Correspondence
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contraceptive. Australas J Dermatol 1991; 32: 55–59. Saez M, Garcia-Bustinduy M, Noda A, et al. Sweets syndrome induced by oral contraceptive. Dermatology 2002; 204: 84. Bouman A, Heineman MJ, Faas MM. Sex hormones and the immune response in humans. Hum Reprod Update 2005; 11: 411–423. Klinger G, Graser T, Mellinger U, et al. A comparative study of the effects of two oral contraceptives containing dienogest or desogestrel on the human immune system. Gynecol Endocrinol 2000; 14: 15–24. Hamill M, Bowling J, Vega-Lopez F. Sweets syndrome and a Mirena intrauterine system. J Fam Plann Reprod Health Care 2004; 30: 115–116. Ozkaya E, Buyukbabani N. Neutrophilic fixed drug eruption caused by naproxen: a real entity or a stage in the histopathologic evolution of the disease? J Am Acad Dermatol 2005; 53: 178–179. Van Voorhees A, Stenn KS. Histological phases of Bactrim-induced fixed drug eruption. The report of one case. Am J Dermatopathol 1987; 9: 528–532.
Ingrown nail with a giant granulation tissue successfully treated with the gutter method
Ingrown nail or onychocryptosis is a condition in which the spike of the nail damages the lateral nail fold.1–3 The damaged nail fold is easily infected with bacteria such as staphylococci and is often accompanied by intractable
paronychia, resulting in the development of hypergranulation tissue on the nail fold. Here we report a case of ingrown nail with a giant granulation tissue covering the toe. A 78-year-old woman with chronic kidney disease presented to our clinic with a large red nodule on the right big toe. The lesion had been treated with systemic minocycline and topical steroid ointment for two years; however, the nodule grew larger. Physical examination revealed a red granulomatous nodule on the toe. The nodule, which covered the entire nail, was exudative and had a hemorrhagic appearance with an offensive smell (Fig. 1a). The nail edge penetrated the lateral nail fold; therefore, this case was diagnosed as an ingrown nail with giant granulation tissue. To exclude the diagnoses of malignant melanoma or squamous cell carcinoma, we performed a skin biopsy of the nodule. Histological examination revealed proliferation of capillaries, stromal edema, and abundant mixed inflammatory cells, suggesting that the nodule was not malignant skin tumor but granulation tissue (Fig. 1f). An invasive approach, including classic wedge excision or partial matrix phenolization, is preferred for treating a severe ingrown toenail. Because the patient refused surgical interventions, we employed the gutter method, a non-invasive procedure during which a plastic tube is inserted underneath the nail and fixed with acrylic resin.4,5 During the gutter method, the patient was not administrated with systemic antibiotics. Three months after the gutter method was
(a)
(b)
(c)
(d)
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Figure 1 (a) Giant granulation tissue on the toe. (b) The plastic tube is inserted into the edge of the nail. The hemorrhagic nodule has decreased in size 3 months after starting the gutter method. (c) After 6 months of treatment, hypergranulation is localized at the lateral nail fold. (d) The granulation tissue has completely regressed and swelling of the big toe has disappeared. (e) An artificial acrylic nail is attached to the nail to prevent onychogryphosis. (f) Proliferation of capillaries, stromal edema, and abundant mixed inflammatory cells are observed during histological examination. (Hematoxylin and eosin, 940) ª 2015 The International Society of Dermatology
International Journal of Dermatology 2015, 54, e182–e196
e191
e192
Correspondence
initiated, the hemorrhagic nodule was markedly smaller, and the nail could be easily detected (Fig. 1b). Hence, we continued the gutter method for this patient (Fig. 1c). One year after initial treatment, the hypergranulation tissue had completely regressed and swelling of the big toe disappeared (Fig. 1d). The nail was covered with the artificial acrylic nail for preventing onychogryphosis, which is caused by brief nail or dystrophic nail (Fig. 1e). An ingrown toenail is an uncomfortable condition caused by penetration of the lateral nail fold.2 This disorder is usually accompanied by granulation tissue, which reduces patient quality of life because of pain, bleeding, and offensive smell.2 Treatment of hypergranulation tissue on the toe includes topical steroid application, cryosurgery, systemic use of antibiotics, and surgical resection.6 The giant granulation tissue in this case developed because of penetration of the soft tissue by a nail spicule; thus, management of the ingrown nail was necessary for treatment of the lesion. The development of giant granulation tissue in the case reported here appears to be caused by inadequate treatment. The gutter method is a non-surgical treatment during which a plastic tube is inserted under the nail.4,5 This therapy is highly promising for treatment of an ingrown nail, which can be a mild or moderate case without chronic inflammation, granulation, or nail fold hypertrophy. Recent reports demonstrated that this method was suitable for ingrown nails caused by the epidermal growth factor receptor kinase inhibitor treatment such as gefitinib.7 The current case of ingrown nail associated with giant granulation tissue covering the toe proved curable using the gutter method. Although long-term use of gutter therapy is required for complete remission, this method can be selected for treatment of a severe ingrown nail associated with giant hypergranulation. Acknowledgments We thank Professor Yoshihiko Mitsuhashi of the Department of Dermatology, Tokyo Medical University, for helpful discussion.
Kazutoshi Harada, MD, PhD Miyuki Yamaguchi, MD Miyuki Matsuzawa, MD Shinji Shimada, MD, PhD Department of Dermatology Faculty of Medicine University of Yamanashi Yamanashi Japan E-mail: [email protected] International Journal of Dermatology 2015, 54, e182–e196
Conflicts of interest: None.
References 1 Eekhof JA, Van Wijk B, Knuistingh Neven A, et al. Interventions for ingrowing toenails. Cochrane Database Syst Rev 2012; 4: CD001541. 2 Heidelbaugh JJ, Lee H. Management of the ingrown toenail. Am Fam Physician 2009; 79: 303–308. 3 Park DH, Singh D. The management of ingrowing toenails. BMJ 2012; 344: e2089. 4 Arai H, Arai T, Nakajima H, et al. Formable acrylic treatment for ingrowing nail with gutter splint and sculptured nail. Int J Dermatol 2004; 43: 759–765. 5 Wallace WA, Milne DD, Andrew T. Gutter treatment for ingrowing toenails. Br Med J 1979; 2: 168–171. 6 Gerritsma-Bleeker CL, Klaase JM, Geelkerken RH, et al. Partial matrix excision or segmental phenolization for ingrowing toenails. Arch Surg 2002; 137: 320–325. 7 Harada K, Yamaguchi M, Miyajima S, et al. Gutter method: noninvasive management of ingrown nails caused by epidermal growth factor inhibitor treatment. Clin Exp Dermatol 2012; 37: 703–704.
Topical steroid-induced tinea pseudoimbricata: a striking form of tinea incognito
Editor, We report six cases of steroid-modified tinea corporis and tinea cruris from two clinics in Vadodara, India, all of which showed the same distinct morphological pattern. All patients exhibited a central erythematous, scaly, pruritic plaque from which one to three centrifugally spreading, concentric circles emerged. The borders of the circles were raised and scaly (Fig. 1a–d). The nails, soles, and palms were spared. The patients included three women and three men, all of whom were aged 18–40 years and were healthy. None of them had visited a dermatologist, but they had all applied potent topical steroids mixed with antibiotics or antifungals intermittently following advice from local pharmacists or friends. Tests conducted in the dermatology clinic for KOH were positive in four of the six patients (two refused investigation), and cultures showed Trichophyton rubrum (n = 3) and Trichophyton mentagrophytes (n = 1). All patients were cured with oral and topical terbinafine. This clinical manifestation is called tinea pseudoimbricata1–3 because of its clinical resemblance to the infection typically caused by Trichophyton concentricum.4 Similar cases have been described in patients treated with topical corticosteroids and in those with some form of immunosuppression.1–3 Dermatophyte invasion of the skin is marked by the activation of specific genes that synthesize antigens such as ª 2015 The International Society of Dermatology
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contraceptive. Australas J Dermatol 1991; 32: 55–59. Saez M, Garcia-Bustinduy M, Noda A, et al. Sweets syndrome induced by oral contraceptive. Dermatology 2002; 204: 84. Bouman A, Heineman MJ, Faas MM. Sex hormones and the immune response in humans. Hum Reprod Update 2005; 11: 411–423. Klinger G, Graser T, Mellinger U, et al. A comparative study of the effects of two oral contraceptives containing dienogest or desogestrel on the human immune system. Gynecol Endocrinol 2000; 14: 15–24. Hamill M, Bowling J, Vega-Lopez F. Sweets syndrome and a Mirena intrauterine system. J Fam Plann Reprod Health Care 2004; 30: 115–116. Ozkaya E, Buyukbabani N. Neutrophilic fixed drug eruption caused by naproxen: a real entity or a stage in the histopathologic evolution of the disease? J Am Acad Dermatol 2005; 53: 178–179. Van Voorhees A, Stenn KS. Histological phases of Bactrim-induced fixed drug eruption. The report of one case. Am J Dermatopathol 1987; 9: 528–532.
Ingrown nail with a giant granulation tissue successfully treated with the gutter method
Ingrown nail or onychocryptosis is a condition in which the spike of the nail damages the lateral nail fold.1–3 The damaged nail fold is easily infected with bacteria such as staphylococci and is often accompanied by intractable
paronychia, resulting in the development of hypergranulation tissue on the nail fold. Here we report a case of ingrown nail with a giant granulation tissue covering the toe. A 78-year-old woman with chronic kidney disease presented to our clinic with a large red nodule on the right big toe. The lesion had been treated with systemic minocycline and topical steroid ointment for two years; however, the nodule grew larger. Physical examination revealed a red granulomatous nodule on the toe. The nodule, which covered the entire nail, was exudative and had a hemorrhagic appearance with an offensive smell (Fig. 1a). The nail edge penetrated the lateral nail fold; therefore, this case was diagnosed as an ingrown nail with giant granulation tissue. To exclude the diagnoses of malignant melanoma or squamous cell carcinoma, we performed a skin biopsy of the nodule. Histological examination revealed proliferation of capillaries, stromal edema, and abundant mixed inflammatory cells, suggesting that the nodule was not malignant skin tumor but granulation tissue (Fig. 1f). An invasive approach, including classic wedge excision or partial matrix phenolization, is preferred for treating a severe ingrown toenail. Because the patient refused surgical interventions, we employed the gutter method, a non-invasive procedure during which a plastic tube is inserted underneath the nail and fixed with acrylic resin.4,5 During the gutter method, the patient was not administrated with systemic antibiotics. Three months after the gutter method was
(a)
(b)
(c)
(d)
(e)
(f)
Figure 1 (a) Giant granulation tissue on the toe. (b) The plastic tube is inserted into the edge of the nail. The hemorrhagic nodule has decreased in size 3 months after starting the gutter method. (c) After 6 months of treatment, hypergranulation is localized at the lateral nail fold. (d) The granulation tissue has completely regressed and swelling of the big toe has disappeared. (e) An artificial acrylic nail is attached to the nail to prevent onychogryphosis. (f) Proliferation of capillaries, stromal edema, and abundant mixed inflammatory cells are observed during histological examination. (Hematoxylin and eosin, 940) ª 2015 The International Society of Dermatology
International Journal of Dermatology 2015, 54, e182–e196
e191
e192
Correspondence
initiated, the hemorrhagic nodule was markedly smaller, and the nail could be easily detected (Fig. 1b). Hence, we continued the gutter method for this patient (Fig. 1c). One year after initial treatment, the hypergranulation tissue had completely regressed and swelling of the big toe disappeared (Fig. 1d). The nail was covered with the artificial acrylic nail for preventing onychogryphosis, which is caused by brief nail or dystrophic nail (Fig. 1e). An ingrown toenail is an uncomfortable condition caused by penetration of the lateral nail fold.2 This disorder is usually accompanied by granulation tissue, which reduces patient quality of life because of pain, bleeding, and offensive smell.2 Treatment of hypergranulation tissue on the toe includes topical steroid application, cryosurgery, systemic use of antibiotics, and surgical resection.6 The giant granulation tissue in this case developed because of penetration of the soft tissue by a nail spicule; thus, management of the ingrown nail was necessary for treatment of the lesion. The development of giant granulation tissue in the case reported here appears to be caused by inadequate treatment. The gutter method is a non-surgical treatment during which a plastic tube is inserted under the nail.4,5 This therapy is highly promising for treatment of an ingrown nail, which can be a mild or moderate case without chronic inflammation, granulation, or nail fold hypertrophy. Recent reports demonstrated that this method was suitable for ingrown nails caused by the epidermal growth factor receptor kinase inhibitor treatment such as gefitinib.7 The current case of ingrown nail associated with giant granulation tissue covering the toe proved curable using the gutter method. Although long-term use of gutter therapy is required for complete remission, this method can be selected for treatment of a severe ingrown nail associated with giant hypergranulation. Acknowledgments We thank Professor Yoshihiko Mitsuhashi of the Department of Dermatology, Tokyo Medical University, for helpful discussion.
Kazutoshi Harada, MD, PhD Miyuki Yamaguchi, MD Miyuki Matsuzawa, MD Shinji Shimada, MD, PhD Department of Dermatology Faculty of Medicine University of Yamanashi Yamanashi Japan E-mail: [email protected] International Journal of Dermatology 2015, 54, e182–e196
Conflicts of interest: None.
References 1 Eekhof JA, Van Wijk B, Knuistingh Neven A, et al. Interventions for ingrowing toenails. Cochrane Database Syst Rev 2012; 4: CD001541. 2 Heidelbaugh JJ, Lee H. Management of the ingrown toenail. Am Fam Physician 2009; 79: 303–308. 3 Park DH, Singh D. The management of ingrowing toenails. BMJ 2012; 344: e2089. 4 Arai H, Arai T, Nakajima H, et al. Formable acrylic treatment for ingrowing nail with gutter splint and sculptured nail. Int J Dermatol 2004; 43: 759–765. 5 Wallace WA, Milne DD, Andrew T. Gutter treatment for ingrowing toenails. Br Med J 1979; 2: 168–171. 6 Gerritsma-Bleeker CL, Klaase JM, Geelkerken RH, et al. Partial matrix excision or segmental phenolization for ingrowing toenails. Arch Surg 2002; 137: 320–325. 7 Harada K, Yamaguchi M, Miyajima S, et al. Gutter method: noninvasive management of ingrown nails caused by epidermal growth factor inhibitor treatment. Clin Exp Dermatol 2012; 37: 703–704.
Topical steroid-induced tinea pseudoimbricata: a striking form of tinea incognito
Editor, We report six cases of steroid-modified tinea corporis and tinea cruris from two clinics in Vadodara, India, all of which showed the same distinct morphological pattern. All patients exhibited a central erythematous, scaly, pruritic plaque from which one to three centrifugally spreading, concentric circles emerged. The borders of the circles were raised and scaly (Fig. 1a–d). The nails, soles, and palms were spared. The patients included three women and three men, all of whom were aged 18–40 years and were healthy. None of them had visited a dermatologist, but they had all applied potent topical steroids mixed with antibiotics or antifungals intermittently following advice from local pharmacists or friends. Tests conducted in the dermatology clinic for KOH were positive in four of the six patients (two refused investigation), and cultures showed Trichophyton rubrum (n = 3) and Trichophyton mentagrophytes (n = 1). All patients were cured with oral and topical terbinafine. This clinical manifestation is called tinea pseudoimbricata1–3 because of its clinical resemblance to the infection typically caused by Trichophyton concentricum.4 Similar cases have been described in patients treated with topical corticosteroids and in those with some form of immunosuppression.1–3 Dermatophyte invasion of the skin is marked by the activation of specific genes that synthesize antigens such as ª 2015 The International Society of Dermatology
