 2006

    The possibility of onychomycosis should be seriously excluded by KOH test and culture.What is the value of using griseofulvin for one month only?.Could be nail lichen planus?

    ReplyDelete

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