Discucss about the Dermatologic Condition Assessment.
The current paper is an analysis of a patient scenario in dermatology and podiatry. A patient case study is posed with a pictorial of a specific dermatological lesion(s). The lesion will be described and a differential diagnosis tree constructed. It will highlight the most likely differentials and a preferred differential that fits the clinical scenario more than the others. A rationale for the preferred differential will be provided and finally, an evidence-based management strategy for the preferred differential diagnosis will be discussed.
The case study is of a 46-year-old male who presented for general nail care due to a suspicious lesion on his left hallux nail. The lesion had been there for three months, had been increasing in size and could have been traumatic as he did not recall but reports it is likely since he had been renovating his house for the past several months.
The lesion is a chronic subungual brown discoloration on the left hallux nail. It is next to the medial nail fold and measures approximately 2 by 10 mm in its greatest dimension. it is irregular in shape. The lesion is a patch and appears flat and the area surrounding it is non-erythematous. Associated nail changes noted include regular nail pitting and ridging.
According to the case presented, the likely diagnoses include onychomycosis, psoriasis, subungual hematoma, subungual melanoma and chloronychia (Soutor & Hordinsky, 2013).
Involvement of the nail in psoriasis affects approximately 50% of patients (Baran, 2010). The clinical manifestations include nail pitting that is irregular, described as thimble pitting, onycholysis which is when the nail separates from the nail bed and nail discoloration (Tan, Chong, & Tey, 2012). The nail discoloration in psoriasis is however irregular and described as oil drop discoloration (Tan, Chong, & Tey, 2012). Psoriasis is unlikely in the patient due to the pattern of discoloration. The patient has a clearly demarcated brown discoloration that is unlike the oil drop discoloration of psoriasis. Also, the nail pitting in the patient is fine and regular unlike the thimble pitting in psoriasis. Nail psoriasis usually presents in association with other psoriatic manifestations especially psoriatic arthropathy where it occurs in 90% of cases (Tan, Chong, & Tey, 2012). The patient in the case, however, did not have any other complaints.
Subungual hematomas can be due to an acute traumatic injury to the digit (Cohen, Schulze, & Nelson, 2007). When acute, presents as red discoloration under the nail bed but when they become chronic turn to a blue, black or brown appearance (Cohen, Schulze, & Nelson, 2007). The patient had a history of working with tools and reports there is a possibility of trauma. It is unlikely the patient could have a subungual hematoma since he reports that the lesion is increasing in size. This could, however, happen if there is a superimposed bacterial or fungal infection after the initial hematoma (Soutor & Hordinsky, 2013). In that case, the approach to management will be diagnosing the infective agent.
Also termed green nail syndrome, it is nail infection by the bacterium Pseudomonas aeruginosa and presents as a greenish-yellow, greenish-brown or greenish- black nail plate, with onycholysis and non-tender nail folds (Chiriac, Brzezinski, Foia, & Marincu, 2015). The source of infection is however mostly for those who carry out wet work. The patient had a predisposition of suspected microtrauma to the nail. However, the patient has no history of wet work. It is not associated with nail pitting. There was no paronychia inflammation or suppuration that is seen in Pseudomonas infection.
Melanoma is a malignant tumor of melanocytes and could arise from the nail. Recognition of melanoma of the skin is a problem due to its silent presentation mimicking hematoma or fungal infection (Bristow, de Berker, Acland, Turner, & Bowling, 2010). There is a relationship between melanomas and ultraviolet light exposure and family history of the same (Bristow, de Berker, Acland, Turner, & Bowling, 2010). The disease produces a black to brown discoloration under the nails similar to the patient’s presentation. It is however not related to trauma.
The rationale for the preference of this differential is the symptomatology and the case scenario. Onychomycosis is a chronic fungal infection of the nails. It makes up for nearly half of all nail disorders (Soutor & Hordinsky, 2013). It is more common among males, the immunosuppressed or diabetics. Trauma and nail dystrophy predisposes one to these infections. In 60 to 80% of cases, they are caused by the fungal class of dermatophytes including Trichophyton rubrum, Trichophyton. mentagrophytes and E. floccosum (Tchernev et al., 2013). Non-dermatophyte molds (NDMs) and candida also cause onychomycosis. The commonest presentation is discoloration of the nail plate (Tchernev et al., 2013). The findings include brown, yellow or orange streaks or patches under the nail plate. Nail changes with the progressive disease include nail thickening and separation from the nail bed. Toenails are affected more than fingernails by more than seven fold (Singal & Khanna, 2011).
The patient fulfills all the symptomatic presentation as he presents with a brown patch under the hallux nail plate. The streak is following suspected trauma, is chronic in nature and enlarging progressively. The patient has a history of exposure to trauma in harsh environments as he had been renovating his house prior to the presentation of the lesion. It is therefore likely that he picked up a nail fungal infection and presented later due to the chronic nature of the condition. The patient had no other complaints since onychomycosis does not present with systemic effects and is fairly localized.
Although some patients may view onychomycosis at an early stage as merely a cosmetic issue, it can progress and prove to be a real distressing pathology (Singal & Khanna, 2011). It leads to discomfort wearing shoes, walking, and self-esteem issues. It is also a contagion and can spread to family members. It can lead to complications such as osteomyelitis, ulcers, and cellulitis not forgetting the financial impact of dealing with such complications (Ameen, Lear, Madan, Mohd Mustapa, & Richardson, 2014). It is, therefore, clinically relevant to manage this disorder using the best available means.
Due to the different number of organisms causing onychomycosis and the different clinical presentations, laboratory diagnosis of onychomycosis should be done before any treatment is initiated (Mikailov, Cohen, Joyce, & Mostaghimi, 2016). The rationale behind this is that the different organisms have specific management strategies and empirical treatment may be unsuccessful. It is also useful to rule of non-infective causes such as melanoma and psoriasis and to identify mixed infections that usually exist together with onychomycosis. The laboratory diagnosis involves careful specimen collection from the affected digit usually from the discolored or brittle parts of the nail (Singal & Khanna, 2011). The nail in question is clipped at the affected region using aseptic techniques and the scrapings collected. Lab identification involves organism culture and visualization under microscopy (Singal & Khanna, 2011). For suspected fungal infection, direct microscopy is done under 10-30% KOH and examined for fungal elements for example hyphae, yeast or spores (Ameen, Lear, Madan, Mohd Mustapa, & Richardson, 2014). Confirmatory specimen culture using primary culture media is done next. Newer introduced means of diagnosis have shown improved result sensitivity and include DNA analysis of the specimen with PCR or using dual flow cytometry (Ameen, Lear, Madan, Mohd Mustapa, & Richardson, 2014). According to Barak, Asarch, & Horn, (2010), periodic acid Schiff is more sensitive than using microscopy.
After the lab isolation of the offending organism, treatment with antifungal therapy is initiated. It can either be topical, systemic or combination with both modalities. Topical treatment is limited to superficial infections due to the limited absorption of the drug past the hard nail plate. Evidence recommends the use of the following agents: amorolfine which has shown effectiveness in 50% of cases, ciclopirox that is effective with 34% mycological cure, and tioconazole that achieved cure rates of 22% (Ameen, Lear, Madan, Mohd Mustapa, & Richardson, 2014). Other topical agents used include eficonazole, terbinafine, Butenafine, Bifonazole and Salicylic acid. They is, however, limited evidence data to support their application.
Systemic therapy is mainly with terbinafine, griseofulvin, fluconazole, itraconazole, and ketoconazole. Griseofulvin has demonstrated cure rates of up to 40% (Ameen, Lear, Madan, Mohd Mustapa, & Richardson, 2014). Studies that compared it to terbinafine and itraconazole and found it weaker (Ameen, Lear, Madan, Mohd Mustapa, & Richardson, 2014). Terbinafine is a good broad-spectrum antifungal and is fungicidal against a large number of dermatophytes. When compared with itraconazole, it proved stronger with cure rates of 55% compared with 26% in itraconazole (Ameen, Lear, Madan, Mohd Mustapa, & Richardson, 2014). Fluconazole is another option with cure rates ranging from 47% to 62% (Ameen, Lear, Madan, Mohd Mustapa, & Richardson, 2014). Other newer drug therapies exist but their efficacy data is insufficient.
Combination therapy should be used to lower relapse and improve the cure rates. An example is the use of a combination of itraconazole and amorolfine that achieved 83% cure compared to 41% for those who received itraconazole alone (Lecha, 2001). Another trial using terbinafine and amorolfine resulted in cure rate of 27% compared to 17% with terbinafine monotherapy (Baran et al, 2000). Combination therapy should, therefore, be attempted.
Surgical intervention to help drug penetration and to remove diseased tissue has been shown to be effective additional strategies. The whole nail could be removed in avulsion or part of the nail as in debridement. For the patient’s case, partial removal is a better option in combination with topical and systemic antifungals (Malay, Borowsky, Downey & Mlodzienski, 2009).
Conclusion
Evaluation of the case study, construction of the differential diagnosis tree and clinical assessment of the case scenario yielded the most likely differentials to be nail psoriasis, subungual hematoma, subungual melanoma, and chloronychia. The preferred differential diagnosis, however, was onychomycosis due to the presentation and scenario. The management of onychomycosis involves first lab identification of the causative organism and strict antifungal therapy to target the same. Modalities of treatment include topical, systemic and combination therapy. Combination therapy is recommended due to higher cure rates. To supplement antifungal therapy, surgical avulsion or debridement can be used to reduce diseased tissue and aid drug penetration.
References
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Barak, O., Asarch, A., & Horn, T. (2010). PAS is optimal for diagnosing onychomycosis. Journal of cutaneous pathology, 37(10), 1038-1040.
Baran, R. (2010). The burden of nail psoriasis: an introduction. Dermatology, 221(1), 1-5.
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Bristow, I. R., de Berker, D. A., Acland, K. M., Turner, R. J., & Bowling, J. (2010). Clinical guidelines for the recognition of melanoma of the foot and nail unit. Journal of Foot and Ankle Research, 3, 25. https://doi.org/10.1186/1757-1146-3-25
Chiriac, A., Brzezinski, P., Foia, L., & Marincu, I. (2015). Chloronychia: green nail syndrome caused by Pseudomonas aeruginosa in elderly persons. Clinical interventions in aging, 10, 265.
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compared with terbinafine alone in the treatment of dermatophytic toenail onychomycoses affecting the matrix region. Br J Dermatol, 142, 1177-1183.
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Malay, D.S., Yi, S., Borowsky, P., Downey, M.S., & Mlodzienski, A.J. (2009). Efficacy of debridement alone versus debridement combined with topical antifungal nail lacquer for the treatment of pedal onychomycosis: A randomized, controlled trial. J Foot Ankle Surg, 48, 294-308
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