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Nail psoriasis is a chronic, inflammatory condition which is difficult to treat, linked with greater psoriasis severity, and may be associated with anxiety and significant functional impairment of the quality of life. The 1064 nm Nd: YAG laser was reported to yield satisfactory results in the treatment of nail psoriasis. The aim of the study was to assess the clinical and ultrasonographic efficacy of long-pulsed 1064 nm Nd: YAG laser in the treatment of fingernail psoriasis and compare its effect to control fingernails. This intra-patient randomized controlled trial analyzed 86 fingernails collected from 13 patients suffering from cutaneous and nail psoriasis. The nails were randomized into two groups. Group A was treated with Nd: YAG laser once monthly for three sessions while group B served as control. Assessment took place at baseline, 1 and 3 months after the last treatment session. For scoring, the 32-points target NAPSI scoring systems was used. Additionally, two blinded dermatologists’ score of improvement, patients’ pain assessment by visual analogue score and ultrasonographic assessment were all performed. At the end of follow up, the medians of tNAPSI score, plate definition, matrix thickness, bed thickness and bed vascularity decreased significantly in the Nd: YAG laser treated group in comparison to baseline ( p = 0.001 , 0.006 , 0.039 , < 0.001 and 0.010 , respectively). While, there was a non-significant reduction in median tNAPSI score in the control group at last follow up, however, ultrasonography recorded a significant reduction in the medians of plate definition, bed thickness and vascularity ( p = 0.002 , 0.011 and 0.033 , respectively) from the baseline. Comparison of the Nd: YAG laser and the control groups showed no significant difference from baseline regarding the medians of tNAPSI, tNAPSI percentile improvement, pits count, blinded evaluation of photographs and ultrasonographic assessments. In conclusion, Nd: YAG laser showed clinical and ultrasonographic improvement in fingernail psoriasis. Ultrasonography is a useful noninvasive tool in diagnosing and monitoring the clinical and even the subclinical changes in nail psoriasis. Nail psoriasis although difficult to treat, may show spontaneous improvement.

Methotrexate injections intralesionally as a treatment for psoriatic nails proved to be effective in large-scale studies as well as individual case reports, but the process is painful and time-consuming. The objective of this study was to compare the efficacy and safety of combined fractional CO2 laser (Fr. CO2) 10,600 nm and methotrexate gel versus methotrexate 1% gel alone in treatment of nail psoriasis. In this intra-patient randomized comparative study, 36 patients were treated for finger nail psoriasis. One hand was randomly selected to be treated with a Fr. CO2 laser at 10,600 nm in monthly sessions in addition to the daily application of methotrexate 1% gel for 4 months (Fr. CO2 group) . The other hand was treated with daily application of methotrexate 1% gel alone for the same period (non-laser group) . Evaluation was done at the end of 4 months treatment and 3 months after treatment both clinically and dermoscopically. In addition, histopathological evaluation was done 3 months after treatment. At the end of treatment, both hands experienced significant improvement in total nail psoriasis severity index (NAPSI) ( P  = 0.001,for each hand) with no significant difference between both ( p  = 0.593). Three months after treatment, the improvement in NAPSI score in Fr. CO2 group was significantly greater than that in non-laser group ( p  = 0.001). The dermoscopic evaluation showed significant improvement in both hands at the end of treatment and 3 months after treatment. Regarding microscopic examination of nail psoriatic, the mean value of nail plate thickness and subungual thickness significantly decreased, three months after treatment in both groups with significant higher improvement in Fr. CO2 group compared with non-laser group ( p  = 0.011, 0.000), respectively. Nail plate serous lake, subungual serous lake, parakeratosis and Munro’s abscess significantly improved 3 months after treatment. with no significant difference between both sides. Although minimal pain during the session was in 20% and erythema in 37.1% of patients that last less than 24 h were noticed in Fr. CO2 group, patient satisfaction was still higher among patients in this group ( p  = 0.02). It is concluded that topical methotrexate 1% gel is an effective topical treatment for nail psoriasis. However, Fr. CO2 laser-assisted delivery of methotrexate 1% gel is superior to unassisted methotrexate 1% gel application.

Background Pseudomonas aeruginosa is the most common pathogen causing bacterial nail infections, producing a classic blue-green pigment, known as chloronychia. Clinical examination and dermoscopic findings, as well as diagnosis and treatment, have not been well characterized. Objective The aim was to characterize the clinical and dermoscopic findings of P. aeruginosa infection of the nails and assess treatment efficacy. Methods This is a retrospective study of patients with P. aeruginosa nail infection diagnosed between January 27, 2017 and May 28, 2019. Demographics, history, clinical and dermoscopic findings, diagnostics tests, and treatment were documented and analyzed. Results Twenty-six patients with P. aeruginosa nail infections were analyzed, with 21 patients completing treatment, two lost to follow-up, and three still undergoing treatment. Clinical examination findings were notable for onycholysis in 76.9% of patients. Green discoloration was seen in 38.5% of patients and green-brown discoloration in 30.8%. A majority of the patients had only one nail involved (73.1%). Dermoscopic findings were significant for greenish pigmentation in 37.5% of patients and 88.9% of cases presenting with a fading border. Wound cultures of nail plates were more sensitive (40%) than dermatopathology (16.7%), but the difference was not statistically significant ( p value = 0.1596). All patients were treated with ophthalmic 0.3% gentamicin topical solution nightly for a 3-month period and those who completed therapy had complete resolution of their infection. Limitations The limitations of the study were the retrospective design and the small cohort size. Conclusion Clinical examination findings of onycholysis coupled with a green or green-brown discoloration involving one or more digits and dermoscopic findings of greenish discoloration with a fading border are consistent with a diagnosis of Pseudomonas nail infection. Gentamicin topical solution is an effective, inexpensive, easy-to-use treatment for this condition. Larger randomized clinical trials are necessary to compare efficacy with other therapeutic options.

   Purpose Common side effects of taxane chemotherapy are nail toxicity and peripheral neuropathy (CIPN) causing severe impact on the quality of life. Different methods of cryotherapy to prevent these side effects have been tested. We investigated the use of machine-controlled cooling of hands and feet to reduce nail toxicity and CIPN in patients receiving taxane chemotherapy. Methods Patients receiving Docetaxel (planned dose ≥ 300 mg/m 2 ) or Paclitaxel (planned dose ≥ 720 mg/m 2 - ) in the adjuvant or palliative setting of different cancers were included. The dominant hand and foot were cooled to approximately 10 °C using the Hilotherapy machine. The contralateral hand and foot were used as intrapatient comparison. The primary endpoint was the occurrence of any CIPN due to paclitaxel or nail toxicity due to Docetaxel. Both the intention to treat population (ITT) and the per protocol population (PPP) were analyzed. Results A total of 69 patients, 21 treated with Docetaxel and 48 with Paclitaxel, were included at our centre between 08/2020 and 08/2022. Nail toxicity due to Docetaxel was overall not significantly improved by cooling in the ITT or PPP but a significant benefit across visits was found for the ITT. CIPN due to Paclitaxel was numerically better in the ITT and significantly better in the PPP. A significant benefit of cooling on CIPN occurrence across visits was found for the ITT and the PPP. Cooling was very well tolerated. Conclusion Cooling of hands and feet has a clinically meaningful impact on reducing occurrence of CIPN and nail toxicity on treatment with taxanes. Effects are more significant over time and are dose dependent. Trial registration number. 2020–00381. Date of registration. 24th February 2020.

ObjectiveTo estimate the incidence of psoriatic arthritis (PsA) in patients with psoriasis who had received a continuous treatment with biological disease-modifying antirheumatic drugs (bDMARDs) compared with phototherapy.MethodsA retrospective non-randomised study involving patients with moderate-to-severe plaque psoriasis, who were prescribed at least 5 years of bDMARDs or at least three narrow-band ultraviolet light B (nb-UVB) phototherapy courses, and did not have a diagnosis of PsA at enrolment. Development of PsA in each patient was assessed by a rheumatologist according to the Classification for Psoriatic Arthritis criteria. The annual and cumulative incidence rate of PsA was estimated by using an event per person-years analysis. Cox proportional hazards models were undertaken to assess the hazard risk (HR) of PsA after adjustment for confounders.ResultsA total of 464 psoriatic patients (bDMARDs, n=234 and nb-UVB, n=230) were followed between January 2012 and September 2020 (corresponding to 1584 and 1478 person year of follow-up for the two groups, respectively). The annual incidence rate of PsA was 1.20 cases (95% CI 0.77 to 1.89) versus 2.17 cases (95% CI 1.53 to 3.06) per 100 patients/year in the bDMARDs versus phototherapy group, respectively (HR 0.29, 0.12–0.70; p=0.006). The variables independently associated with higher risk of PsA were older age (adjusted HR 1.04, 1.02–1.07), nail psoriasis (adjusted HR 3.15, 1.63–6.06) and psoriasis duration >10 years (adjusted HR 2.02, 1.09–3.76); notably, bDMARDs treatment was associated with a lower risk of incident PsA (adjusted HR 0.27, 0.11–0.66).ConclusionsbDMARDs treatment may delay or reduce the risk of incident PsA in patients with moderate-to-severe chronic plaque psoriasis.

Nail psoriasis is a refractory disease that affects 50–79% skin psoriasis patients and up to 80% of patients with psoriatic arthritis (PsA). The pathogenesis of nail psoriasis is still not fully illuminated, although some peculiar inflammatory cytokines and chemokines seems to be the same as described in psoriatic skin lesions. Psoriatic nail involving matrix can cause pitting, leukonychia, red spots in lunula, and nail plate crumbling, while nail bed involvement can result in onycholysis, oil-drop discoloration, nail bed hyperkeratosis, and splinter hemorrhages. The common assessment methods of evaluating nail psoriasis includes Nail Psoriasis Severity Index (NAPSI), Nail Assessment in Psoriasis and Psoriatic Arthritis (NAPPA), Nail Psoriasis Quality of life 10 (NPQ10), and so on. Treatment of nail psoriasis should be individualized according to the number of involving nail, the affected site of nail and presence of skin and/or joint involvement. Generally, topical therapies are used for mild nail psoriasis, while biologic agents such as etanercept are considered for severe nail disease and refractory nail psoriasis. Even though the current literature has shown some support for the pathogenesis, clinical presentation, or therapies of nail psoriasis, systemic review of this multifaceted disease is still rare to date. We elaborate recent developments in nail psoriasis epidemiology, pathogenesis, anatomy, clinical manifestation, diagnosis, differential diagnosis, and therapies to raise better awareness of the complexity of nail psoriasis and the need for early diagnosis or intervention.

Nail diseases, including various fungal infections, paronychia, and psoriasis, affect millions, and their treatment relies on visual inspection, which may result in inaccurate and delayed treatments. This study explores the use of synthetic nail disease data generated through stable diffusion models to increase the accuracy of the machine learning model. We aim to incorporate enhanced data transformation techniques by utilizing a few-shot learning technique with a small amount of data representation in the text-to-image stable diffusion model. This model renders synthetic data, which provides variety and diversity while preserving the critical components of the original data. The experimental results display the efficacy of the synthetic data that helps provide robustness to the pre-trained CNN MobileNetV2 and Vision Transformer model on a custom real-world nail disease dataset, providing an increased accuracy of 3.26% for MobileNetV2 and 3.02% for Vision Transformers.

Nail unit melanoma (NUM) is an uncommon form of melanoma and is often diagnosed at later stages. Approximately two-thirds of NUMs are present clinically as longitudinal melanonychia, but longitudinal melanonychia has a broad differential diagnosis. Clinical examination and dermoscopy are valuable for identifying nail findings concerning malignancy, but a biopsy with histopathology is necessary to confirm a diagnosis of NUM. Surgical treatment options for NUM include en bloc excision, digit amputation, and Mohs micrographic surgery. Newer treatments for advanced NUM include targeted and immune systemic therapies. NUM in pediatric patients is extremely rare and diagnosis is challenging since both qualitative and quantitative parameters have only been studied in adults. There is currently no consensus on management in children; for less concerning melanonychia, some physicians recommend close follow-up. However, some dermatologists argue that the “wait and see” approach can cause delayed diagnosis. This article serves to enhance the familiarity of NUM by highlighting its etiology, clinical presentations, diagnosis, and treatment options in both adults and children.

Changes in nail color can provide important clues of underlying systemic and skin disease. In particular, white discoloration (leukonychia) has a high prevalence with a wide array of potential relevant causes, from simple manicure habits to life-threatening liver or kidney failure. Therefore, a reliable assessment of the patient with leukonychia is essential. In the past, two classifications for leukonychia have been presented. The morphological classifies the nail according to the distribution of the white lines: total, partial, transversal, and longitudinal leukonychia. Mees’ and Muehrcke’s lines are examples of transversal leukonychia, while Terry’s and Lindsay’s nails are examples of total and partial leukonychia. The anatomical classifies according to the structure responsible for the white color: the nail plate in true leukonychia, the nail bed in apparent leukonychia, and the surface only in pseudoleukonychia. In this review, both morphological and anatomical features have been combined in an algorithm that enables clinicians to approach leukonychia efficiently and effectively.

Atopic dermatitis (AD) is a common chronic, recurrent inflammatory disease, yet its accompanying nail abnormalities have long received insufficient attention. The clinical characteristics, underlying mechanisms, and assessment systems for nail dystrophy in AD remain unclear. AD-associated nail dystrophy can manifest in various forms, including Beau’s lines, nail pitting, koilongchia, trachyonychia, leukonychia, brachyonychia, melanoychia, onychomadesis, onychoschizia, onycholysis, and paronychia. Current treatments face limitations such as slow onset of action and uncertain efficacy with traditional therapies, particularly with limited drug options for the pediatric populations. With the deepening of research into the Th2 inflammatory pathway, biologics such as dupilumab have shown therapeutic potential. Through retrospective analysis, this paper presents the effectiveness and safety of dupilumab in five pediatric AD patients with nail dystrophy under 12 years old. After at least 12 weeks of treatment, their skin lesions and nail dystrophy both showed marked improvement. Additionally, we reviewed four reported cases in the literature of adult AD patients with nail dystrophy who experienced significant improvement in nail changes after dupilumab treatment. These results suggest that dupilumab may be an effective treatment for nail dystrophy in AD. This case series provides the first evidence demonstrating the significant efficacy of dupilumab for nail dystrophy in pediatric AD patients. However, further large-scale prospective studies are still needed to better guide clinical practice.