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Fare clic per modificare stile

Managemene of nail disorders in children Bianca Maria Piraccini, MD, PhD, Chair

F074 - Medical and Surgical Management of Nail

Bianca Maria Piraccini Disorders
DISCLOSURES
Pierre fabre-Ducray, Difa Cooper, Dercos-L’Oreal, ISDIN, Legacy Healthcare , Pfeizer , Eli-
Lilly (honoraria)
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Nail biting/onycophagia
Nail disorders in children
• uncommon cause of consultation • Rare before the of 3 years, peaks in childhood and adolescence
• present at birth or acquired • prevalence of about 30% at around 6 year of age
• prevalence of some diseases different compared to adults • occurs as a result of boredom or working on difficult problems rather than
• treatment difficult anxiety
Types
• congenital/hereditary
• inflammatory
• infecHve
• traumaHc
• neoplasHc

3 Congenital micronychia Halteh

4 et al. J Dermatolog Treat. 2017;28: 166-172.

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Nail biting (onychophagia) Nail biting/onycophagia

• short nail plate

• Beau’s lines
• hyponychium evident
• periungual scaling/blood crusts/
hyperkeratosis
• longitudinal melanonychia

Shortening of the fingernails, with transverse axes longer than the longitudinal ones.
The hyponychium and nail bed skin become visible
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Nail bi=ng/onycophagia
Nail biting/onycophagia
Longitudinal melanonychia

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Nail biting/onycophagia
Longitudinal melanonychia

The periungual skin may show sings of biting and chewing, evident as wounds, crusts
and scales or as diffuse inflammation
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Nail bi3ng
Treatment
• Non-pharmacological therapies

Halteh et al. J Dermatolog Treat. 2017;28: 166-172.

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Nail bi3ng Nail biting

Treatment
Treatment • N-acetyl cysteine (NAC) 800-1200 mg/day

• bitter tasting lacquers (containing denatonium benzoate and

sucrose octaacetate)

• reminder technique

After 6 months
Koritzky & Yechiam. Behav Modif. 2011; 35: 511-30. Lee & Lipner SR. Int J Environ Res Public Health. 2022; 19(11): 6370.
13 14Kashetsky et. J Eur Acad Dermatol Venereol. 2023; 3:e73-e76.

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Nail bi3ng Nail biting

Complications Complications

• change in the oral bacteria (< Enterobacteriaceae) • Periungual warts

• dental problems: apical root resorption, alveolar destruction, malocclusions, temporo-
mandibular disorders and gum injuries.
• negative social and psychological consequences for the patients and their parents

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Periungual warts Periungual warts

• HPV- 1, 2, 4, 27, 57 and 63 Most affected anatomical sites

• most common between 5 and 20 years
• Frequent spontaneous regression: 30% at 3 months, 50% at 1 year and 90% in 5 years
• Proximal and lateral nail folds
• sub- or periungual hyperkeratotic lesions involving multiple fingers • Hyponychium/Nail bed

Favored by
ü Maceration
ü Abrasion
ü Onychophagia
ü manicure
ü "wet" manual work

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Periungual warts Periungual warts

ü Colarette
• Keratotic papules ü Roughness
ü Mosaic model
• Yellowish coloration ü Point hemorrhages (not splinters)

• Multiple black dots (dermoscopy)

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Subhadarshani S, et al. Dermoscopy of Subungual Wart. DPC 2019;9:22-3.

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Periungual warts:
Periungual warts
peri/subungual nodules • Kerato'c papules
• Keratotic papules • Yellowish colora'on
• Yellowish coloration • Mul'ple black dots
• Multiple black dots

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Periungual warts Periungual warts

ü Colarette
ü Roughness
ü Mosaic model Treatments - frustrating
ü Point hemorrhages (not
splinters) Topical
Surgical

Treatment is chosen based on:

• Number and size of lesion(s)
• host age and immunity
• resistance to prior therapy

Aggressive treatments do not necessarily correlate with improvement ! ! !

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Periungual warts - Treatment topical immunotherapy

with difeninciproterone
Destructive treatments Antiproliferative agents Immunological therapies (DFC)
Most performed Intralesional/Topical -
Highest level of recommendation ?? Podophyllin Propionium bacterium parvum
diphencyprone
Chemicals - acid solutions 5-fluorouracil immunomodulators
Interventions – cryotherapy Bleomycin (imiquimod)
lasers
electrofulguration Systemic – levamisole
surgical excision zinc sulfate

V e a se y JV . U se o f im iq u im o d in th e tre a tm e n t o f ch ro n ic p e riu n g u a l w a rts. Su rg C o sm e t D e rm a to l. R io d e Ja n e iro v .1 1 n .4 o u c-d e c. 2 0 1 9 p . 3 2 5 -9 .

N o rie g a L F , V a la n d ro L S, D i C h ia cch io N G , V ie ira M L , D i C h ia cch io N . T re a tm e n t o f v ira l w a rts w ith in tra le sio n a l b le o m y cin . Su rg C o sm e t D e rm a to l. 2 0 1 8 ;1 0 (1 ):1 6 -2 0 .
A h n C S, H u a n g W W . Im iq u im o d in th e tre a tm e n t o f cu ta n e o u s w a rts: a n e v id e n ce -b a se d re v ie w . A m J C lin D e rm a to l. 2 0 1 4 ;1 5 (5 ):3 8 7 -9 9 .
N o fa l A , N o fa l E , Y o se f A , N o fa l H . T re a tm e n t o f re ca lcitra n t w a rts w ith in tra le sio n a l m e a sle s, m u m p s, a n d ru b e lla v a ccin e : a p ro m isin g a p p ro a ch . In t J D e rm a to l. 2 0 1 5 ;5 4 (6 ):6 6 7 -7 1 .
N o fa l A , Sa la h E , N o fa l E , Y o se f A . In tra le sio n a l a n tig e n im m u n o th e ra p y fo r th e tre a tm e n t o f w a rts: cu rre n t co n ce p ts a n d fu tu re p ro sp e cts. A m J C lin D e rm a to l. 2 0 1 3 ;1 4 (4 ):2 5 3 -6 0 .
25 th a l J, M cL e o d M P , Za ia c M . M a n a g e m e n t o f u n g u a l w a rts. D e rm a to l T h e r. 2 0 1 2 ;2 5 (6 ):5 4 5 -5 0 .
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Nail biting Acute paronychia- Treatment

Complications
As microbiological examinaJon is not always feasible, topical
Acute paronychia fusidic acid can be used in mild forms, and oral fluorquinolone in
severe acute paronychia
• usually 1-2 fingers
• causes: penetration of bacteria (Staph, Strept) after skin damage
• due to ü nail biting
ü cuticle picking
ü nail sucking
• acute inflammation more marked on one side
• may regress or evolve into abscess

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Acute paronychia Be aware …

Acute paronychia may cause permanent nail dystrophy
Onychomadesis is a common sequela
• rare
• not dependent to severity of inflammation

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Subungual hematoma
Brown-black nail discoloration
• Hematoma
• Melanic pigmentation

Clues for dermoscopical diagnosis:

Ø Shape: round or with rounded margin
Ø Color: black, purple red, brown, fading
at the periphery
Ø Peripheral blood spots
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Melanonychia

Clues for dermoscopical diagnosis:

Ø Shape: rectangular or triangular, from
PNF to distal margin
Ø Color: black-brown-grey with lines
Ø Distal margin: may show upper or lower
pigmentation

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Melanonychia
• Pigment production results from
– melanocyte activation Cells 2023, 12, 964. https://doi.org/10.3390/cells12060964
– melanocyte proliferation
• benign (hyperplasia or nevus) • 21 cases of NUM in children have been reported to date, with only 4
• malignant (melanoma) cases diagnosed as invasive and no instances of metastasis or death
• There is controversy surrounding these cases, their pathology, and
whether they are true cases of melanoma

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Melanocyte nevi in children Dermoscopy of melanonychia

• Rare
Is not reliable in children
• The most common cause of longitudinal melanonychia of childhood
• Clinical and dermoscopical features should be not evaluated using the Indicators of malignancy in adults, not always
reliable, are:
parameters utilized in adults
• brown background of the band
• irregular margins
• lines not parallel and not continuous

37 Di Chiacchio et al. An Bras Dermatol. 2013; 88: 309-13.

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Main issues in children melanonychia Nail matrix nevus

Nail matrix nevus undergoing
fading of the pigmentation
• How frequent is nail melanoma in children?

Extremely rare, the diagnosis of melanoma in situ perhaps overdone

• Are there clinical or dermoscopic criteria that suggest a nail

melanoma in children?

Dark skin photoptype and darkening of the pigmentaJon are sole useful
clues

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Nail matrix nevus

Melanonychia in children
• Periodic follow-up

Tangential biopsy of the nail matrix

When
Ø Parents are too anxious
Ø the band rapidly enlarges and involves the
whole nail and its color is dark-black
Irregular pattern of the bands
and presence of melanin granules

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Subungual exostosis Subungual exostosis

• Distolateral subungual nodule
• Subungual hard nodule • Onychoscopy shows collereOe and dilated
• Rare < 7 years capillaries
• Toenail • x-rays shows overgrowth of the dorsal bone
• Trauma may be a predisposing factor composed of trabeculae
• May be tender

X-ray diagnostic

Starace et al. J Dtsch Dermatol Ges. 2023; 21: 116-129.

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Subungual exostosis Subungual exostosis

• The success rate of surgical resection is more than 90%
• recurrences are related to inadequate tumor resection
• Resection of the entire lesion, including the fibrocartilage cap, is essential to
avoid local recurrence

Li et l. Front Pediatr. 2022 Dec 8;10:1075089.

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Thank you!

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