Onychomycosis, the Active Invasion of a Normal Nail Unit by a Dermatophytic Versus the Colonization of an Existing Abnormal Nail Unit by Environmental Fungus.

Onychomycosis was described by early investigators as the presence of an abnormal nail unit and a member of the order Mycota, producing the abnormality. This interpretation has caused more than 50 years of confusion in the dermatologic literature. Unquestionably, the clinician sees more abnormal toenails than fingernails, and investigators have described a multitude of fungi as the cause of the clinically abnormal toenail. In 2010, developmental scientists proved, what we have long recognized, that there is no bilateral symmetry in living organisms and, therefore, one sole is different from the other. This causes a gait asymmetry, coupled with the pressure the closed shoe exerts on toenails while walking. This produces a series of abnormalities, which are clinically identical to what has been described for dermatophytic onychomycosis. These are fungus free and result in toenail niches. These toenail abnormalities were recently described as the asymmetric gait nail unit syndrome (AGNUS). It is possible that environmental fungi can colonize these toenail niches and, therefore, were described by investigators as a new onychomycosis entity In the normal host, onychomycosis should be only used to describe the active invasion of the nail bed (NB) corneocytes by a dermatophyte, as seen in dermatophytic onychomycosis. Dermatophytes only affect those hosts who have inherited the dermatophytosis susceptibility gene, transmitted as an autosomal dominant trait. In studies encompassing 3,000 abnormal toenails, only 27%-30% were found as dermatophyte culture positive, 25% were negative and the rest environmental fungi were recovered.

An Open-Label Evaluator Blinded Study of the Efficacy and Safety of a New Nutritional Supplement in Androgenetic Alopecia: A Pilot Study.

Objective: To evaluate the effectiveness of a novel oral supplement, Forti5®, containing green tea extract, omega 3 and 6 fatty acids, cholecalciferol, melatonin, beta-sitosterol, and soy isoflavones, and in the management of subjects with androgenetic alopecia. Design: A prospective case series of 10 subjects. Setting: Open-label, evaluator-blinded, proof-of-concept study. Participants: Ten adult subjects with androgenetic alopecia completed the study. Subjects were not allowed to use oral or topical hair growth products in the 24 weeks preceding the study or during the study. The nutritional supplement was administered at a dosage of two tablets daily for 24 weeks. Measurements: Clinical evaluations were performed at baseline and at 24 weeks. Efficacy was evaluated using hair mass index measured by cross section trichometer, terminal hair count measured with dermoscopy and Investigator Global Photography Assessment. Results: Overall 80 percent of subjects (8/10) were rated as improved after 24 weeks of supplementation (mean change of +1.4 equivalent to slightly-to-moderately increased). Forty percent of subjects (4/10) were rated as moderately improved (2+), and 10 percent (1/10) were rated as greatly improved (3+). There was a significant improvement in terminal hair count (mean increase of 5.9% or 4.2 more terminal hairs in the area examined, p=0.014) and in Hair Mass Index (mean increase of 9.5% or 4.5 higher Hair Mass Index, p=0.003). Conclusion: These preliminary results indicate that Forti5® a novel nutritional supplement that contains cholecalciferol, omega 3 and 6 fatty acids, melatonin, antioxidants, and botanical 5-alpha reductase inhibitors, may be a useful adjunct in the treatment of androgenetic alopecia.

Melasma Associated with Topical Estrogen Cream.

A 47-year-old woman presented with hyperpigmented patches on her upper extremities. The patient had begun using a topical estrogen cream in the affected areas prior to noticing the hyperpigmentation. A diagnosis of melasma secondary to topical estrogen cream was made. While systemic hormones are a well-documented trigger for the development of melasma, this case represents the first report of melasma associated with topical estrogens. Topical estrogens are frequently prescribed to postmenopausal women for skin rejuvenation. Melasma should be discussed as a potential side effect of systemic as well as topical estrogen preparations.

Patient Factors and Their Association with Nonmelanoma Skin Cancer Morbidity and the Performance of Self-skin Exams: A Cross-Sectional Study.

Objective: Mohs micrographic surgery is widely utilized for the treatment of nonmelanoma skin cancers with the advantage of tissue sparing and higher cure rate. The preoperative tumor size and post-Mohs micrographic surgery defect size are useful surrogate measures of nonmelanoma skin cancer morbidity. The authors sought to evaluate whether gender, Hispanic ethnicity, socioeconomic status, sun-safe practices and self-skin exams affected tumor size and Mohs micrographic surgery defect size. They also investigated factors associated with self-skin exams. Design: A cross-sectional survey-based study. Setting: Two dermatologic surgery clinics-one academic-associated and the other private. Participants: Patients receiving Mohs surgery for nonmelanoma skin cancers. Measurements: Tumor size and Mohs defect size and their relationship to patient factors ascertained from a survey, as well as the number of patients performing self-skin exams. The authors used t-tests and analysis of variance to compare tumor and defect sizes for each patient factor. Chi-squared tests were used to determine the factors associated with self-skin exams performance. Results: Lower education was associated with greater head and face tumor area (95mm2 vs. 41mm2, P=0.019), but not Mohs micrographic surgery defect size. Other studied patient factors were not associated with an increased morbidity. Hispanics performed self-skin exams at a lower rate than non-Hispanics (27% vs. 46%, p=0.03). Conclusion: This study innovatively uses tumor and Mohs micrographic surgery defect area as a measure of morbidity, allowing for identification of populations at need for improved education and prevention. (J Clin Aesthet Dermatol. 2016;9(9):16-22.).

Topical application of the Wnt/ß-catenin activator methyl vanillate increases hair count and hair mass index in women with androgenetic alopecia.

BACKGROUND: Activation of the WNT/ß-catenin pathway has emerged as a potential therapeutic target in androgenetic alopecia (AGA). Methyl vanillate (MV) - a safe plant-derived ingredient - has been recently shown to activate the WNT/ß-catenin signaling. Objectives Two distinct substudies were conducted. First, we designed a 6-month, uncontrolled, open-label clinical study to investigate whether topically applied MV may increase hair count and hair mass index (HMI) in female AGA. Second, we conducted a molecular study on the effect of MV on WNT10B mRNA expression in scalp biopsies of women with AGA. METHODS: A total of 20 Caucasian women (age range: 25-57 years) with AGA (Sinclair grade 1-2) were included. The research product was an alcohol-free formulation supplied in the form of a spray containing 0.2% MV as the active ingredient. RESULTS: In the clinical study, hair count and HMI were found to increase at 6 months by 6% (P < 0.01) and 12% (P < 0.001), respectively, compared with baseline. No participant discontinued treatment due to adverse effects, and the overall patient satisfaction was good. At the molecular level, the topical application of the research product resulted in a 32% increase in WNT10B mRNA expression levels in the temporal scalp area (P < 0.001). CONCLUSION: Our pilot data suggest that topical MV can increase hair count and HMI by inducing WNT10B expression in the scalp, potentially serving as a novel treatment strategy for female AGA.

Clinical pearl: the squeeze maneuver.

Plantar warts can be distinguished from calluses using the squeeze maneuver, a quick and easy method to diagnose plantar warts. This technique negates the need for an expensive diagnostic tool.

Best way to remove a subungual tumor.

"Subungual tumors are relatively rare; yet dermatologists are often called upon to examine, diagnose, and treat these patients. Many dermatologists do not feel comfortable performing surgical procedures of the nail unit. With knowledge of the nail unit anatomy and execution of few simple techniques, dermatologist can safely and effectively remove subungual tumors in the office setting. This article reviews the basic steps for removal of a subungual tumor. It discusses preoperative evaluation, highlights techniques to avoid complete nail plate avulsion, and touches on potential complications and postoperative care."

Nail abnormalities associated with systemic pathologies.

Nail abnormalities can arise in conjunction with or as a result of systematic pathologies. These pathologies include single-organ diseases, multisystemic diseases, and drug-induced insults. Clinical signs associated with these conditions include dyschromias, vascular alterations, periungual tissue changes, textural dystrophies, contour alterations, and growth-rate alterations. The associated systemic pathologies may affect any part of the nail apparatus, including the nail matrix, the nail plate, the nail bed, the underlying vasculature, and the periungual tissues. The anatomical location and extent of damage determine the clinically manifested anomaly.

Horizontal running mattress suture modified with intermittent simple loops.

Using the combination of a horizontal running mattress suture with intermittent loops achieves both good eversion with the horizontal running mattress plus the ease of removal of the simple loops. This combination technique also avoids the characteristic railroad track marks that result from prolonged non-absorbable suture retention. The unique feature of our technique is the incorporation of one simple running suture after every two runs of the horizontal running mattress suture. To demonstrate its utility, we used the suturing technique on several patients and analyzed the cosmetic outcome with post-operative photographs in comparison to other suturing techniques. In summary, the combination of running horizontal mattress suture with simple intermittent loops demonstrates functional and cosmetic benefits that can be readily taught, comprehended, and employed, leading to desirable aesthetic results and wound edge eversion.