Stefano Caccavale, MD Department of Dermatology Second University of Naples Via Sergio Pansini, 5 80131 Napoli Italy E-mail: [email protected] Conflict of interest: None declared. References 1 Perez-Perez LC. General features and treatment of notalgia paresthetica. Skinmed 2011; 9: 353–358. 2 Alai NN, Skinner HB, Nabili ST, et al. Notalgia paresthetica associated with cervical spinal stenosis and cervicothoracic disk disease at C4 through C7. Cutis 2010; 85: 77–81. 3 Lo Schiavo A, Brancaccio G, Romano F, et al. Nerve injury and localized skin lesions: an instance of immunocompromised district. Skinmed 2012; 10: 260–261. 4 Fleischer AB, Meade TJ, Fleischer AB. Notalgia paresthetica: successful treatment with exercises. Acta Derm Venereol 2011; 91: 356–357. 5 Stevenson CJ. Occupational skin disease. Postgrad Med J 1989; 65: 374–380.

Recognizing and treating retronychia

Editor, Onychocryptosis results from the embedding of the nail into the periungual lateral skin folds. By contrast, proximal ingrowth of the nail is much less frequent. We report two cases of proximal ingrown nail, a condition termed retronychia. An 18-year-old woman had a 5-month history of painful, left great toenail changes after shoe trauma. The condition had been previously treated with antifungals but had shown no clinical improvement. Proximal paronychia of the hallux was observed, with purulent discharge, granuloma formation, and distal xanthonychia (Fig. 1a). Conservative treatment with betamethasone and gentamicin cream was first attempted. Despite a moderate improvement in inflammatory signs after one month, the pain persisted, and onychomadesis was apparent when the distal nail plate was pressed. Nail avulsion was performed, exhibiting a thickened proximal nail with a Y-shaped inner edge caused by the presence of two nail layers (Fig. 1b). Healing was uneventful. Two months later, 40% of the nail had regrown normally (Fig. 1c). A 19-year-old woman presented with persistent inflammatory signs that had concerned both halluces for six months. Both nails had stopped growing. The patient ª 2014 The International Society of Dermatology

had applied a topical antifungal without improvement. She denied physical trauma, although the presence of marks left by shoes hinted at this. Bilateral paronychia of the proximal nail fold (PNF), xantonychia, and periungual granulomata were observed. Evident onychomadesis was present on the right hallux. As in Patient 1, conservative treatment was initiated (Fig. 1d). Use of comfortable shoes was also recommended. After one month, bilateral complete onychomadesis displayed a new, underlying, actively growing nail plate and complete resolution of the paronychia (Fig. 1e). Two months later, both nails had almost fully regrown normally, although they exhibited distal Beau lines and leuconychia as a result of the previous halt in growth (Fig. 1f). Retronychia is characterized by the embedding of the nail into the PNF. It was described in 1999 by De Berker and Renall.1 Although fewer than 40 cases have been reported, retronychia may not be rare but instead may represent a condition that is not recognized and is inadequately treated.2–6 Trauma of an acute physical or systemic nature disrupts the longitudinal growth of the nail. As toenails are more prone to mechanical trauma, retronychia mainly affects these over the fingernails. In our experience, retronychia is more frequent in women, especially those wearing ill-fitting shoes, and sportspeople. After trauma, several degrees of onycholysis may ensue. Direct consequences include the loss of association between the nail and the nail bed, which no longer supports the nail’s forward growth. The nail is then more susceptible to losing its attachment to the matrix. Furthermore, it becomes subject to back-and-forth and tilting movements that repeatedly pierce and traumatize the PNF, causing inflammation. When a new nail is formed, repeated injury prevents the new plate from adhering to the nail bed, perpetuating the cycle of inflammation.4 Ecographic studies indicate a direct mechanism, proposing inflammation and scarring at the PNF as the origin of traction forces that cause a posterior translation of the nail and proximal onychocryptosis.5,6 Patients refer to pain and halted nail growth. Chronic proximal paronychia is observed, along with periungual granuloma, oozing, onycholysis or onychomadesis, and changes in nail color. As the two cases reported here indicate, treatment can be adapted. Surgical nail avulsion is fast, inexpensive, and curative and should be considered the first-line treatment of retronychia. The avulsed nail is proximally thickened and exhibits two or more inner layers. Conservative treatment is associated more often with recurrence and requires additional visits and a longer follow-up. Knowledge of this condition avoids unnecessary courses of otherwise ineffective medication (e.g. antifungals), as happened in the present cases. International Journal of Dermatology 2015, 54, e38–e55










Figure 1 Patient 1: (a) initial presentation shows proximal paronychia, xantonychia and oozing; (b) the nail plate after surgical avulsion evidences a Y-shaped margin, and (c) a new normal nail is visible 2 months after surgery. Patient 2: (d) initial presentation shows bilateral paronychia of the proximal nail fold, xantonychia, proximal granuloma and partial onychomadesis; (e) bilateral onychomadesis is apparent after 1 month of conservative treatment, and (f) at 3 months after the initiation of treatment, nails are almost fully grown

Therefore, the diagnosis of retronychia should be considered in the presence of the triad of persistent chronic proximal paronychia, a proximally thickened nail, and proximal periungual granuloma, particularly in the setting of trauma. Nail avulsion is therapeutic and usually confirms the diagnosis.

Joana Cabete, MD Andre Lencastre, MD Department of Dermatology Hospital de Santo Ant onio dos Capuchos Centro Hospitalar de Lisboa Central (Hospital of Santo Ant onio dos Capuchos, Lisbon Hospital Center) Lisbon Portugal E-mail: [email protected] References 1 De Berker DA, Renall JR. Retronychia – proximal ingrowing nail. J Eur Acad Dermatol Venereol 1999; 12 (Suppl. 2): 126.

International Journal of Dermatology 2015, 54, e38–e55

2 De Berker DA, Richert B, Duhard E, et al. Retronychia: proximal ingrowing of the nail plate. J Am Acad Dermatol 2008; 58: 978–983. 3 Dahdah MJ, Kibbi AG, Ghosn S. Retronychia: report of two cases. J Am Acad Dermatol 2008; 58: 1051–1053. 4 Baumgartner M, Haneke E. Retronychia: diagnosis and treatment. Dermatol Surg 2010; 36: 1610–1614. 5 Wortsman X, Wortsman J, Guerrero R, et al. Anatomical changes in retronychia and onychomadesis detected using ultrasound. Dermatol Surg 2010; 36: 1615–1620. 6 Wortsman X, Calderon P, Baran R. Finger retronychias detected early by 3D ultrasound examination. J Eur Acad Dermatol Venereol 2012; 26: 254–256.

Cutaneous markers of systemic manifestations of tuberous sclerosis complex

Editor, Tuberous sclerosis complex (TSC) is a multi-system syndrome. Establishing some features of TSC can help in the identification of other major manifestations. A study was designed to describe the cutaneous, neurological, and other systemic manifestations of TSC in children, and to determine the associations between cutaneous manifesta-

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Recognizing and treating retronychia.

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