Friday, 15 August 2014

Shiny trachyonychia

Trachyonychia (Gk trachys rough, onychos nail) presents as a rough surface affecting the entire nail plate in up to 20 nails. Thus trachyonychia may involve one, several or all digits and when most or all digits are involved, the term twenty-nail dystrophy is commonly used. Trachyonychia may affect patients from all age groups although it is most commonly diagnosed in children. Familial forms exist. Spontaneous resolution might occur.

Based on appearance, trachyonychia is divided into two types*: (1) Opaque trachyonychia where nail is ridged and rough, and is deprived of its natural lustre. The nail appears sandpapered in a longitudinal direction (severe trachyonychia). (2) Shiny trachyonychia where the nail plate is shiny with numerous, closely aggregated, small superficial pits. This shiny appearance may be accentuated by a camera flash or by tangential light from a pen-torch (mild trachyonychia). The severity of trachyonychia frequently varies from nail to nail and the shiny and opaque varieties of the disease may coexist in the same patient.

The most common presentation is as an isolated nail abnormality (idiopathic) where histopathology shows spongiosis and a lymphocytic infiltrate of the nail matrix. It can be associated with psoriasis (pitting of the fingernails may be the only manifestation for months or even years), alopecia areata, lichen planus (it may be its sole manifestation and some regard nail lichen planus as a distinct condition) and other conditions. Unilateral involvement may occur in complex regional pain syndrome. Localized trachyonychia in a judo player** from the repeated grabbing of opponents’ uniforms has been described. Routine biopsy is not recommended.

Treatment is often useless and several forms have been suggested. Tazarotene alone or in association with topical steroids may improve the condition. The safety of tazarotene has not been established in patients under the age of 18 years.

Shiny trachyonychia affecting all the fingernails 

*Baran RDuprè AChristol BBonafe JLSayag JFerrere JL'ongle grèsè peladique. Ann Dermatol Venereol 1978105:387392.

**Shelley WBShelley DE‘Judo’ nailsCutis 199556912.

This page was last updated in August 2014

Sunday, 3 August 2014

Palmar lichen planus

Plamar lichen planus can be difficult to diagnose if present as an isolated finding.  Itchy (or painful) erythematous scaly plaque is characteristic. The lesions tend to be firm and rough with a yellowish hue. It is one of the therapy-resistant variants of lichen planus. Although lesions on the volar aspect of the wrists are common, lesions on the adjacent palms are less common and lack the characteristic shape and colour of lesions elsewhere. They may be broadly sheeted or show up as punctate keratoses. Vesicle-like papules are recorded. Itching may be absent. Palmoplantar lichen planus may also present as erosive-ulcerative type. When such changes occur in isolation, diagnosis is difficult; and conditions such as eczema, tinea, secondary syphilis, psoriasis, porokeratosis, callosities and warts must be excluded. Histopathologically findings are identical to those of classic lichen planus.

The primary lesions of lichen planus are characteristic, almost pathognomonic violaceous, flat-topped, polygonal papules. Papules expand to plaques. The colour of the lesions initially is erythematous but well-developed lesions are violaceous, and resolving lesions are often hyperpigmented. The surface is shiny with scant adherent scales. On the surface, grey or white lines, known as Wickham’s striae, may traverse the surface of the papules. Dermoscopy may enhance the visualization of this important diagnostic element.  Most patients react to the itching of lichen planus by rubbing rather than scratching but itching can be absent. The four Ps-purple, polygonal, pruritic papule are a mnemonic to help you recall the findings that characterise lichen planus.   The centre of the papule shows irregular acanthosis of the epidermis, irregular thickening of the granular layer, and compact hyperkeratosis. A focal increase in thickness of the granular layer and infiltrate corresponds to the presence of Wickham’s striae. The basal damage is associated with a band-like infiltrate of lymphocytes and some macrophages which press against the undersurface of the epidermis. Occasional lymphocytes extend into the basal layer. The infiltrate however does not obscure the interface or extend into the mid-epidermis.  Pigmentary incontinence with dermal melanophages is characteristic. Postinflammatory pigmentation may persist for some time.

Potent topical corticosteroids (with or without occlusion) remain the treatment of choice for lichen planus in patients with classic and localized disease.

Improvement after use of very potent topical corticosteroid with occlusion 

This page was last updated in August 2014

Main Works of Reference List (The first eight are my top favourites)

  • British National Formulary
  • British National Formulary for Children
  • Guidelines (BAD - BASHH - BHIVA - Uroweb)
  • Oxford Handbook of Genitourinary Medicine, HIV, and Sexual Health
  • Oxford Handbook of Medical Dermatology
  • Rook's Textbook of Dermatology
  • Simple Skin Surgery
  • Weedon's Skin Pathology
  • A Concise Atlas of Dermatopathology (P Mckee)
  • Andrews' Diseases of the Skin
  • Andrology (Nieschlag E FRCP, Behre M and Nieschlag S)
  • Bailey and Love's Short Practice of Surgery
  • Davidson's Essentials of Medicine
  • Davidson's Principles and Practice of Medicine
  • Fitzpatrick's Colour Atlas and Synopsis of Clinical Dermatology (Klaus Wolff FRCP and Richard Allen Johnson)
  • Fitzpatrick’s Dermatology in General Medicine
  • Ganong's Review of Medical Physiology
  • Gray's Anatomy
  • Hamilton Bailey's Demonstrations of Physical Signs in Clinical Surgery
  • Hutchison's Clinical Methods
  • Lever's Histopathology of the Skin
  • Lever's Histopathology of the Skin (Atlas and Synopsis)
  • Macleod's Clinical Examination
  • Martindale: The Complete Drug Reference
  • Oxford Handbook of Clinical Examination and Practical Skills
  • Oxford Textbook of Medicine
  • Practical Dermatopathology (R Rapini)
  • Sexually Transmitted Diseases (Holmes K et al)
  • Statistics in Clinical Practice (D Coggon FRCP)
  • Stockley's Drug Interactions
  • Treatment of Skin Disease: Comprehensive Therapeutic Strategies
  • Yen & Jaffe's Reproductive Endocrinology