History: This 76 yo retired registered nurse had distal onycholysis of her right thumb nail a little over a year ago. It eventually "spread" to involve all finger nails. Her medications include lorazepam, citalopram, Premarin and thyroid. All have been taken for many years. She has not used acrylic nails for more than five years. No unusual trauma, but she does use a nail file now. She was seen for around a year by a provider who was treating her with ciclopirox. The patient admits to being very anxious and plays with her nails.
O/E.: The patient is a pleasant, well-groomed woman who appears anxious and concerned. She has distal onycholysis of all finger nails. Toe nails are normal. Scant subungual debris.
Clinical Photos:
Lab: Three KOH preps negative. Fungal cultures were obtained 30 July, 2008.
Pathology: A "few" fungal elements were reported on PASD stained clipping of an affected nail
Diagnosis: Distal onycholysis. I am leaning away from onychomycosis. This would be an unusual presentation. I think this will likely be traumatic onycholysis.
Therapy: Pending culture report, I initiated therapy with 15% sulfactamide in ethanol twice daily. She was asked not to use a nail file and to clip separated portions of nails every day or so. Also, keep hands out of water as much as possible.
Questions: What are your thoughts? Any further work-up?
References:
1. eMedicine.com
Any artificial nail usage or creative manicuring techniques? TSH levels?
ReplyDeleteAny artificial nail usage or creative manicuring techniques? TSH levels?
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ReplyDeleteI have treated many patients with these findings. In this setting I believe the most likely diagnosis is isolated nail bed psoriasis. Koebnerization with activities that traumatized the nails, especially if long exacerbate the problem. I always ask about joint pain as there is an association between nail psoriasis and DIP psoriatic arthritis.
ReplyDeleteAdditional work-up: consider nail plate clipping to include hyponychium as proximal as possible to point of attachment. Send to pathology for PAS. This is the most sensitive test to r/o onychomycosis.
TX: Realistic expectations that this may take months to years to improve and may recur.
Keep all nails as short as possible. If tolerated trim nearly to the point of attachment.
Instill gently (with a very small paintbrush such as one would use for water colors) Clobestasol soln qhs. Bid application is better but compliance is difficult.
Three times weekly instill clear vinegar as an antipsuedomonal.
See the patient back every two to three months.
Pitfalls: secondary yeast or dermatophyte
in my openion the patient need to r/o nail psoriasis.there is a possibility she have nail psoriasis,trauma or other factors contrebute to separete distal nail plate more.thyroid functions also need to evaluate to r/o 20 nail distrophy.
ReplyDeleteAgree most likely traumatic. I would also check her thyroid function test and what dose thyroxine is she taking. Consider nail psoriasis and trial daivonex creme at night for a few months.
ReplyDeleteDr. Amin ,Bangladesh
ReplyDeleteIt looks to me nail psoriasis .Psoriatic arthropathy should be enquired cautiously .
I agree with trauma and/or nail psoriasis. I usually treat with triamcinolone acetonide injections, 5 mg/cc, into the LATERAL nail folds monthly, instilling about 0.2 cc in each lateral nail fold. We use an anesthetic spray prior to each injection. It usually works very well. Baseline pictures are essential for compliance.
ReplyDeleteHi,
ReplyDeleteI searched for distal onycholysis and saw this page. I have the same problem but just on my thumbs due to trauma and wearing tight shoes last year. I have been dermatologist and a podiatrist. The fungus test came back negative. My dermotologist told me last year just to keep nails short and cut them straight and when I saw him second time (because it had grown a little bit) he again was sure that it was not a fungus and was trauma and called it distal onycholysis. I am so worried about this I wanted to know if there is any treatment that could prevent the condition to become worse.
My nails started this once I started thyroid therapy for Hypo. 15 years later my nails are 100% destroyed. I've seen everyone and have tried everything for nail psoriasis treatment. Psoriasis has slowly been taking body over. My scalp is just insane.
ReplyDeleteI was ordered a thyroid scan and have had to stop all thyroid meds for a period of six weeks. In week four- my scalp is almost 90% back to normal and most importantly my nails are growing back normally.... I can not believe this. The amount of stress and embarrassment this has caused over the years is indescribable.
cfaxo@hotmail.com