5/22/2018

1

5/22/2018

2

5/22/2018

3

Morgan AM et al, in Krull E., ed. Nail surgery: a text and atlas, 2001

De Berker D. Nail anatomy. Clinics in Dermatology. 2013;31(5):509–515.

Proximal nail fold

False cuticle

Lateral nail fold

Lunula

Nail plate and bed

Onychodermal band Hyponychium

5/22/2018

4

Jiaravuthisan MM, Sasseville D, Vender RB, Murphy F, Muhn CY. Psoriasis of the nail: anatomy, pathology, clinical presentation, and a review of the literature on therapy. J. Am. Acad. Dermatol. 2007;57(1):1–27.

5/22/2018

5

Eponychial epithelium

Distal matrix

Proximal matrix

Dorsal matrix

Keratogenous zone

5/22/2018

6

Distal nail matrix

Nail bed epithelium

True cuticle

False cuticle

Nail plate

A granular zone in the matrix or bed is abnormal

5/22/2018

7

Lateral nail grooveNail bed

Bone

Longitudinal ridges

(not rete!)

5/22/2018

8

Onychodermal band

Hyponychium

CD10+ onychodermis

5/22/2018

9

Jellinek N. J Am Acad Dermatol. 2007;56(5):803-810. Richert B, Theunis A, Norrenberg S, André J. J Am Acad Dermatol. 2013;69(1):96-104.

Haneke E. Anatomy of the nail unit and the nail biopsy. Semin Cutan Med Surg. 2015;34(2):95-100.

Courtesy of Monica Lawry, MD

5/22/2018

10

Courtesy of Nilton Di Chiacchio, MD, PhD

Courtesy of Phoebe Rich, MD

Courtesy of Phoebe Rich, MD

5/22/2018

11

Courtesy of Monica Lawry, MD

Courtesy of Nilton DiChiacchio, MD, PhD

5/22/2018

12

A1A2

A3-A6

5/22/2018

13

5/22/2018

14

Orchard GE, Torres J, Sounthararajah R. Use of softening agents to improve the production of formalin-fixed, paraffin-embedded sections of nail tissue: an assessment. Br J Biomed Sci. 2008;65(2):68-70.Wlodek C, Lecerf P, Andre J, Ruben BS, de Berker D. An international survey about nail histology processing techniques. J Cutan Pathol. 2017;44(9):749-756.

Mondragon G. Histotechnologist to histopathologist: amethod for processing specimens of nails. DermatopatholPractical Conceptual 1996;2:41-2.

5/22/2018

15

“BEFORE”

5/22/2018

16

“AFTER”

5/22/2018

17

Nazarian RM et al. J Am Acad Dermatol. 2012; 66 (4):655-60. Alers JC, et al. J Histochem Cytochem Off J Histochem Soc. 1999;47(5):703-710.Choi S-E, Hong SW, Yoon SO. J PatholTransl Med. 2015;49(3):236-242.

Hafner J, Haenseler E, Ossent P, Burg G, Panizzon RG. Benzidine stain for the histochemical detection of hemoglobin in splinter hemorrhage (subungual hematoma) and black heel. Am J Dermatopathol. 1995;17(4):362-367.

5/22/2018

18

FONTANA

AIR BUBBLES

5/22/2018

19

DAB STAIN“BENZIDINE”

5/22/2018

20

5/22/2018

21

Important…Sample subungual debris, not just nail plate

5/22/2018

22

5/22/2018

23

Courtesy of Dr. N. DiChiacchio

Pigmented superficial onychomycosis

5/22/2018

24

Perforating hyphae of molds

Sinuous hyphae, truncated spores, perforating hyphae

5/22/2018

25

Courtesy of Phoebe Rich, MD

5/22/2018

26

5/22/2018

27

PAS-D

Courtesy of Monica Lawry, MD

5/22/2018

28

5/22/2018

29

Moulage, Munster

5/22/2018

30

Adapted from: Jiaravuthisan MM, Sasseville D, Vender RB, Murphy F, Muhn CY. Psoriasis of the nail: anatomy, pathology, clinical presentation, and a review of the literature on therapy. J. Am. Acad. Dermatol.

2007;57(1):1–27.

leukonychia

5/22/2018

31

• Nail pits:

• Leukonychia:

• Splinter hemorrhages:

• Onycholysis/oil spots:

• Thickening:

Nail unit psoriasis

Clippings for diagnosis

Courtesy of Eleni Linos, MD

Pits

Subungual hyperkeratosis

Neutrophils

5/22/2018

32

Nail pits in psoriasis

Onychomycosis

Werner B, Fonseca GP, Seidel G. Microscopic nail clipping findings in patients with psoriasis. Am J Dermatopathol. 2015;37(6):429-439.

5/22/2018

33

Nail bed psoriasis

•Oil spots

•Hyperkeratosis

•Splinter hemorrhage

5/22/2018

34

P04-7660 JT

Pustular psoriasis with onycholysis

(acrodermatitis of Hallopeau)

Courtesy of Janet Hickman, MD

5/22/2018

35

Histologically difficult to diagnose psoriasis

Courtesy of Christine Miller, MD

5/22/2018

36

5/22/2018

37

5/22/2018

38

5/22/2018

39

Lichen planus

Splitting, ridging, thinning

Pterygium

Erythema, telangiectasia, sclerosis

Pterygium

Splitting, ridging, thinning

Graft versus host disease

Courtesy of Sarah Arron, MD, PhD

5/22/2018

40

Courtesy of Monica Lawry, MD

OnychorrexisHyperkeratosis

Courtesy of Siegrid Yu, MD

5/22/2018

41

5/22/2018

42

5/22/2018

43

Courtesy of Patrick Unemori, MD

Late changes, pterygium

5/22/2018

44

Atrophic and late LP

Courtesy of Monica Lawry, MD

5/22/2018

45

Late atrophic changes

5/22/2018

46

Courtesy of Sandra Yeh, MD

5/22/2018

47

5/22/2018

48

Kim M et al. Int J Dermatol. 2015;54(11):1255-1260.

Tosti A, Peluso AM, Misciali C, Cameli N. J Am Acad Dermatol.

1997;36(6 Pt 1):908-913.

5/22/2018

49

5/22/2018

50

5/22/2018

51

Nail eczematous dermatitis due to acrylate gel manicure

Courtesy of Mark Holzberg, MD

5/22/2018

52

Mattos Simoes Mendonca M, LaSenna C, Tosti A. Severe Onychodystrophy due to Allergic Contact Dermatitis from Acrylic Nails. Skin Appendage Disord. 2015;1(2):91-94.

Trachyonychia

“20 nail dystrophy”

Tosti A, Bardazzi F, Piraccini BM, Fanti PA.

Idiopathic trachyonychia (twenty-nail dystrophy): a

pathological study of 23 patients. Br J Dermatol. 1994

Dec;131(6):866-72.

5/22/2018

53