03/22/2014    Bryan C. Markinson, DPM

Notes from the Council for Nail Disorders Meeting

The Council for Nail Disorders Meeting concluded
today in Denver, Colorado. The program was full of
topics of interest to podiatric specialists,
including onychomycosis, laser treatment,
longitudinal melanonychia, and nail unit surgical
techniques. I thought I would pass along some key
points that were made at the meeting:

1) Treatment for onychomycosis without
confirmatory culture or histology is UNACCEPTABLE.
Many commented on patients with history of
treatment failure who never were tested. Although
some dermatologists and non-dermatology MDs treat
without benefit of culture, this practice is
rampant in podiatry. This issue has been debated
in PM News before, and those that feel that
eyeball diagnosis is okay would be in a very small
minority.

2) When we see pigmented streaks in nail plates,
we are often concerned about melanoma of the nail
unit, and rightly so. However, several cases of
non melanocytic tumors such as onychopapilloma,
onychomatricoma, and Bowen’s disease of the nail
matrix causing pigmented nail streaks were
presented.

3) After much discussion about biopsy techniques
of the nail matrix for pigmented streaks, shave
biopsies of the matrix for melanoma are preferred
over punches unless the width of the streak is
less than the diameter of the punch. So for broad
lesions 4mm or greater in the matrix, shave biopsy
is preferred so that the dermatopathologist can
see the entire breath of the lesion. Bertrand
Richert, MD from Belgium, showed cases of large
width shaves of matrix that produced no nail
dystrophy, another benefit of this technique.
Robert Baran, MD from France, and considered by
many as the dean of nail disease science, stated
that punches of the nail matrix up to 4mm will NOT
produce nail dystrophy in most cases, but 4mm is
the upper limit.

4) Always include the nail when submitting nail
unit biopsy specimens. Several dermpath cases were
presented showing the major diagnostic portion can
be tagging on to the nail, especially when the
nail avulsions are too traumatic. This created
some controversy as many dermatologists,
especially in Europe, like to leave the nail plate
on the digit after matrix surgery. This was also
postulated as a reason for recurrent benign
streaks as the melanocytic lesion left tagging to
the plate is put back over the surgical bed. My
personal opinion is to send the nail along with
the matrix specimen.

5) Glomus tumors of the nail units can be
associated with as yet undiagnosed
neurofibromatosis -1

6) Candida albicans can be a significant cause of
onychomycosis, especially in nails presenting that
are soft and crumbly and easily removed from the
nail bed.

Bryan C. Markinson, DPM, NY, NY,
bryan.markinson@mountsinai.org

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