الفهرس 
Nail ApparatusOnly 14 pages are availabe for public view
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Abstract
ail disorders are defined according to their appearance and the part of the nail affected (from distal to proximal): hyponychium, onychodermal band (ODB), nail bed, nail plate, lateral nail folds (perionychium), lunula (distal part of the matrix), cuticle, nail matrix and proximal nail fold. The nail is formed by the keratinous mass pressed between the nail bed and the eponychial fold and grows distally. This is very important when evaluating a treated onychmycotic nail to follow up with the prognosis and response to treatment. Nail dermoscopy is becoming more and more frequently utilized for the diagnosis of nail disorders. Dermoscopic features of nail signs are always very interesting and surprising and help in our understanding of the nails.
Dermoscopy; is a non-invasive diagnostic imaging technique which allows the visualization of subtle clinical features of the skin surface and appendages details not visible to the naked eye, allowing magnifications of up to 200x. It is widely used for evaluating and diagnosing all nail diseases and should be utilized routinely, as it provides important information. As any other examination, nail dermoscopy (onychoscopy) requires a good knowledge of nail anatomy & physiology and the pathogenesis of the nail diseases: we have to know which part of the nail we have to look at.
All nail disorders can be observed by dermoscopy. Dermoscopic features of nail signs are always very inking and saving, and may help in understanding nails diseases. The study of the nail plate surface should be done with dry dermoscopy, since using gel covers surface abnormalities, while observation of color abnormalities requires it in other skin diseases. After a clinical and dermoscopic examination, the causative organism should be differentiated by cultural techniques.
Onychomycosis is a common disease, accounting for up to 50%-60% of all ungual pathologies. It is not life-threatening, but it is a disease of considerable value that can generate many psychological and occupational problems impairing patient’s quality of life. Onychomycosis can be caused by dermatophytes, molds and yeasts. Nails may be infected by two different dermatophytes, two dermatophytes and a yeast, a dermatophyte, a yeast and a mold.
The clinical patterns of OM are: distal and lateral subungual onychomycosis (DLSO), proximal subungual onychomycosis (PSO), superficial white onychomycosis (SWO), endonyx onychomycosis (EO), total dystrophic onychomycosis (TDO), candidal onychomycosis (CO) and fungal melanonychia. Dermoscopic examination typically reveals: A whitish discoloration of the nail, superimposed longitudinal parallel striation, and jagged proximal edges with spikes. Moreover, sometimes there is small splinter hemorrhages and always there is prescence of various nail discolorations (chromonychia/aurora borealis) with green, yellow or brown colors may occur.
Our objective was to study the dermoscopic characteristics of onychomycosis and correlate dermoscopic picture with the causative organism, aiming to assist clinicians in correctly evaluating & diagnosing onychomycosis with the help of dermoscopy.
We conducted a comparative cross-sectional study, on 60 patients suspected to have finger(s) and/or toe(s) nail onychomycosis (corresponds to 1200 fingernails and toenails). These patients was randomly recruited from the outpatient clinic of dermatology at Ain Shams University Hospitals, during the period from December 2014 till July 2015. After clinical and mycological examination to diagnose onychomycosis, 50 patients only was confirmed to have onychomycosis, and these were included in the study (corresponding in total to 132 affected fingernails and/or toenails). Further evaluation was done by dermoscopy for these 50 patients to address dermoscopic features of onychomycosis (regarding the nail color, texture, and/or features) and correlate it with the causative organism.
We concluded from our results that, males are more affected with onychomycosis than females, as 52% was males and 48% were females. Toenails are more likely than fingernails to be infected with percentage of 66% to 34%, respectively. Fingernails and toenails both can be affected in the same individual, regardless the causative organism.
Results showed presence of 7 clinical patterns of onychomycosis. TDO was the major clinical pattern present in 28% of patients, followed by the DSO type 24%, DLSO 20%, CO 10%, LSO 8%, PSO 4% and longitudinal melanonychia pattern (melanoychia striata) 4%. from this part of longitudinal melanonychia, we conclude 2 theories: either onychomycosis can be present on top of a melanocytic nevi (should be confirmed with histopathological method) or that NDM can produce longitudinal pigmentation in the nail plate as a specific feature for it. This might give a new rise to new variation in the appearance of onychomycosis cause by Aspergillus niger species to produce melanonychia stariata pattern.
The most common organisms which were isolated in culture were NDM (specifically Aspergillus niger) (88%) and Yeast (Candida) (12%). We concluded from his study that NDM and yeasts were common aetiological agents of onychomycosis, adding, that among the NDM, Aspergillus niger was the commonest isolate which was obtained of the Aspergillus spp.
Regarding Aspergillus niger, it was recognized in the present study as a primary & main pathogen to cause onychomycosis in 88% of our cases, and this is related to variation in geographical areas and climatic changes.
Results showed also that there are 3 confirmatory dermoscopic features to diagnose onycomycosis; that were present in all cases. Spikes, longitudinal striations and/or aurora borealis (nail discoloration) was seen in Aspergillus niger cases in 63.6%, 63.6% and 95.4% respectively. In Candida; spikes, longitudinal striations and aurora borealis was present in 83.3%, 83.3% and 100% respectively. Concluding that dermoscopy is 100% specific in diagnosing onychomycosis but cannot differentiate a specific causative organism.
The results also showed that there was no significance with these 3 diagnostic dermoscopic features of onychomycosis with a specific causative organism regarding Aspergillus niger or Candida. We concluded that there is no correlation between a specific dermoscopic pattern for onychomycosis that is caused by a specific causative organism, and all patterns can be seen with all fungal species.
As for, Aspergillus niger and Candida spp it was difficult to detect a specific dermoscopic picture of the fungal agent responsible for a particular type of onychomycosis. There was no significant difference between Aspergillus niger and Candida cases as regard site of affection in the nail unit. No significant difference between Aspergillus niger and Candida spp cases as regard overall number of affected nails.
Treatment was done for 10 patients from this study, with DLSO, DSO and CO in finger and/or toenails, using long pulsed Nd:YAG 1064-nm laser with parameters of: fluence: 30 J/cm, pulse duration 30 ms, spot size 5mm, frequency ranging 1 Hz, and the cooling system was switched off during the session. Total sessions range was 4-6, with 1 week interval.
Long pulse Nd:YAG 1064-nm laser was effective for onychomycosis and have high fungicidal effect. It is a simple method without significant complications or side effects and is expected to become an alternative or replacement therapy for onychomycosis. It is effective and helpful in treating fungal species resistant to medical treatment such as Aspergillus spp.