Hot Topics In Podiatric Dermatology Evan Rieder, MD · Acne Pustulosis Hyperostosis Osteitis AKA chronic recurrent multifocal osteomyelitis, pustulotic arthro-osteitis Misdiagnosis,

Dermatologist, Psychiatrist

Assistant Professor of Dermatology

The Ronald O. Perelman Department of

Dermatology

Hot Topics In Podiatric Dermatology

Evan Rieder, MD

The Ronald O. Perelman Department of Dermatology 2

Disclosures

Advisory Board Member:

UCB Pharmaceuticals

Consultant:

UCB Pharmaceuticals

Unilever

Podiatrists & Dermatologists

The Ronald O. Perelman Department of Dermatology

The Ronald O. Perelman Department of Dermatology 4

General Outline

Bumps

Stripes

Collimated Lights

The Power of Observation



Robert Ryman, Untitled 1960-1961



Bumps


Outline


Common Podiatric Rashes

Keys To Differential Diagnosis

Uncommon Presentations

Bumps


Classic Psoriasis

Well-demarcatedErythematous plaqueSilvery scale

Classic locations:Scalp, elbows, knees, buttocks

3% of the population

Nail, joint involvement common

Dx: clinical +/- biopsy

Tx: topical steroids, nbUVB, immunomodulators


Psoriasis of the Foot & Lower Leg

May appear like classic plaque psoriasis

However may have different presentation

Patchy or generalized thickening and scaling of nearly entire surface of palms / soles without redness•Keratoderma

Greater associations with nail and joint psoriasis

Chronic, difficult to treat


Palmoplantar Pustulosis

Different presentation

Palms and soles, especially lateral

Localized or entire surface

Sterile pustules admixed with

yellow-brown macules +/- scaly

erythematous plaques

No longer considered psoriasis

10-25% of patients with

palmoplantar pustulosis also have

plaque psoriasis


SAPHO Syndrome

May be associated with sterile inflammatory bone lesions

SynovitisAcnePustulosisHyperostosisOsteitis

AKA chronic recurrent multifocal osteomyelitis, pustulotic arthro-osteitis

Misdiagnosis, mistreatment common

Dermatology referral


Psoriasis / Palmoplantar Pustulosis

Important differential diagnosis

Tinea pedis

•Pustular or bullous variant

Eczematous dermatitis

•Dyshidrotic

•Contact (allergic or irritant)

Scabies

Uncommon diagnoses:

•Bazex syndrome

•Bullous disorders


Common Differential Diagnoses


Tinea pedis

Pruritic

Macular

Scaly (thin)

Erythematous

Leading edge of scale

KOH+


Eczematous dermatidites

Dyshidrotic:

Tense, deep-seated vesicles of

palms +/- soles

Intensely pruritic


Eczematous dermatidites

Contact:

Well-demarcated

Erythematous

Diffuse scale

+/-Serous drainage

+/-Vesicobullae

Distribution of contactant: e.g.

cream, sandal

•May need patch testing

•History is relevant


Kline 2008

Scabies

Interdigital burrows: fingers > toes

Severe pruritus

Not restricted to palms and soles

History is relevant

When widespread / on feet, think

crusted


Crusted scabies

Thick, crusted plaques

Typically acral, may be generalized

Dystrophic nails

May not see burrows

Severe pruritus

Socioeconomic considerations


Uncommon Diagnoses


Bazex Syndrome

Acrokeratosis Paraneoplastica

Psoriatic-appearing nails

Psoriasiform erythematous,

squamous lesions of feet, ears,

nose

•Visible without disrobing

•Not common areas for psoriasis

Assoc with UGI or respiratory

malignancies

Medical referral is mandatory


Sator PG et al, 2006

Blistering Disorders

Bullous Pemphigoid

•Erythematous wheals tense

bullae (lower abdomen, thighs,

forearms)

•May result in milia with healing

•May have underlying systemic

illness or medication trigger


Blistering Disorders

Epidermolysis Bullosa Acquisita

•Erosions of feet / hands, tense

vesicobullae that may be

hemorrhagic

•May also result in milia with

healing

•May be associated with IBD


Take Home Points

Sometimes scaly red plaques are just psoriasis

Lower leg psoriasis may have an atypical presentation

Sometimes the differential diagnosis is broad

Observation of key clinical features can be very helpful in events when

diagnosis is uncertain

Dermatologic +/- medical referral to rule out atypical syndromes or

underlying systemic disease


Stripes

(Longitudinal) Melanonychia


Outline

Non-Melanocytic

Melanocytic

Tips for Diagnosis

Common & Rare Conditions

Image via regionalderm.com

30

Melanonychia

Non-Melanocytic

Nail stainingFungal

MelanonychiaSubungual

hemorrhage

Melanocytic

Melanocyte activation

Single

Trauma-induced

Periungualtumor-induced

Nail apparatus lentigo

Multiple

Drug/systemic dz-induced

Ethnic type nail pigmentation

Laugier-Hunzikersyndrome

Peutz Jegherssyndrome

Melanocytic hyperplasia

Benign

Nail matrix nevus

Malignant

Subungualmelanoma

31

Non-Melanocytic

Nail stainingFungal


hemorrhage

32

A patient presents for a routine exam

and you see yellow discoloration of

multiple fingernails. How can this help

you meet your Clinical Quality

Measures (CQM) for meaningful use?

Recording smoking status for

patients 13 years or older is a core

objective

Smoking cessation medical

assistance is an additional set CQM

Hardin ME, Greyling LA, Davis LS. Nicotine staining of the hair and nails.

J Am Acad Dermatol. 2015 Sep;73(3):e105-6. doi: 10.1016/j.jaad.2015.05.020.

Clinical Scenario

Location: Bilateral thumbnails, 2nd & 3rd

fingernails of dominant hand

Causes:

•Brown: hobbies, occupational exposure to

foods, clothing dyes

•Yellow: smoking, nail polish (red)

Dermoscopy of Pigment:

•Irregularly shaped

•Well-demarcated border, may be parallel

to PNF

Tx: Easily removed w/ 15 blade

33

Jin H, Kim JM, Kim GW, et al. Diagnostic criteria for and clinical

review of melanonychia in Korean patients. J Am Acad Dermatol.

2016 Jan 30.

Hardin ME, Greyling LA, Davis LS. Nicotine staining of the hair and nails.

J Am Acad Dermatol. 2015 Sep;73(3):e105-6. doi: 10.1016/j.jaad.2015.05.020

Nail Staining

Nail Staining

www.dailymail.co.uk/news/article-1384841/The-incredible-paintings-amputee-Chinese-artist-creates-pictures-toes-mouth.html

Huang Guofu

35

A 39yo man presents with 1 month of

discoloration of multiple toenails. He is

concerned about melanoma. He has no

personal or family h/o of skin cancer.

What questions are important to ask this

patient?

-Medication history

-Trauma

Most appropriate next steps?

-PAS, fungal culture, +/- PCR

-Dermoscopy

Wang YJ, Sun PL. Fungal melanonychia caused by Trichophyton rubrum and the

value of dermoscopy. Cutis. 2014 Sep;94(3):E5-6.

Clinical Scenario

A Word On Dermoscopy

Non-invasive diagnostic test for

evaluation of lesions of skin, hair, &

nails

Low-powered microscope with

contact or polarized light to reduce

surface light-scatter interference

Image via: www.medicalexpo.com/prod/dermlite/product-79388-506390.html

A Word On Dermoscopy

Helpful tool, low cost,

portable

Eliminates biopsies

Pilot study of pigmented

lesions shows that

old dogs can learn

new tricks

Pigmented lesions are much

more difficult to assess than nails

Lasers for Onychomycosis

Terushkin et al 2010

Location: toenails > fingernails

•Men > Women

Causes: Most common

1) Non-Dermatophyte, dematiaceous fungus:

Scytalidium dimidiatum

2) Dermatophyte, nondematiaceous fungus:

Trichophyton rubrum

38

Fungal Melanonychia

Clinical clue: often spares matrix

Dermoscopy of pigment:

•Pigment streak w/ distal widening

•Yellowish streaks w/ jagged borders

composed of spikes

Dx: KOH, fungal Cx

(cycloheximide-free media)

Tx: Azole (Fluconazole, Itraconazole);

Allylamine (Terbinafine)

39Wang YJ, Sun PL. Fungal melanonychia caused by Trichophyton rubrum

and the value of dermoscopy. Cutis. 2014 Sep;94(3):E5-6.

Fungal Melanonychia

40Wang YJ, Sun PL. Fungal melanonychia caused by Trichophyton rubrum

and the value of dermoscopy. Cutis. 2014 Sep;94(3):E5-6.

Fungal Melanonychia: Dermoscopy

Ohn et al, JAAD 2017

• Pigmented streak

• Distal widening

• Yellowish streaks

• Jagged borders

• Spikes

41

A 35yo construction worker presents to your clinic after slamming his hand

in a door. You notice that the nail bed edges are disrupted. Would you

perform a nail bed trephination for evacuation of the subungual

hematomas? Are there any additional exams that you would order?

Bharathi RR, Bajantri B. Nail bed injuries and deformities of nail.

Indian J Plast Surg. 2011 May;44(2):197-202. doi: 10.4103/0970-0358.85340.

Clinical Scenario

Location: single or multiple nails;

toes > fingers (great toe)

Causes: trauma (overt episode,

exercise)

Dermoscopy of pigment: purple-

black: homogenous, globular &

peripheral fading patterns

42

Photos courtesy: Dr. Jennifer Stein

Subungual Hemorrhage

Dx: Serial dermoscopy (color fading & distal movement of

features), does not involve matrix

Radiology: X-Ray of affected digit to r/o:

• Fracture of distal phalanx

• Extensor tendon avulsion of distal phalanx

Tx: Drainage indicated when:

•1) Pain present & 2) Nail edges intact•Previously: nail bed trephination only for subungual hematomas <25-50% of nail surface

(>25-50%, tx avulsion with repair of any underlying nail bed laceration)

•More recently: if nail plate is partially adherent, not displaced out of PNF may leave

nail plate in place and subungual hematoma may be trephined

43

Subungual Hemorrhage

Not all brown discoloration of the nail is due to melanin

Dermoscopy and non-invasive diagnostic testing may be of utility

Nail bed trephination may be indicated for hematomas of any

size if the nail edges are not disrupted

•If edges are disrupted higher likelihood of nail bed injury &

associated distal phalanx fx may lead to a secondary nail

deformity if not surgically repaired

44

Summary: Non-Melanocytic

45

Melanonychia

Non-Melanocytic

Nail stainingFungal


hemorrhage

Melanocytic


Single

Trauma-induced



Multiple






Benign

Nail matrix nevus

Malignant

Subungualmelanoma

Melanocyte activation: •Normal # of melanocytes with increased production of melanin epithelial

hyperpigmentation

Melanocyte hyperplasia:• Increased # of melanocytes (proliferation)

46

Melanonychia: Melanocytic

Dermoscopy: Melanocytic Activation v Proliferation

Melanocyte activation: thin, regular

gray lines on grayish background

v

Melanocyte proliferation: homogenous

brown color of background band with:

- regular pattern of brown lines:

longitudinal parallel lines w/ regular

spacing & thickness

-irregular pattern of brown to black

lines: w/ irregular spacing &

thickness, disruption of parallelism

Braun RP, Baran R, Le Gal FA, et al. Diagnosis and management of nail pigmentations. J Am Acad Dermatol. 2007 May;56(5):835-47.

2007 Feb 22.

Melanin Melanocytes

48

Melanonychia

Non-Melanocytic

Nail stainingFungal


hemorrhage

Melanocytic


Single

Trauma-induced



Multiple






Benign

Nail matrix nevus

Malignant

Subungualmelanoma

49

Melanocytic


Single

Trauma-induced

Periungualtumor-

induced

Nail apparatus

lentigo

Multiple


Ethnic type nail

pigmentation


PeutzJeghers

syndrome

Trauma-induced:

•Location: fingernails > toes (thumb, 2nd nail)

•Causes: occupational trauma, onychotillomania,

overt trauma w/ nail plate deformity, repeated minor

trauma to toe/s (may involve multiple digits)

•Dermoscopy of pigment: thin, regular gray lines

on grayish background; abnormal surface of nail

plate; (+) blood spots

50

Melanocyte activation: single nail involved

Trauma-induced Melanonychia

51Photo courtesy: Dr. Shane Meehan

Don’t try this at

home!

Periungual tumor-induced:

•Location: fingernails, toenails

•Causes: digital mucous cyst, warts, fibromas, SCC,

onychomatricoma

•Dermoscopy of pigment: thin, regular gray lines on grayish

background; abnormal surface of nail plate; (-) blood spots

52


Nail apparatus lentigo:

•Location: fingernails (L thumb/2nd), toenails (R great toe)

•Cause: epithelial hyperpigmentation


background

53


Nail apparatus Lentigo

54

Photos courtesy of: Dr. Jennifer Stein

55

Melanocytic


Single

Trauma-induced

Periungualtumor-

induced

Nail apparatus

lentigo

Multiple


Ethnic type nail

pigmentation


PeutzJeghers

syndrome

Drug/Systemic disease-induced:

•Location: fingernails > toenails

•Causes:

Medications:

Antiretrovirals (Zidovudine, Lopinavir)

Chemotherapeutics (5-FU, MTX)

Antimalarials (Hydroxychloroquine)

Systemic Disease:

Scleroderma, SLE, HIV, Addison’s Dz (Bissell’s lines)

56

Melanocyte activation: Multiple nails involved

Drug-induced melanonychia

57

G. Micali, F. Lacarrubba (Eds.) Dermatoscopy in clinical practice: beyond

pigmented lesions. Informa Healthcare Ltd, London; 2010.

Ethnic type nail pigmentation:

•Location: fingernails > toenails

dark-skinned (Type V, VI) > light-skinned patients


background

58



59

Photo courtesy: Dr. Jennifer Stein

Laugier-Hunziker syndrome:

•Adult onset; sporadic, AD

•Location: fingernails, oral mucosa (lips, buccal mucosa,

tongue), genitals


background

60


Peutz Jeghers syndrome:

•Congenital/Childhood onset; AD (STK11 mutation)

•Location: oral mucosa + genital + digits (rarely)


background

•Malignancy risk: GI, breast, others

61


62

Melanonychia

Non-Melanocytic

Nail stainingFungal


hemorrhage

Melanocytic


Single

Trauma-induced



Multiple






Benign

Nail matrix nevus

Malignant

Subungualmelanoma

63

Melanocytic

Melanocyte hyperplasia

Nail matrix nevus

Subungualmelanoma

Nail matrix nevus:

•Location: fingernails > toenails; single nail > multiple nails

•Dermoscopy of pigment: homogenous brown color of

background band w/ regular pattern of brown lines:

longitudinal parallel lines w/ regular spacing & thickness

64

Melanocyte Proliferation

Nail Matrix Nevus

65

G. Micali, F. Lacarrubba (Eds.) Dermatoscopy in clinical practice: beyond pigmented

lesions. Informa Healthcare Ltd, London; 2010.Braun RP, Baran R, Le Gal FA, et al. Diagnosis and management of nail pigmentations. J Am

Acad Dermatol. 2007 May;56(5):835-47. Epub 2007 Feb 22.

Subungual melanoma:

•Location: thumb > great toe > index finger

•(+) Hutchinson’s Sign, (+/-) nail dystrophy

•50% of pts recollect preceding trauma

66

Melanocyte Proliferation

Subungual Melanoma

67

Worrisome features:

1) Pigment wider at

the base

2) Multiple, variegated

uneven bands

3) Destruction of nail

plate/associated

dystrophy

4) Pigment beyond

nail/Hutchinson’s sign

Longitudinal Melanonychia Dermoscopy Summary

Ohn et al JAAD 2017.

(A) Age: peak incidence in 5th to 7th decades of life, AA, Asians, Native

Americans (in whom subungual melanoma accounts for ≤ 1/3 of all melanoma)

(B) Brown-black band w/ breadth greater than 3 mm with variegated borders

(C) Change in nail band or lack of change in morphology despite adequate tx

(D) Digit most commonly involved: thumb > great toe > index finger

(E) Extension of the brown-black pigment onto the proximal and/or lateral nailfold

(+ Hutchinson’s sign)

(F) Family or personal history of dysplastic nevus or melanoma

69

Levit EK, Kagen MH, Scher RK, et al. The ABC rule for clinical detection of subungual melanoma. J Am Acad Dermatol. 2000 Feb;42(2 Pt 1):269-74.

ABCDEFs of Subungual Melanoma

Most melanonychias are benign, but it is essential to

r/o subungual melanoma

Detailed history, clinical exam & medication review

are important for diagnosis

Dermoscopy may aid in diagnosis & monitoring

If in doubt, perform a nail matrix biopsy

70

Longitudinal Melanonychia - Conclusions

Collimated Lights



Emerging Therapeutics in Nail Disease

Onychomycosis

•Lasers

•Photodynamic Therapy

• Iontophoresis

Psoriasis

•Lasers

• Intense Pulsed Light


Outline

Why lasers?

Mechanisms

Data

Future Directions


Background

Onychomycosis: the most common nail disease affecting ~14% of the

population

•Multiple modalities of treatment

•Orals

•Topicals

•Multimodal treatment

Challenges:

•Nail plate

•Patient compliance

•Low cure rates

•High rates of relapse

•Uncertain follow-up time

•Potential adverse events (e.g. hepatotoxicity, drug-drug interactions)


de Berker, 2009. Elewski BE, Charif MA. Gupta AK, et al 2000. Ghannoum MA, et al, 2000.

Why Lasers?

Principle of Selective Thermolysis

•Selective targeting of fungus?

•Better penetration, reduced side effects, physician control

Six Lasers FDA Cleared for the “temporary increase of clear nail of

patients with onychomycosis”

•Based on Equivalence Data

•Not on RCTs

•5 are Nd:YAG (1064nm), 1 is a diode (635/405nm)


FDA.gov

Mechanisms of Action

Ideally based on TRT of fungi or melanin

•Time required for heated tissue to lose 50% of heat through diffusion

•Related to size of target chromophore

• If time >TRT, target is not treated but collateral damage inflicted

In reality, most mechanisms are uncertain


Kalokasidis K et al. 2013. Ortiz AE et al, 2014. Carney et al, 2013. Haedersdal M et al, 2016. Gupta & Versteeg, 2017


Nd:YAG: bulk heating

Selective photothermolysis?

• T ↑ induced by energy absorption by lipids and moisture within fungal &

host cells heat shock response affects transcription / translation death

by induced cell imbalance

• T. rubrum death within 15 min of exposure at 50ºC

• T> 45ºC pain, necrosis in humans

• Theoretically**, pulses should alleviate this

• Lower temperatures can lead to fungistasis, but later spore germination

Fungistasis or fungicide?


Kalokasidis K et al. 2013. Ortiz AE et al, 2014. Carney et al, 2013. Haedersdal M et al, 2016. Gupta & Versteeg, 2017; Carney et al 2013


QS lasers: selective photothermolytic and photomechanical effects

•Which are target chromophores: melanin in cell wall or fungi?

•Light absorption peak for t. rubrum is 415nm

•Chitin, xanthomegnin, and melanin produced by t. rubrum

•Pigments are virulence factors that protect fungi from host immune responses

and ROS with destruction there could be an antifungal effect

•At 532nm QS Nd:YAG can suppress t. rubrum due to large amounts of

xanthomegnin it contains

•However only wavelengths 750 – 1300nm can penetrate the nail plate

•At 1064nm, wavelength is beyond absorption spectrum




Nd:YAG Outstanding Issues

•TRTs of mycelia and spores are not precisely known

•Are short pulses sufficient for fungicide or only fungistasis?

•How long do elevated temperatures need to be sustained to kill spores without

damaging surrounding tissues?

• Is there a mismatch between the wavelength needed to penetrate the nail plate

and that required to target necessary chromophores?




Diode: antimicrobial plus increased immune response?

•Dual wave, Non-thermal or “low level laser”

Antimicrobial

•405nm (blue) light: antimicrobial, antibacterial, antifungal effects

Increased immune response

•635nm (red) light: increase immune response by increasing circulation

Theory of photomodulation to increase immune activation:

•Light exposure target chromophore (iron and copper-containing enzyme

cytochrome C oxidase in the mitochondrial respiratory chain) increased

production of mitochondrial products PMNs stimulated to generate

additional ROS increased fungicidal capacity


Gupta & Versteeg, 2017; Bhatta et al, 2017


Erbium and CO2: ablative v fractionated

•Vaporization of nail bed +/- enhanced topical drug delivery

fCO2 Photothermal effects

On fungus

•↑ tissue T direct fungicide as H2O converted to steam swelling, pressure

microexplosions in fungi

On microenvironment

•Exfoliation and vaporization of target tissues remodeling and destruction of

fungal growth environment

Enhanced topical drug delivery

•Enhanced absorption via microscopic holes in nail bed


Kalokasidis K et al. 2013. Ortiz AE et al, 2014. Carney et al, 2013. Haedersdal M et al, 2016. Gupta & Versteeg, 2017

General Data

Fraught with limitations

Most reports are case series, uncontrolled trials without placebo or randomization

Numbers of subjects are low

Treatment numbers range from 1 – 12 sessions

Follow-up ranges from 0 – 12 months

Few pure laser studies: often use concomitant antifungals

Measurements: no consistency

• Type of onychomycosis

• Species

• Diagnosis (Culture / PAS)

• Clinical measurements

• How cure and clinical improvement defined

• Fingers v toenails

47% of 1064nm device trials reported a positive response

60% reported clinical and mycologic cure in >50% of treated subjects


Francuzik et al 2016

Randomized Studies With A Comparison Group

Author Year Laser

Source

Wavelength (nm) No. of treated

patients

No. of nails Follow-

up (mo)

CRR (%) MCR (%) Rand

omized

Controlled

Landsman et al. 2010, 2012 Diode 870, 930 26 26 9 35 38 Yes YesP

Zhang et al. 2012 Nd:YAG 1064 33 154 6 51-53 NA Yes YesA

Hollmig et al. 2014 Nd:YAG 1064 17 57 12 0.24M 33** Yes Yes

Li et al. 2014 Nd:YAG 1064 37 112 (50*, 62) 6 62.5 74*

83.9

Yes YesB

Ortiz et al. 2014 Nd:YAG 1320 10 10 3 40C 50 Yes YesS

Xu 2014 Nd:YAG 1064 15 31 6 64.52 77.42 Yes YesT1

El-Tatawy et al. 2015 Nd:YAG 1064 20 NA 6 100 80 Yes YesT2

Kim et al 2016 Nd:YAG 1064 56 217 6 76 15 Yes YesT3

Karsai et al 2017 Nd:YAG 1064 20 82 12 0 0 Yes Yes

Park et al 2017 Nd:YAG 1064 128 NA 0 NA 72 Yes YesT4


Adapted from Wiznia et al, 2016; Karsai et al; Park et al; Kim et al

CRR - Clinical Response Rate; Defined by linear clearing of the nail unless otherwise noted

MCR - Mycologic Cure Rate; Defined by negative fungal culture unless otherwise noted

* Fingernails

**At 3 monthsM Reported as mean proximal nail plate clearance in millimetersC Reported as clinical clearance rateP Placebo-controlledS Subjects served as their own controlsA Nd:YAG with half the number of treatments served as control groupB Fingernails and toenails served as control groups for each otherT1 Oral terbinafine served as control groupT2, T3, T4 Topicals served as control group (T2 – terbinafine, T3 – naftifine, T4 – amorolfine)

Nd:YAG n = 352

CRR = 0-100%

MCR = 0-84%

f/u = 0-12 mo

Compelling (?) Data: Erbium & CO2

Author Year Fractionated Wavelength (nm) Fluence

(J/cm2) or

Power (W)

No. of patients No. of nails Follow-up (mo) CRR (%) MCR (%) Controlled

Apfelberg et al. 1984 No 10600 NA 9 NA 6 NA 67* No

Borovoy et al. 1992 No 10600 8-10 W 200 NA 36 75 NA No

Lim et al. 2014 Yes 10600 160mJ 24 119 3 71 50 No

Bhatta et al. 2016 Yes NA 99mJ 75 356 6 73 80 No

Zhang et al. 2016 Yes 2940 35-62J/cm2 9 20 3 90 75 No

Zhou et al. 2016 Yes 10600 10-15mJ 60 233 6 73A 57B Yes***

Shi et al. 2017 Yes 10600 15mJ 31 124 3 69* 74** No


CRR - Clinical Response Rate; Defined by linear clearing of the nail unless otherwise notedA Greater than 60% clear B Less than 5% nail affected

MCR - Mycologic Cure Rate; Defined by negative fungal culture unless otherwise noted

**Negative fungal microscopy (KOH)

***CO2 arm served as control v CO2 + topical

Adapted from Wiznia et al; Shi et al; Zhang et al; Zhou et al

Fractionated CO2

n = 190

CRR = 69-90%

MCR = 50-80%

3-12 tx, q2-4 wk

daily antifungal

Adverse Effects

•Pain

•Necrosis, especially in diabetics

•Risk of anesthesia


Leverone et al, 2015

How to Approach This?

Assume that lasers do not work and do not use them

•A recent ”real-world” study (Rivers et al)

Use lasers for only selected indications

•DLSO, in patients intolerant / unwilling to use prescriptions, those with better

prognosis

Employ multimodal treatment

•Time, money

Attempt fractionally ablative methods

Consider the language that is being used


Rivers et al 2016

Education

Dispel the notion of treatment of

onychomycosis

•Temporary increase in clear nail

•Offer treatment for cosmesis only

•Analogous to botulinum toxin,

hyaluronic acid fillers

Set expectations

Recognize your own moral compass


Image via greaterspringfield.nimbledeals.com

Future Studies: Standardization

Lasers as monotherapy

How best to identify controls

• Untreated digit of contra foot v untreated individuals

Follow-up times

Treat all affected nails to control for reinfection

Separate by onychomycosis subtype, location (fingers v toes)

• Growth rates differ between fingers and toes as will time to treatment endpoints and

measurements

Methods for quantifying clinical improvement

• Cure rates – clinical and mycological

• Cosmesis

• Treatment


Gupta et al 2016

Lasers: The Bottom Line

Studies generally of poor quality, without standardization

Comparisons difficult to make

The optimal non-ablative laser needs

•Activity against melanin/fungal elements AND pulse duration matching TRT

•Adequate nail penetration

Fractionated Erbium and CO2

• Initial data look promising

•Mechanism makes sense


Conclusions

The differential diagnosis of podiatric rashes is broad and includes uncommon

systemic conditions

Careful clinical examination can help narrow differentials

Most melanonychias are benign

Following an algorithm helps to demystify these conditions

Detailed history and examination, including dermoscopy, can help

Lasers hold promise for the cosmetic / medical treatment of onychomycosis

Data are early, methodologies are unsound, improved standards will help


Acknowledgements

APMA

Council for Nail Disorders

Chris Adigun, MD

Kristen Lo Sicco, MD

Euphemia Mu, MD

Nicola Quatrano, MD

Jennifer Stein, MD, PhD

Antonella Tosti, MD

Lauren Wiznia, MD

Questions:

[email protected]

@drevanrieder


References – Bumps

1. Kline A. Allergic contact dermatitis of the foot after use of Mastisol skin adhesive: a case report. Foot and Ankle Online

Journal 2008. doi: 10.3827/faoj.2008.0102.0002

2. Sator PG, Breier F, Gschnait F. Acrokeratosis paraneoplastica (Bazex's syndrome): Association with liposarcoma. J Am

Acad Dermatol 2006; 55:1103.

All other clinical information and photos obtained from:

UpToDate

VisualDx

Dermnetnz.com


References – Stripes

1. Bae SH, Kim NH, Lee JB, et al. Total melanonychia caused by Trichophyton rubrum mimicking subungual melanoma. J

Dermatol. 2016 Apr 9. doi: 10.1111/1346-8138.13386. [Epub ahead of print]

2. Beggs AD, Latchford AR, Vasen HF, et al. Peutz-Jeghers syndrome: a systematic review and recommendations for management.

Gut. 2010 Jul;59(7):975-86.

3. Braun RP, Baran R, Le Gal FA, et al. Diagnosis and management of nail pigmentations. J Am Acad Dermatol. 2007

May;56(5):835-47. Epub 2007 Feb 22.

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Novel Therapeutics: Photodynamic Therapy

•Mechanism: free radicals

•Treatment parameters varied: 1-22 sessions, q1-8wks, wavelengths of

light 470 – 750nm, fluence 18 – 228J/cm2

•Recent meta-analysis: 17 studies, 214 patients total, one RCT

•Strengths: minimal side effects, targeted, may work where other

treatments have failed, across dermatophytes, molds, yeast; endonyx

•Weaknesses: early data, impractical – time intensive – requires

significant debridement / avulsion / nail softening / nail drilling or

fractionation


Bhatta et al, 2016

Novel Therapeutics: Iontophoresis

•Mechanism: application of small current to increase transport of

molecules via co-transport with water or ion flux

•May hold promise for enhancing absorption of topical antifungals

•Data: in vitro and one pilot study with questionable results


Sotiriou et al, 2010; Amichai et al, 2010

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