Nail disease in neonatal abstinence syndrome.

BACKGROUND/OBJECTIVES: Neonatal abstinence syndrome (NAS) incidence continues to rise in the United States due to increasing opioid use disorder in pregnancy. While cutaneous excoriations have been noted in NAS, there is a paucity of literature regarding abnormal nail findings in NAS. METHODS: A retrospective, observational case series was conducted of twelve patients with NAS and abnormal nail findings who were admitted to the neonatal intensive care unit between January 1, 2018, and May 1, 2020. RESULTS: Twelve neonates (10 male, 2 female, mean gestational age at birth 38.1 weeks) with NAS diagnosis and abnormal nail findings were identified between January 1, 2018, and May 1, 2020. NAS was diagnosed by elevated Modified Finnegan Neonatal Abstinence Syndrome Tool (M-FNAST) scores. All patients required pharmacologic treatment for NAS with seven (58.3%) requiring phenobarbital in addition to first-line morphine. Common nail findings included periungual erythema, yellow crusting, desquamation of the proximal and/or distal lateral nail folds and sheared distal nail edges. Two patients (16.7%) required antibiotic treatment for paronychia. Peak M-FNAST scores were positively correlated with number of abnormal nail findings (r = .58, P = .047). CONCLUSIONS: Twelve neonates with severe NAS demonstrated similar nail abnormalities, likely secondary to NAS agitation and motor hyperactivity. Nail exams, therefore, are important in the setting of suspected or confirmed NAS to limit continued nail trauma and infection. Our findings also introduce an association between NAS severity and abnormal nail findings, which will require larger studies for further confirmation.

Botanical Briefs: Phytophotodermatitis Caused by Giant Hogweed (Heracleum mantegazzianum).

Giant hogweed (Heracleum mantegazzianum) is an invasive flowering weed that can reach a height of 13 feet. Although it is the appearance of the plant that can draw attention, contact with the sap in combination with exposure to the sun can result in severe phytophotodermatitis. Due to the growing prevalence of giant hogweed, the number of cases of H mantegazzianum-associated phytophotodermatitis in the United States is increasing. We report the case of a 27-year-old man who presented with a blistering rash on the neck and arms that developed 18 to 24 hours after trimming giant hogweed plants without photoprotection. A diagnosis of giant hogweed phytophotodermatitis should be considered for patients presenting with acute erythema and bullae in sun-exposed areas after exposure to the plant. Additionally, the public would benefit from education, especially during summer months, on identifying the plant and reducing phototoxin exposure to reduce the risk for phytophotodermatitis.

Ovoid palatal patch: a clue to anti-TIF1γ dermatomyositis.

An 80-year-old woman presented with a several-year history of progressive hair loss and scalp pruritus. No other rashes or muscle weakness were noted on examination. Scalp biopsy showed interface dermatitis, dense perivascular and periadnexal lymphocytic infiltrate, mucin and scarring alopecia. Laboratory analysis did not show evidence of myositis. The patient was started on hydroxychloroquine for possible cutaneous lupus erythematosus. On follow-up, she presented with a new violaceous rash on the superior eyelids and a well-defined oval patch on the mid-hard palate suspicious for dermatomyositis. Myositis-specific autoantibodies revealed presence of anti-transcriptional intermediary factor-1γ (anti-TIF1γ) in the serum. Anti-TIF1γ autoantibody-positive dermatomyositis is a newly recognised subtype of dermatomyositis that is highly associated with amyopathic disease and has an increased risk of malignancy, making prompt diagnosis crucial. This case highlights the utility of a thorough oral exam in patients suspected to have connective tissue disease as the distinctive ovoid palatal patch is nearly pathognomonic for anti-TIF1γ dermatomyositis.