Dermatologic Condition Assessment: Patient Case Study Analysis

This case study presents a 46-year-old male with a suspicious lesion on his left hallux nail. The analysis includes a description of the dermatological lesion, which is a chronic subungual brown discoloration. A differential diagnosis tree is constructed, considering conditions like onychomycosis, psoriasis, subungual hematoma, subungual melanoma, and chloronychia. The most likely differential, onychomycosis, is justified based on the patient's symptoms and history. The assignment then provides an evidence-based management strategy for onychomycosis, including laboratory diagnosis, topical, systemic, and combination therapies, and surgical interventions. The study emphasizes the importance of identifying the causative organism and using appropriate antifungal treatments to improve patient outcomes and prevent complications.

RUNNING HEAD: DERMATOLOGIC CONDITION 1
DERMATOLOGIC CONDITION ASSESSMENT
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DERMATOLOGIC CONDITION 2
Introduction
The current paper is an analysis of a patient scenario in dermatology and podiatry. A patient
case study is posed with a pictorial of a specific dermatological lesion(s). The lesion will be
described and a differential diagnosis tree constructed. It will highlight the most likely
differentials and a preferred differential that fits the clinical scenario more than the others. A
rationale for the preferred differential will be provided and finally, an evidence-based
management strategy for the preferred differential diagnosis will be discussed.
Case description
The case study is of a 46-year-old male who presented for general nail care due to a
suspicious lesion on his left hallux nail. The lesion had been there for three months, had been
increasing in size and could have been traumatic as he did not recall but reports it is likely
since he had been renovating his house for the past several months.
Dermatology description
The lesion is a chronic subungual brown discoloration on the left hallux nail. It is next to the
medial nail fold and measures approximately 2 by 10 mm in its greatest dimension. it is
irregular in shape. The lesion is a patch and appears flat and the area surrounding it is non-
erythematous. Associated nail changes noted include regular nail pitting and ridging.
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Differential Diagnosis Tree
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Justification of Differentials Diagnosis
According to the case presented, the likely diagnoses include onychomycosis, psoriasis,
subungual hematoma, subungual melanoma and chloronychia (Soutor & Hordinsky, 2013).
1. Nail psoriasis
Involvement of the nail in psoriasis affects approximately 50% of patients (Baran, 2010). The
clinical manifestations include nail pitting that is irregular, described as thimble pitting,
onycholysis which is when the nail separates from the nail bed and nail discoloration (Tan,
Chong, & Tey, 2012). The nail discoloration in psoriasis is however irregular and described
as oil drop discoloration (Tan, Chong, & Tey, 2012). Psoriasis is unlikely in the patient due to
the pattern of discoloration. The patient has a clearly demarcated brown discoloration that is
unlike the oil drop discoloration of psoriasis. Also, the nail pitting in the patient is fine and
regular unlike the thimble pitting in psoriasis. Nail psoriasis usually presents in association
with other psoriatic manifestations especially psoriatic arthropathy where it occurs in 90% of
cases (Tan, Chong, & Tey, 2012). The patient in the case, however, did not have any other
complaints.
2. Subungual hematoma
Subungual hematomas can be due to an acute traumatic injury to the digit (Cohen, Schulze, &
Nelson, 2007). When acute, presents as red discoloration under the nail bed but when they
become chronic turn to a blue, black or brown appearance (Cohen, Schulze, & Nelson, 2007).
The patient had a history of working with tools and reports there is a possibility of trauma. It
is unlikely the patient could have a subungual hematoma since he reports that the lesion is
increasing in size. This could, however, happen if there is a superimposed bacterial or fungal
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infection after the initial hematoma (Soutor & Hordinsky, 2013). In that case, the approach to
management will be diagnosing the infective agent.
3. Chloronychia
Also termed green nail syndrome, it is nail infection by the bacterium Pseudomonas
aeruginosa and presents as a greenish-yellow, greenish-brown or greenish- black nail plate,
with onycholysis and non-tender nail folds (Chiriac, Brzezinski, Foia, & Marincu, 2015). The
source of infection is however mostly for those who carry out wet work. The patient had a
predisposition of suspected microtrauma to the nail. However, the patient has no history of
wet work. It is not associated with nail pitting. There was no paronychia inflammation or
suppuration that is seen in Pseudomonas infection.
4. Subungual melanoma
Melanoma is a malignant tumor of melanocytes and could arise from the nail. Recognition of
melanoma of the skin is a problem due to its silent presentation mimicking hematoma or
fungal infection (Bristow, de Berker, Acland, Turner, & Bowling, 2010). There is a
relationship between melanomas and ultraviolet light exposure and family history of the same
(Bristow, de Berker, Acland, Turner, & Bowling, 2010). The disease produces a black to
brown discoloration under the nails similar to the patient’s presentation. It is however not
related to trauma.
Preferred differential: Onychomycosis
The rationale for the preference of this differential is the symptomatology and the case
scenario. Onychomycosis is a chronic fungal infection of the nails. It makes up for nearly half
of all nail disorders (Soutor & Hordinsky, 2013). It is more common among males, the
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immunosuppressed or diabetics. Trauma and nail dystrophy predisposes one to these
infections. In 60 to 80% of cases, they are caused by the fungal class of dermatophytes
including Trichophyton rubrum, Trichophyton. mentagrophytes and E. floccosum (Tchernev
et al., 2013). Non-dermatophyte molds (NDMs) and candida also cause onychomycosis. The
commonest presentation is discoloration of the nail plate (Tchernev et al., 2013). The findings
include brown, yellow or orange streaks or patches under the nail plate. Nail changes with the
progressive disease include nail thickening and separation from the nail bed. Toenails are
affected more than fingernails by more than seven fold (Singal & Khanna, 2011).
The patient fulfills all the symptomatic presentation as he presents with a brown patch under
the hallux nail plate. The streak is following suspected trauma, is chronic in nature and
enlarging progressively. The patient has a history of exposure to trauma in harsh
environments as he had been renovating his house prior to the presentation of the lesion. It is
therefore likely that he picked up a nail fungal infection and presented later due to the chronic
nature of the condition. The patient had no other complaints since onychomycosis does not
present with systemic effects and is fairly localized.
Evidence-Based Management of Onychomycosis
Although some patients may view onychomycosis at an early stage as merely a cosmetic
issue, it can progress and prove to be a real distressing pathology (Singal & Khanna, 2011). It
leads to discomfort wearing shoes, walking, and self-esteem issues. It is also a contagion and
can spread to family members. It can lead to complications such as osteomyelitis, ulcers, and
cellulitis not forgetting the financial impact of dealing with such complications (Ameen,
Lear, Madan, Mohd Mustapa, & Richardson, 2014). It is, therefore, clinically relevant to
manage this disorder using the best available means.
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Due to the different number of organisms causing onychomycosis and the different clinical
presentations, laboratory diagnosis of onychomycosis should be done before any treatment is
initiated (Mikailov, Cohen, Joyce, & Mostaghimi, 2016). The rationale behind this is that the
different organisms have specific management strategies and empirical treatment may be
unsuccessful. It is also useful to rule of non-infective causes such as melanoma and psoriasis
and to identify mixed infections that usually exist together with onychomycosis. The
laboratory diagnosis involves careful specimen collection from the affected digit usually from
the discolored or brittle parts of the nail (Singal & Khanna, 2011). The nail in question is
clipped at the affected region using aseptic techniques and the scrapings collected. Lab
identification involves organism culture and visualization under microscopy (Singal &
Khanna, 2011). For suspected fungal infection, direct microscopy is done under 10-30%
KOH and examined for fungal elements for example hyphae, yeast or spores (Ameen, Lear,
Madan, Mohd Mustapa, & Richardson, 2014). Confirmatory specimen culture using primary
culture media is done next. Newer introduced means of diagnosis have shown improved
result sensitivity and include DNA analysis of the specimen with PCR or using dual flow
cytometry (Ameen, Lear, Madan, Mohd Mustapa, & Richardson, 2014). According to Barak,
Asarch, & Horn, (2010), periodic acid Schiff is more sensitive than using microscopy.
After the lab isolation of the offending organism, treatment with antifungal therapy is
initiated. It can either be topical, systemic or combination with both modalities. Topical
treatment is limited to superficial infections due to the limited absorption of the drug past the
hard nail plate. Evidence recommends the use of the following agents: amorolfine which has
shown effectiveness in 50% of cases, ciclopirox that is effective with 34% mycological cure,
and tioconazole that achieved cure rates of 22% (Ameen, Lear, Madan, Mohd Mustapa, &
Richardson, 2014). Other topical agents used include eficonazole, terbinafine, Butenafine,
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Bifonazole and Salicylic acid. They is, however, limited evidence data to support their
application.
Systemic therapy is mainly with terbinafine, griseofulvin, fluconazole, itraconazole, and
ketoconazole. Griseofulvin has demonstrated cure rates of up to 40% (Ameen, Lear, Madan,
Mohd Mustapa, & Richardson, 2014). Studies that compared it to terbinafine and
itraconazole and found it weaker (Ameen, Lear, Madan, Mohd Mustapa, & Richardson,
2014). Terbinafine is a good broad-spectrum antifungal and is fungicidal against a large
number of dermatophytes. When compared with itraconazole, it proved stronger with cure
rates of 55% compared with 26% in itraconazole (Ameen, Lear, Madan, Mohd Mustapa, &
Richardson, 2014). Fluconazole is another option with cure rates ranging from 47% to 62%
(Ameen, Lear, Madan, Mohd Mustapa, & Richardson, 2014). Other newer drug therapies
exist but their efficacy data is insufficient.
Combination therapy should be used to lower relapse and improve the cure rates. An example
is the use of a combination of itraconazole and amorolfine that achieved 83% cure compared
to 41% for those who received itraconazole alone (Lecha, 2001). Another trial using
terbinafine and amorolfine resulted in cure rate of 27% compared to 17% with terbinafine
monotherapy (Baran et al, 2000). Combination therapy should, therefore, be attempted.
Surgical intervention to help drug penetration and to remove diseased tissue has been shown
to be effective additional strategies. The whole nail could be removed in avulsion or part of
the nail as in debridement. For the patient’s case, partial removal is a better option in
combination with topical and systemic antifungals (Malay, Borowsky, Downey &
Mlodzienski, 2009).
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Conclusion
Evaluation of the case study, construction of the differential diagnosis tree and clinical
assessment of the case scenario yielded the most likely differentials to be nail psoriasis,
subungual hematoma, subungual melanoma, and chloronychia. The preferred differential
diagnosis, however, was onychomycosis due to the presentation and scenario. The
management of onychomycosis involves first lab identification of the causative organism and
strict antifungal therapy to target the same. Modalities of treatment include topical, systemic
and combination therapy. Combination therapy is recommended due to higher cure rates. To
supplement antifungal therapy, surgical avulsion or debridement can be used to reduce
diseased tissue and aid drug penetration.
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References
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Association of Dermatologists' guidelines for the management of onychomycosis
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Barak, O., Asarch, A., & Horn, T. (2010). PAS is optimal for diagnosing
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Baran, R. (2010). The burden of nail psoriasis: an introduction. Dermatology, 221(1), 1-5.
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