- Email: [email protected]
Videodermoscopy of the hyponychium in nail bed psoriasis
714 Letters
J AM ACAD DERMATOL APRIL 2008
foam versus placebo in the treatment of androgenetic alopecia in men. J Am Acad Dermatol 2007;57:767-74. 2. Thiboutot DM, Weiss J, Bucko A, Eichenfield L, Jones T, Clark S, et al. Adapalene-benzoyl peroxide, a fixed-dose combination for the treatment of acne vulgaris: results of a multicenter, randomized double-blind, controlled study. J Am Acad Dermatol 2007;57:791-9.
RESEARCH
3. Gorouhi F, Solhpour A, Beitollahi JM, Afshar S, Davari P, Hashemi P, et al. Randomized trial of pimecrolimus cream versus triamcinolone acetonide paste in the treatment of oral lichen planus. J Am Acad Dermatol 2007;57:806-13. doi:10.1016/j.jaad.2007.11.003
LETTERS
Videodermoscopy of the hyponychium in nail bed psoriasis To the Editor: Since videodermoscopy shows the vascular pattern as a constant feature of scalp psoriasis1 (interfollicular, twisted, red loops representing capillary loops in dermal papillae in a condition of epidermal hyperplasia), we decided to use this device to evaluate the capillary network of the fingernail hyponychium in patients with nail bed psoriasis in an attempt to find a tool aiding clinicians in the diagnosis and follow-up of this disorder. Psoriasis limited to the nail bed is often a diagnostic challenge; it may be clinically indistinguishable from idiopathic onycholysis and it may also mimic onychomycosis and nail bed lichen planus. Changes in the microvasculature of the nailfold area are a well-studied phenomenon in connective tissue disorders. Previous studies2 have examined these changes in nail psoriasis, with potentially confusing results, in the authors’ opinion caused by the special hairpin arrangement of nailfold capillaries. In contrast, the simple architecture of the hyponychium capillary network makes capillary loops in this anatomic area appear as regular red dots because of their perpendicular arrangement to the skin (each red dot observed represents the top of one loop)3 and more easy to study and quantify or qualify. Between September 2006 and April 2007, we evaluated with videodermoscopy the fingernail hyponychium of 30 patients with nail bed psoriasis (Fig 1). In all patients the diagnosis of psoriasis was confirmed by an association with skin or scalp psoriasis. Five patients with nailbed lichen planus and 15 control subjects without diseased nails were used for comparison. Conduction of the study was approved by the Ethics Committee at the University of Bologna, Italy. We found 340 (after evaluating between 320 and 370) to be the ideal power of magnification for the videodermoscope because of the ease in counting the capillaries, and we used alcohol for the interface solution (Kodan spray, Schulke and Mayr, Vienna, Austria).
Fig 1. Clinical presentation of nailbed psoriasis.
In all patients with psoriasis, the capillaries of the hyponychium were visible, dilated, tortuous, elongated, and irregularly distributed (Fig 2). The capillary density (ie, the number of capillaries per power field [340]) was different in each patient (range, 23 to 84 at baseline) and positively correlated with disease severity. The capillaries were not observed in patients with lichen planus, whereas in 6 of the 15 normal control subjects, capillaries were visible and always limited to the second, third, and fourth digits of the dominant hand. Their shape was less tortuous and were reduced in number (range, 15 to 43) (Fig 3) and more regularly distributed compared with those in psoriatic patients. This observation in the hyponychium of patients with nail psoriasis contrasts with the previously reported decrease in nailfold capillary density in nail psoriasis,2 but in accordance with the increased capillary density that is reported in perilesional skin of patients with skin psoriasis.4 Quantitative assessment of the hyponychial capillaries also correlated with the response to treatment: patients observed after a 3-month course of treatment (calcipotriol ointment twice a day) showed a significant decrease in the number of visible capillaries. It is the authors’ belief that patients with nail lichen planus demonstrated no capillary change because the pathology lacks particular vascular abnormalities. Indeed, nonvascular features have been reported to be the most
Letters 715
J AM ACAD DERMATOL VOLUME 58, NUMBER 4
capillaries, a videodermoscope capable of providing a computerized count of the capillaries would greatly enhance the practicality of this imaging modality. Unfortunately, 310 magnification of the handheld dermoscope was inadequate to visualize the capillaries, making this widely available instrument less effective than the videodermoscope. Matilde Iorizzo, MD,a Maurice Dahdah, MD,b Colombina Vincenzi, MD,a and Antonella Tosti, MDa Departments of Dermatology, University of Bolognaa and American University of Beirutb Funding sources: Council for Nail Disorders (2006 grant to Dr Iorizzo for data collection). Conflicts of interest: None declared. Special thanks to the Council for Nail Disorders for the grant given to Dr Iorizzo in 2006.
Fig 2. Same patient as shown in Fig.1. Capillaries of the hyponychium as seen by videodermoscopy. (Magnifications: A, 340; B, 370.)
Fig 3. Capillary changes in control subject (dominant hand, 340 magnification). Vessels are less tortuous and less numerous.
significant dermoscopic features in patients with cutaneous lichen planus.5 In normal control subjects, we believe the visualization of capillaries was related to the microtrauma the dominant hand has to deal with every day. None of our patients demonstrated punctate hemorrhages.6 Videodermoscopy is a noninvasive imaging modality that may assist in the diagnosis of nailbed psoriasis, particularly in clinically ambiguous cases, and may supplement the clinical impression of response to therapy. Although the study instrument required manual quantification of individual
Correspondence to: Matilde Iorizzo, MD, Department of Dermatology, University of Bologna, Via Massarenti 1, 40138, Bologna, Italy E-mail: [email protected] REFERENCES 1. Ross EK, Vincenzi C, Tosti A. Videodermoscopy in the evaluation of hair and scalp disorders. J Am Acad Dermatol 2006;55: 799-806. 2. Bhushan M, Moore T, Herrick AL, Griffiths CE. Nailfold video capillaroscopy in psoriasis. Br J Dermatol 2000;142:1171-6. 3. Humbert P, Sainthillier JM, Mac-Mary S, Petitjean A, Creidi P, Alibia F. Capillaroscopy and videocapillaroscopy assessment of skin microcirculation: dermatologic and cosmetic approaches. J Cosmet Dermatol 2005;4:153-62. 4. De Angelis R, Bugatti L, Del Medico P, Nicolini M, Filosa G. Videocapillaroscopic findings in the microcirculation of the psoriatic plaque. Dermatology 2002;204:236-9. 5. Va´zquez-Lo´pez F, Manjo´n-Haces JA, Maldonado-Seral C, RayaAguado C, Pe´rez-Oliva N, Marghoob AA. Dermoscopic features of plaque psoriasis and lichen planus: new observations. Dermatology 2003;207:151-6. 6. Marchiori Bakos R, Bakos L. Use of dermoscopy to visualize punctate hemorrhages and onycholysis in ‘‘Playstation thumb’’. Arch Dermatol 2006;142:1664-5. doi:10.1016/j.jaad.2007.11.026
The need for leadership: How can we better train the next generation of dermatologists? To the Editor: The necessity for physicians to be effective leaders is widely accepted.1-5 Nevertheless, current residency curricula continue to focus on creating knowledgeable and skilled physicians in the realms of clinical judgment and technical skills, but generally do not emphasize leadership skill training.1-3 Although we agree with many that
J AM ACAD DERMATOL APRIL 2008
foam versus placebo in the treatment of androgenetic alopecia in men. J Am Acad Dermatol 2007;57:767-74. 2. Thiboutot DM, Weiss J, Bucko A, Eichenfield L, Jones T, Clark S, et al. Adapalene-benzoyl peroxide, a fixed-dose combination for the treatment of acne vulgaris: results of a multicenter, randomized double-blind, controlled study. J Am Acad Dermatol 2007;57:791-9.
RESEARCH
3. Gorouhi F, Solhpour A, Beitollahi JM, Afshar S, Davari P, Hashemi P, et al. Randomized trial of pimecrolimus cream versus triamcinolone acetonide paste in the treatment of oral lichen planus. J Am Acad Dermatol 2007;57:806-13. doi:10.1016/j.jaad.2007.11.003
LETTERS
Videodermoscopy of the hyponychium in nail bed psoriasis To the Editor: Since videodermoscopy shows the vascular pattern as a constant feature of scalp psoriasis1 (interfollicular, twisted, red loops representing capillary loops in dermal papillae in a condition of epidermal hyperplasia), we decided to use this device to evaluate the capillary network of the fingernail hyponychium in patients with nail bed psoriasis in an attempt to find a tool aiding clinicians in the diagnosis and follow-up of this disorder. Psoriasis limited to the nail bed is often a diagnostic challenge; it may be clinically indistinguishable from idiopathic onycholysis and it may also mimic onychomycosis and nail bed lichen planus. Changes in the microvasculature of the nailfold area are a well-studied phenomenon in connective tissue disorders. Previous studies2 have examined these changes in nail psoriasis, with potentially confusing results, in the authors’ opinion caused by the special hairpin arrangement of nailfold capillaries. In contrast, the simple architecture of the hyponychium capillary network makes capillary loops in this anatomic area appear as regular red dots because of their perpendicular arrangement to the skin (each red dot observed represents the top of one loop)3 and more easy to study and quantify or qualify. Between September 2006 and April 2007, we evaluated with videodermoscopy the fingernail hyponychium of 30 patients with nail bed psoriasis (Fig 1). In all patients the diagnosis of psoriasis was confirmed by an association with skin or scalp psoriasis. Five patients with nailbed lichen planus and 15 control subjects without diseased nails were used for comparison. Conduction of the study was approved by the Ethics Committee at the University of Bologna, Italy. We found 340 (after evaluating between 320 and 370) to be the ideal power of magnification for the videodermoscope because of the ease in counting the capillaries, and we used alcohol for the interface solution (Kodan spray, Schulke and Mayr, Vienna, Austria).
Fig 1. Clinical presentation of nailbed psoriasis.
In all patients with psoriasis, the capillaries of the hyponychium were visible, dilated, tortuous, elongated, and irregularly distributed (Fig 2). The capillary density (ie, the number of capillaries per power field [340]) was different in each patient (range, 23 to 84 at baseline) and positively correlated with disease severity. The capillaries were not observed in patients with lichen planus, whereas in 6 of the 15 normal control subjects, capillaries were visible and always limited to the second, third, and fourth digits of the dominant hand. Their shape was less tortuous and were reduced in number (range, 15 to 43) (Fig 3) and more regularly distributed compared with those in psoriatic patients. This observation in the hyponychium of patients with nail psoriasis contrasts with the previously reported decrease in nailfold capillary density in nail psoriasis,2 but in accordance with the increased capillary density that is reported in perilesional skin of patients with skin psoriasis.4 Quantitative assessment of the hyponychial capillaries also correlated with the response to treatment: patients observed after a 3-month course of treatment (calcipotriol ointment twice a day) showed a significant decrease in the number of visible capillaries. It is the authors’ belief that patients with nail lichen planus demonstrated no capillary change because the pathology lacks particular vascular abnormalities. Indeed, nonvascular features have been reported to be the most
Letters 715
J AM ACAD DERMATOL VOLUME 58, NUMBER 4
capillaries, a videodermoscope capable of providing a computerized count of the capillaries would greatly enhance the practicality of this imaging modality. Unfortunately, 310 magnification of the handheld dermoscope was inadequate to visualize the capillaries, making this widely available instrument less effective than the videodermoscope. Matilde Iorizzo, MD,a Maurice Dahdah, MD,b Colombina Vincenzi, MD,a and Antonella Tosti, MDa Departments of Dermatology, University of Bolognaa and American University of Beirutb Funding sources: Council for Nail Disorders (2006 grant to Dr Iorizzo for data collection). Conflicts of interest: None declared. Special thanks to the Council for Nail Disorders for the grant given to Dr Iorizzo in 2006.
Fig 2. Same patient as shown in Fig.1. Capillaries of the hyponychium as seen by videodermoscopy. (Magnifications: A, 340; B, 370.)
Fig 3. Capillary changes in control subject (dominant hand, 340 magnification). Vessels are less tortuous and less numerous.
significant dermoscopic features in patients with cutaneous lichen planus.5 In normal control subjects, we believe the visualization of capillaries was related to the microtrauma the dominant hand has to deal with every day. None of our patients demonstrated punctate hemorrhages.6 Videodermoscopy is a noninvasive imaging modality that may assist in the diagnosis of nailbed psoriasis, particularly in clinically ambiguous cases, and may supplement the clinical impression of response to therapy. Although the study instrument required manual quantification of individual
Correspondence to: Matilde Iorizzo, MD, Department of Dermatology, University of Bologna, Via Massarenti 1, 40138, Bologna, Italy E-mail: [email protected] REFERENCES 1. Ross EK, Vincenzi C, Tosti A. Videodermoscopy in the evaluation of hair and scalp disorders. J Am Acad Dermatol 2006;55: 799-806. 2. Bhushan M, Moore T, Herrick AL, Griffiths CE. Nailfold video capillaroscopy in psoriasis. Br J Dermatol 2000;142:1171-6. 3. Humbert P, Sainthillier JM, Mac-Mary S, Petitjean A, Creidi P, Alibia F. Capillaroscopy and videocapillaroscopy assessment of skin microcirculation: dermatologic and cosmetic approaches. J Cosmet Dermatol 2005;4:153-62. 4. De Angelis R, Bugatti L, Del Medico P, Nicolini M, Filosa G. Videocapillaroscopic findings in the microcirculation of the psoriatic plaque. Dermatology 2002;204:236-9. 5. Va´zquez-Lo´pez F, Manjo´n-Haces JA, Maldonado-Seral C, RayaAguado C, Pe´rez-Oliva N, Marghoob AA. Dermoscopic features of plaque psoriasis and lichen planus: new observations. Dermatology 2003;207:151-6. 6. Marchiori Bakos R, Bakos L. Use of dermoscopy to visualize punctate hemorrhages and onycholysis in ‘‘Playstation thumb’’. Arch Dermatol 2006;142:1664-5. doi:10.1016/j.jaad.2007.11.026
The need for leadership: How can we better train the next generation of dermatologists? To the Editor: The necessity for physicians to be effective leaders is widely accepted.1-5 Nevertheless, current residency curricula continue to focus on creating knowledgeable and skilled physicians in the realms of clinical judgment and technical skills, but generally do not emphasize leadership skill training.1-3 Although we agree with many that