BACKGROUND: Nail psoriasis is common in psoriasis vulgaris and even more prevalent in psoriatic arthritis. Dermatoscopy of the nail proves helpful in enhancing the visualization of psoriatic nail lesions.
OBJECTIVE: This systematic review aimed to summarize the existing studies published in the literature that reported the various dermoscopic features of nail psoriasis.
METHODS: A systematic search of two medical databases, PubMed and Scopus, was conducted in April 2023. In total, 11 records were included. The number of reported cases in the included studies was 723.
RESULTS: The average age was 42.39 years. Sixty percent of patients were males, and 40% were females. Pitting constituted the most common onychoscopic feature indicating nail matrix involvement, followed by various other features such as leukonychia, nail plate thickening, transverse and longitudinal ridges, and different lunula abnormalities. The predominant onychoscopic feature indicating nail bed involvement was onycholysis, followed by splinter hemorrhages, oil drop sign, subungual hyperkeratosis, dilated capillaries, agminated capillary dots, erythematous border, and pustules. Vascular abnormalities observed in all locations were present in 52% of patients.
CONCLUSIONS: The clinical signs of nail psoriasis are diverse, and for the majority, they are nonspecific. Nail dermoscopy is a noninvasive tool that enhances the visualization of the nail manifestations of psoriasis. It may facilitate the establishment of diagnostic criteria for this pathology without resorting to more invasive procedures, such as nail biopsy.

The purpose of this review is to consolidate and summarize laser-assisted drug delivery (LADD) for nail diseases, particularly onychomycosis and psoriasis. A PubMed search was conducted in June 2023 using search terms (1) \"laser assisted drug delivery\" AND \"nail,\" (2) \"laser\" AND \"nail,\" and (3) \"nail disorder\" AND \"laser treatment.\" References of papers were also reviewed, yielding 15 papers for this review. Fractional ablative CO2 laser (FACL) and Er:YAG laser can be used for LADD of topical medications such as amorolfine, terbinafine, and tioconazole to treat onychomycosis. A fungal culture should be performed to determine the type of dermatophyte, which will help determine which topical will be most effective. Laser settings varied between studies, but overall LADD tended to be more effective than topical treatments alone. Laser-assisted photodynamic therapy (PDT) was also found to be effective in treating onychomycosis. For psoriatic nails, LADD was used to deliver calcipotriol-betamethasone dipropionate foam, tazarotene, triamcinolone, or methotrexate into the nail. Again, LADD was found to be significantly more effective than topical treatment alone. FACL was the only laser noted for use for LADD in both diseases. Laser-assisted drug delivery for nail disease is a newer approach for onychomycosis and nail psoriasis with several benefits and drawbacks. Dermatologists should discuss the option of LADD with their patients who have recalcitrant onychomycosis or nail psoriasis.

Lichen planus is a chronic inflammatory disorder that may affect the skin, nails, and/or oral mucosa. Bullous lichen planus is a rare variant of lichen planus, which is even less common in the nails. We present a case of nail bullous lichen planus, in a 48-year-old male presenting with a 10-month history of onychodystrophy of all ten fingernails. A longitudinal excision of the left thumbnail was performed, with histopathology consistent with lichen planus with focal transition to bullous lichen planus. He was treated with intralesional triamcinolone injections to the fingernails monthly, with improvements noted after three treatments. Our patient\'s nail bullous lichen planus manifested with longitudinal ridging, white-yellow discoloration, onycholysis, subungual hyperkeratosis, and v-shaped nicking. Histopathological findings included classical lichen planus changes, as well as formation of subepidermal bullae, colloid bodies, and extensive inflammatory infiltrate. Increased awareness and high index of suspicion for this condition are necessary, given the often late diagnosis reported in previously published cases.

Neoplastic lesions (benign or malignant) in the nail region are rare when compared to lesions in the rest of the skin. Despite advances in diagnostic modalities, their diagnosis is frequently delayed or overlooked for days, months, or even years when they are misrecognized or when their approach is not appropriate. Undoubtedly, malignant tumors are the most important lesions since an inopportune diagnosis or treatment can drastically change the patient\'s prognosis. A review of all the scientific evidence on the two main malignant neoplasms of the nail apparatus (melanoma and squamous cell carcinoma) was carried out using the PubMed search engine from 2003 to 2022, in order to expose the appropriate diagnostic approach and treatment of these nail lesions to avoid delays that obscure the prognosis of patients. This review does not include reconstruction modalities after lesion resection, but the emphasis is placed on the great functional impact they produce. Surgical treatment in the early stages is the most important when talking about prognosis and emphasizing it; systemic oncological management of advanced stages is not so deep.

Onychomycosis is the most common nail disease encountered in clinical practice. Its importance extends well beyond aesthetics, often causing pain, difficulty with ambulation and performing daily activities, and impairing quality of life. Many patients fail to achieve cure with antifungal monotherapy and recurrences are common. Combination therapy has therefore gained considerable interest, given the potential for drug synergy and prevention of antifungal resistance, but it has not been well studied. A systematic review of onychomycosis medication only, as well as medication and procedural (laser, debridement, photodynamic therapy), clinical or randomized controlled trials evaluating combination vs. monotherapies was performed. After exclusions, 30 studies were included in the final analysis. There were conflicting results for medication-only trials, with some showing significant benefit of combination therapy over monotherapy, however, trials were not robustly designed and lacked sufficient follow-up. Procedural studies also lacked long-term follow-up, and failed to demonstrate efficacy in some severe onychomycosis cases. Considering the high cure rates demonstrated in pivotal antifungal monotherapy trials, and conflicting results, costs, and safety concerns associated with combination therapy, we recommend that combination therapy be reserved as second-line treatment options in patients with poor prognostic factors or for those who failed monotherapy for onychomycosis.

Onychomatricoma is a primary benign neoplasm of the nail matrix. Currently, a limited number of cases have been reported, so it is still considered a rare neoplasia. However, it is debatable if this condition is underdiagnosed and underreported. Onychomycosis is an important differential diagnosis of onychomatricoma, and sometimes, both these conditions may even coexist in the same nail. As the tumor grows, tissue microenvironment is more vulnerable to dermatophytes. Probably, the altered keratin appears to be susceptible to fungal invasion. Careful clinical assessment and dermoscopic evaluation help nailing the diagnosis. Usually, total nail avulsion is the preferred therapeutic approach when they coexist. Herein, we present a case of a middle-aged woman with onychomycosis and onychomatricoma affecting a single fingernail. The proposed therapy was oral terbinafine for 6 months followed by a conservative surgery. There were dramatic changes in dermoscopic features after fungal treatment, which, to our knowledge, have not been previously reported.

To describe the prevalence of extra-articular manifestations-enthesitis, dactylitis, nail disease, uveitis and IBD-in PsA, and their impact on longitudinal disease outcomes.
We searched Medline, PubMed, Scopus and Web of Science using a predefined protocol in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies using imaging to define extra-articular manifestations (EAMs) were excluded. Where possible, we performed meta-analyses of prevalence estimates, reported as percentages (95% CI). Heterogeneity (I2 statistic) was examined according to study characteristics.
We identified 65 studies amounting to a total of 163 299 PsA patients. Enthesitis was assessed in 29 studies with an average prevalence of 30% (95% CI: 24%, 38%). Dactylitis was reported in 35 studies with an average prevalence of 25% (95% CI: 20%, 31%). Nail disease was present in 60% (95% CI: 52%, 68%) across 26 studies, but definitions were often unclear. Uveitis (3.2%; 95% CI: 1.9%, 5.3%) and IBD (3.3%; 95% CI: 1.5%, 7.1%) were less common. Heterogeneity was high (>95%) in all meta-analyses, but could not be explained by study characteristics. No studies examined the impact of EAMs on longitudinal disease outcomes, except that dactylitis increases radiographic progression.
Enthesitis, dactylitis and nail disease are highly prevalent in PsA, but not uveitis and IBD. EAM patterns differ from axial SpA despite their shared disease mechanisms, which may help further understand differences between spondyloarthritides. More studies are needed on the impact of EAMs on disease outcomes such as response to treatment.