Isolated Nail Dystrophy - Left Thumb
|My Nail 2 March 2015|
"I’m not sure exactly how I damaged my nail, but it happened in May 2014 when I was working outdoors clearing brush. Either I banged it really hard or dropped something on it. It never really hurt, but it quickly became unsightly, with lots of bruising, mottling from black to deep mahogany to orange to yellow. The nail developed a significant ridge until October 2014, when it came off in one piece.
Underneath was what you saw pictured above, a partial nail that is quite horny and yellow on the lower right and not tightly attached; it seems to grow outward rather than lie flat. I had an acrylic nail put on when I had to be very public for a couple of weeks; otherwise I’ve mainly kept a bandaid over it so that I won’t keep hitting it and also because it’s so ugly."
Note: A KOH scraping was negative and fungal culture was taken.
Six month Follow-up.
(Scopulariopsis), a saprophytic fungus and the patient has been using topical Tea Tree oil. There has been marked improvement. We recommend continued conservative management. The nail did not continue to do well and the patient took terbinafine 250 mg a day for 3 month (no benefit).
The patient's nail now shows signs of onycholysis. It now has a green color indicative of "chloronychia." This is probably psudomonas. She has had a nail dystrophy now for ~ two years. I think probably best to treat for pseudomonas, but the patient is wondering if her nail should be removed.
February 24, 2017
|Dermatoscopy of Nail Fragment|
|photomic of Scopularopsis (from WWW)|
The nail was pared back.
The patient will apply 40% urea cream to the nail plate and bed and tape the surrounding area.
She will use topical gentamycin and a topical antifungal.
Pathology: PAS Stains from Nail (2.24.17) Showing fungal elements.
This is the appearance six weeks after nail trimmed back which was followed up by topical gentamycin for pseudomonas, Jublia, and one pulse of itraconazole (400 mg daily for seven days) Two more pulses are planned.
What would be the best topical antifungal available in the U.S. for this patient?
Is there a role for a different systemic antifungal, such as itraconazole? (Terbinafine was not successful)
What role does the taping play?
2. Anchor Taping Method per Dr. Hiroko Arai.