When A Patient Presents With Thick, Yellow Toenails And A Rash On Both Feet

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Author(s): 
Michael Uro, DPM

   Idiopathic onycholysis. This condition occurs more frequently in women and is possibly caused by the same conditions that cause chronic paronychia. In predisposed individuals, frequent contact with water and irritants damages the distal portion of the nail bed.

   Paronychia congenita. Dystrophic, thickened nails and focal palmoplantar keratoderma are commonly associated with this rare condition.4

What You Should Know About Psoriatic Nail Disease

Psoriatic nails reportedly occur in 10 to 55 percent of patients with psoriasis. It occurs in less than 5 percent of those with no other findings of psoriasis.1 Some of the key physical findings in psoriatic nail disease include oil drop or salmon patch lesions of the nail bed, pitting of the proximal nail matrix, Beau’s lines of the proximal nail matrix, leukonychia of the mid-matrix, spotted lunula of the distal matrix or splinter hemorrhage.5

A Closer Look At Treatment Results

Given that this patient had a history of both psoriatic nail disease and onychomycosis, I advised her that even if she received treatment for onychomycosis, her psoriasis would most likely continue to produce the same dystrophic, unsightly nails for which she was seeking treatment. I offered her periodic debridement of her nails, oral antifungal therapy or the 1064 nm Yag laser treatment of onychomycosis. She elected to proceed with the laser treatment.

   Following two laser treatments, she demonstrated significant improvement of her nail condition. However, 11 months after treatment, she had a psoriatic flare-up and some of her nails demonstrated regression. After one more laser treatment, I recommended that she not continue with the laser treatment but return for periodic maintenance care.

   In regard to topical treatments available for psoriatic nails, one may consider high potency corticosteroids such as 5 fluorouracil topical 1% solution or 5% cream (Efudex, Valeant Pharmaceuticals) applied twice daily to the matrix area for six months. Other options include psoralen plus ultraviolet light A (PUVA) or triamcinolone acetonide (Kenalog, Bristol-Myers Squibb) suspension of 2.5 mg per cc into the proximal nail fold, which one may administer every four to six weeks.

   Dr. Uro is in private practice in Sacramento, Calif. He is a past member of the medical advisory board for Patholase. Dr. Uro has disclosed that he is a speaker for Cutera and is currently involved in a retrospective study for the company’s Genesis Plus laser device.

References
1. Elewski BE. Onychomycosis: pathogenesis, diagnosis and management, Clin Microbiol Rev. 1998; 11(3):415-429.
2. Chuang TY. Lichen planus. http://emedicine.medscape.com/article/1123213-overview . Published June 23, 2011. Accessed January 10, 2012.
3. Dockery GD, Bakotic B. What you should know about lichen planus. Pod Today 2007;20(6):52-60.
4. George SJ. Pachyonychia congenital. http://emedicine.medscape.com/article/1106169-overview . Published August 9, 2010. Accessed January 10, 2012.
5. Li C. Nail psoriasis. http://emedicine.medscape.com/article/1107949-overview . Published March 29, 2011. Accessed January 10, 2012.

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