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LIVE BLOG: Update on Nails with Dr. Phoebe Rich

In this live blog from the 10th Annual SDPA Fall Conference, Dr. Phoebe Rich’s lectures on interesting nail cases covering Squamous Cell Carcinoma, Follicular cysts and beyond.  Dr. Rich stresses the array of options for steps to take in nail diagnoses and highlights those which have proved to be most helpful in her experience.

Squamous Cell Carcinoma of the Nail

+ 56 year old woman
+ Tender red plaque on nail fold
+ Tender scaly plaque
+ Previously treated for psoriasis, warts, eczema

+ Biopsy

Things to look for that will move toward decision to biopsy:
+ Symptoms
+ Durations
+ Age/Sex
+ Hx? HPV?
+ The common digits?  (1st and 3rd finger of dominant hand)

Next Step:
+ Get an X-Ray (We need to know if it’s infected the bone)
+ Send for MOH’s
+ Excise with margins

Clinical Presentation

Principle in nail diagnosis: Depends on the nail unit
+ Verrucous
+ Eczematous-like
+ Longitudinal Erthronyschia
+ Onycholysis/Oozing
+ Longitudinal melanonchia

Acrokeratosis Paraneoplastica of Bazex


+ Male patient with enlarged, scaly toe nails, looks fungal
+ KOH and Culture is Negative
+ Here is where we check patient’s skin: Trite-palm is found
+ Diagnosis of Acrokeratosis Paraneoplastica of Bazex means that cancer somewhere in a distant site
+ Malignant of upper respiratory and digestive tract
+ Mets to cervical and upper mediastinal nodes
+ May precede malignancy
+ This condition is rare, but mainly seen in men over 40

Onychomycosis and Nail Psoriasis

Where do we start with nail psoriasis?
+ If mild: start with topical or minimal treatments
+ For mild to moderate nail disease in absence of skin or joint involvement: topical intralesional, other classical systemic meds
+ Moderate to severe nail disease and won’t respond: try biologics
+ Intralesional Conticosteroid Injections
+ Acitretin can be helpful when used in the right way

Yellow Nail Syndrome

+ 60 year old woman with progressively slow growing nails, absent lunula and cuticle onycholysis
+ Take a medical history for pulmonary problems
+ Mainly linked to lymphedema

+ Use vitamin E
+ But treat the lung problem in you can

Follicular Cyst

+ 36 year old female with a new papule on the nail fold
+ Examine carefully to try to determine if it is fluid filled and movable
+ Biopsy for diagnosis
+ This cyst was firm, not fluid-filled, but moveable
+ Removed through incision

[Image by John Millar]

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