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15.5 Nail Biopsy
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with a handheld electrocautery device. After the initial curettage and cauterization, the clinician performs curettage and
electrodessication twice more on the surgical site to complete the procedure. Like the shave biopsy, this biopsy site
will heal by secondary intention and leave a minimal scar.
15.5 Nail Biopsy
The most common techniques to use for a nail biopsy are the
punch and the incisional/excisional methods. These are used
to further investigate pigmented lesions of the nail and nail
unit tumors.
When a patient presents with a dark brown to black longitudinal line on the nail plate, i.e., longitudinal melanonychia, the provider must determine whether to do a nail
biopsy [4]. When planning a punch biopsy of that lesion, the
physician should involve the most proximal part of pigmented area due to the melanocyte presence in the matrix of
the nail unit. Therefore, one should dissect the proximal nail
fold back carefully to expose the nail matrix to have appropriate exposure for the procedure. Due to the possible disturbance of the matrix during this procedure, it is imperative
to discuss with the patient during the informed consent process that permanent nail dystrophy may occur as the nail
grows distally.
Direct a 4mm punch (or smaller/larger depending on the
size of the lesion) to the most proximal part of the pigmented
area. Using a gentle motion, apply the punch tool to the nail
plate and continue to twist the tool through the nail bed [4].
There is minimal to no subcutaneous tissue deep to the nail
bed. The punch instrument will most likely touch the distal
phalanx. When the clinician feels the periosteum of the distal
phalanx, they should carefully pull the punch tool out of the
nail unit, cut the lesion as deeply as possible, and place the
specimen in formalin. One can ll the circular defect remaining in the nail plate with gel foam or another hemostatic
agent and repair the proximal nail fold with suture or
steri-strips.
If a patient presents with a nail bed neoplasm, one may
perform an incisional or excisional biopsy depending on the
size of the lesion. Surgical planning involves rst removing
the nail plate to gain access to the nail bed [4]. Compared to
a biopsy of the nail matrix, excising a nail bed lesion is
unlikely to cause permanent nail dystrophy. Once the lesion
has been removed, it is placed in formalin and sent for histopathologic processing (Figs.15.12, 15.13, and 15.14).
87
Fig. 15.12 Longitudinal melanonychia on great toenail
Fig. 15.13 Application of punch tool to nail
88
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Fig. 15.14 Removal of nail specimen
15 Biopsy Techniques oftheLower Extremity
References
1. Wark KJ, Smith SD, Sebaratnam DF. How to perform a skin
biopsy. Med J Aust. 2020;212(4):156–8.e1. https://doi.org/10.5694/
mja2.50473.
2. Sina B, Kao GF, Deng AC, Gaspari AA. Skin biopsy for
inammatory and common neoplastic skin diseases: optimum time, best location and preferred techniques. A critical
review. J Cutan Pathol. 2009;36(5):505–10. https://doi.
org/10.1111/j.1600- 0560.2008.01175.x.
3. Zuber TJ.Fusiform excision. Am Fam Physician. 2003;67(7):1539–
44, 1547–8, 1550
4. Rich P. Nail surgery. In: Bolognia JL, Rapini RP, et al., editors.
Dermatology. 1st ed. London: Mosby; 2003. p.2321–230.
Dermatologic Therapies oftheLower
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Extremity: Topical andSystemic
16
Dermatological formulations provide topical treatment for
skin conditions and as a rule have a better safety prole compared to systemic agents. The vehicle houses and supports
active ingredients and may enhance penetration beyond the
stratum corneum. An ideal vehicle is odorless, easy to apply,
inexpensive, non-irritating, and stable.
Ointments Ointments are often petrolatum-based and form
an occlusive barrier. Ointments have a greasy consistency
that aid in hydration of the stratum corneum and enhance
potency of the active ingredient. Ointments are well suited
for xerotic skin in non-hair bearing areas.
Creams Creams are emulsions that can either be oil-in-
water or water-in-oil formulations that impart a slight residue to the skin. Creams are readily rinsed off and are more
cosmetically elegant than ointments.
Lotions Lotions are in essence one liquid (oil) surrounded
by another liquid (water) which together create an emulsion
or topical suspension. Lotions are typically less moisturizing
than creams. They are easy to spread on wide body surfaces
and impart a cooling sensation to the skin.
Gels Gels are either alcohol-based or water-based. Alcoholbased gels tend to sting more than water-based gels. Both provide for rapid drying and enhanced penetration. Gels are excellent
vehicles for hair bearing areas and, when tolerated, work well in
moist intertriginous locations such as interdigital spaces.
Sprays Sprays are metered (pre-measured) pumps of emul-
sion that dry quickly and can be readily spread over large
surface areas. Of concern is the potential for inhalation,
especially when used on a chronic basis.
Foams Foams are a dispersion of gas in small amounts of
liquid. Foam formulations are cosmetically elegant and easy
to apply.
Tapes Tapes are strips of an occlusive adhesive impregnated
with an active ingredient. Many are formulated to release the
active ingredient in a time-controlled manner.
Lacquers Lacquers are organic materials with an evapora-
ble solvent that leaves a lm. Lacquers are ideally suited for
use on nails.
Powders Powders contain ground up or pulverized ingredi-
ents. Powders have a drying effect and may be used to minimize excess moisture.
Vehicle choice is an important consideration when treat-
ing disorders of the lower extremities. Ease of spread
enhances compliance when dealing with a large, hair- bearing
surface area such as the lower leg. Depending on the thickness of hair, gels, lotions, sprays, and foams might be preferred over creams or ointments from both cosmetic and
penetration standpoints.
When dealing with thick plantar skin penetration is an
important consideration. In comparison to the forearm, the
plantar foot has ten times less absorption than the axilla [1].
An ointment is ideally suited for this locale but may be difcult to keep in contact with the skin. To avoid the greasy
residue of an ointment in a sock or shoe patients can opt for
a cream, emulsion, or topical suspension.
A topical medication is only effective if utilized as pre-
scribed. Vehicles play a signicant role in patient adherence.
Tolerability, spread-ability, durability, ease of use, cosmetic
elegance, and the need for special storage are just some of
the many factors affecting patient acceptance.
An interesting study measured vehicle preference in pso-
riasis patients [2]. Each subject applied a cream, solution,
gel, ointment, foam, and emollient to forearm skin. Assessed
quality-of-life factors included time needed for application,
smell, feel on skin and hair-bearing sites, clothing stains,
messiness, and method of application. Overall, the preferred
vehicles were solutions and foams. Gender and age may play
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022
T. C. Vlahovic, S. M. Schleicher, Atlas of Lower Extremity Skin Disease, https://doi.org/10.1007/978-3-031-07950-4_16
89
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16 Dermatologic Therapies oftheLower Extremity: Topical andSystemic
a role in vehicle preference as well with women more tolerant of moisturizing bases and a younger audience more
attuned to sprays and foams.
The following tables offer a guide to some common dermatological treatments for lower extremity skin conditions
(Tables 16.1, 16.2, 16.3, 16.4, 16.5, 16.6, 16.7, 16.8, 16.9,
16.10 and 16.11) [3].
Table 16.1 Prescription topical corticosteroid preparations for inammatory skin conditions
Class I Super high potency
Betamethasone dipropionate 0.05% gel, lotion, ointment
Clobetasol propionate 0.05% cream, emollient cream, gel, lotion,
ointment, shampoo, spray, solution
Fluocinonide 0.1% cream
Flurandrenolide 4mcg/cm2 tape
Halobetasol propionate 0.05% cream, foam, lotion, ointment
Class II High potency
Amcinonide 0.1% ointment
Betamethasone dipropionate augmented formulation (AF) 0.05%
cream
Clobetasol propionate 0.025% cream
Desoximetasone cream, ointment, spray 0.25%, gel 0.05%
Diorasone diacetate 0.05% cream, ointment
Fluocinonide 0.05% cream, gel, ointment, solution
Halcinonide 0.1% cream, ointment, solution
Halobetasol propionate 0.01% lotion
Class III High potency
Amcinonide 0.1% cream, lotion
Betamethasone valerate 0.12% foam, 0.1% ointment
Fluocinonide 0.05% emollient cream
Fluticasone propionate 0.005% ointment
Mometasone furoate 0.1% ointment
Triamcinolone acetonide 0.5% cream, ointment
Class IV Mid-potency
Betamethasone dipropionate 0.05% spray
Clocortolone pivalate 0.1% cream
Fluocinolone acetonide 0.025% ointment
Flurandrenolide 0.05% ointment
Fluticasone propionate 0.05% cream
Hydrocortisone valerate 0.2% ointment
Mometasone furoate 0.1% cream, lotion, solution
Triamcinolone acetonide 0.1% cream, ointment, 0.05% ointment,
0.2mg/s spray
Class V Mid-potency
Desonide 0.05% gel, ointment
Fluocinolone acetonide 0.025% cream
Hydrocortisone butyrate 0.1% cream, lotion, ointment, solution
Hydrocortisone probutate 0.1% cream
Hydrocortisone valerate 0.2% cream
Prednicarbate 0.1% emollient cream, ointment
Triamcinolone acetonide 0.1% lotion, 0.025% ointment
Class VI Low potency
Alclometasone dipropionate 0.05% cream, ointment
Desonide 0.05% cream, foam, lotion
Triamcinolone acetonide 0.025% cream, lotion
Table 16.1 (continued)
Class VII Lowest potency
Hydrocortisone 2.5% cream, ointment, solution
Hydrocortisone 2% lotion
Hydrocortisone 1% cream, gel, lotion, ointment, solution, spray
Hydrocortisone 0.5% cream, ointment
Table 16.2 Non-steroidal topical preparations for eczema
Prescription
Calcineurin inhibitor:
Pimecrolimus 1% cream
Tacrolimus 0.03% and 0.01% ointment
JAK inhibitor:
Ruxolitinib 1.5% cream
Phosphodiesterase 4 inhibitor:
Crisaborole 2% ointment
Over-the-counter
Benadryl® Itch Stopping Cream (Johnson & Johnson)
Calamine Lotion
Sarna® Original and Sensitive Anti-Itch Lotion (Crown
Laboratories, Inc)
Tricalm® Steroid-Free Hydrogel (Life Wear Technologies, LLC)
Table 16.3
Prescription topical therapies for plantar verruca
The following drugs are not FDA approved for plantar verruca, but
their use has been supported by clinical studies
Imiquimod 5% cream
Sinecatechins 15% ointment
Fluorouracil 5% cream
Adapalene 0.1% gel
Cantharidin 1% liquid
Table 16.4
Over-the-counter keratolytics and emollients
Urea 40% cream
®
Salicylic acid 5% cream, gel, shampoo (Summers
Keralyt
Laboratories Inc)
AmLactin
®
(15% lactic acid) Foot Repair Cream Therapy (Advantice
Health, LLC)
®
Aveeno
Skin Relief cream, lotion (Johnson & Johnson)
®
cream (L’Oreal)
CeraVe
®
Itch Defense® (Kao USA, Inc)
Curel
®
Cutemol
Dermeleve
Eucerin
Gold Bond Ultimate
Emollient Cream (Summers Laboratories Inc)
®
Soothing Cream (Advanced Derm Solutions, LLC)
®
original healing cream (Beiersdorf)
®
Eczema Relief Cream and Lotion (Sano
Consumer Healthcare)
Lubriderm
Table 16.5
®
lotion (Johnson & Johnson)
Prescription topical antifungals
Ciclopirox olamine 0.77% cream, gel, lotion
Ketoconazole cream and shampoo, 2%
Luliconazole cream 1%
Naftine HCl 1% and 2% cream and 1% and 2% gel
Oxiconazole nitrate cream 1%
Sertaconazole nitrate cream 2%
References
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91
Table 16.6
Over-the-counter topical antifungals
Terbinane hydrochloride cream, gel, spray
Butenane hydrochloride cream
Clotrimazole cream
Miconazole nitrate powder and spray
Table 16.7
Prescription oral antifungals
Terbinane hydrochloride tablets
Itraconazole capsules
Griseofulvin ultramicrosize tablets
Fluconazole tablets
Table 16.8
Laundry detergents for sensitive skin
All® Free Clear (Henkel Corporation)
Arm and Hammer Sensitive Skin (Church & Dwight Co)
®
(Procter and Gamble)
Dreft
®
Free and Gentle (Procter and Gamble)
Tide
Table 16.9
Topical nail therapies: prescription (Rx) and over-the-
counter (OTC) topicals
For nail dystrophy
DermaNail® Nail Conditioner (Summers Laboratories) OTC
Genadur® hydrosoluble nail lacquer (Medimetriks
Pharmaceuticals) Rx
Kerasal® Fungal Nail Renewal Treatment, Advantice Health) OTC
For onychomycosis (all Rx)
Ciclopirox 8% nail solution
Tavaborole topical solution 5%
Jublia® (Enaconazole topical solution 10%, Ortho
Dermatologics)
Table 16.10 (continued)
Agent Psoriatic Arthritis (PsA) or Psoriasis (PsO)
Biologics
TNF-α inhibitors
Etanercept PsA, PsO
Adalimumab PsA, PsO
Iniximab PsA, PsO
Certolizumab pegol PsA, PsO
Golimumab PsA
Interleukin 12 and 23 inhibitor
Ustekinumab PsA, PsO
Interleukin 17 inhibitors:
Secukinumab PsA, PsO
Brodalumab PsO
Ixekizumab PsA, PsO
Interleukin 23 inhibitors:
Tildrakizumab-asmn PsO
Risankizumab-rzaa PsA, PsO
Guselkumab PsA, PsO
Table 16.11 Topical non-steroidal preparations for psoriasis
Vitamin D Analog
calcipotriene 0.005% cream and ointment
calcitriol ointment 3mcg/g
Aryl hydrocarbon receptor agonist
tapinarof cream, 1%
Phosphodiesterase 4 inhibitor
roumilast cream 0.3%
References
Table 16.10
Systemic medications for psoriatic arthritis and
psoriasis
Agent Psoriatic Arthritis (PsA) or Psoriasis (PsO)
Oral medications
Cyclosporine PsO
Methotrexate PsA/PsO
Acitretin PsO
Apremilast PsA, PsO
1. Feldman RJ, Maibach HI. Regional variation in percutaneous penetration of 14C cortisol in man. J Invest Dermatol. 1967;48:181–3.
2. Housman TS, Mellen BG, Rapp SR, Fleisher AB, Feldman
SR.Patients with psoriasis prefer solution and foam vehicles: a quantitative assessment of vehicle preference. Cutis. 2002;70(6):327–32.
3. UpToDate. Comparison of representative topical corticosteroid
preparations (classied according to the United States system).
https://www.uptodate.com/contents/image/print?imageKey=DER
M%2F62402
Index
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A
Abscess, 21
Acral nevus, 53
Acropustulosis, 64, 65
Actinic keratoses, 53
Acute generalized exanthematous pustulosis (AGEP), 82
Angiokeratoma, 54
Antifungal, 19
Antinuclear antibodies (ANA), 50
Arterial ulcers, 77
Asteatotic eczema, 30
Atherosclerosis, 77
Athlete’s foot, 17
Atopic dermatitis, 40
B
Bacterial infections
abscess, 21
cellulitis, 21
erythrasma, 22
folliculitis, 22
impetigo, 23
pitted keratolysis, 23
Basal cell carcinomas (BCCs), 53, 57
Bed bugs, 25
Bullous pemphigoid, 63
C
Calcineurin inhibitor, 90
Calciphylaxis, 79
Cellulitis, 21
Chilblains, 49
Ciclopirox, 20
Contact dermatitis, 39, 40
Corns and calluses, 29
Coronoid lamella, 75
Corynebacterium, 23
COVID toes, 49
Creams, 89
Curettage, 86
Diabetic dermopathy, 71
Diabetic ulcers, 78
Disappearing nail bed (DNB), 7
Drug vehicle, 89
E
Econazole, 20
Eczema, 40
Electrodesiccation, 86
Emollients, 90
Epidermolysis bullosa acquisita (EBA), 63
Erythema, 44
Erythema abigne (EAI), 67
Erythema multiforme, 71, 72
Erythema nodosum, 71, 72
Erythrasma, 22
Excisional biopsies, 85
Exostosis, 13
F
Fibroma/Fibrokeratoma, 12
Fixed drug eruption, 81
Fleas, 25
Foams, 89
Folliculitis, 22
G
Gels, 89
Granuloma annulare (GA), 72
Green nails, 7
H
Hand foot and mouth disease, 23, 24
Herpes simplex, 10
Herpes zoster, 23
Horteae werneckii, 19
Hyfrecator, 84
D
Delusions, 67
Delusions of parasitosis, 68
Dermatitis herpetiformis, 63, 64
Dermatobroma, 53, 54
Dermatophilus congolensis, 23
Dermatophyes, 17
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2022
T. C. Vlahovic, DPM, S. M. Schleicher, MD, Atlas of Lower Extremity Skin Disease,
https://doi.org/10.1007/978-3-031-07950-4
I
Ichthyosis, 31
Idiopathic guttate hypomelanosis, 72
Impetigo, 22
Ingrown toenails, 8
Interdigital tinea pedis, 17
Intractable plantar keratosis (IPK), 29
Irritant dermatitis, 39
93
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Index
J
JAK inhibitor, 90
K
Kaposi’s sarcoma, 57, 58
Keloids, 46
Keratoacanthoma, 58
Keratoderma climactericum, 30, 31
Keratolytics, 32, 90
Ketoconazole, 20
Koilonychia, 3
Kytococcus sedentarius, 23
L
Lacquers, 89
Leukocytoclastic vasculitis, 73, 74
Leukonychia, 5
Lichen planus, 36, 37
Lichen striatus, 37, 38
Lipodermatosclerosis, 73
Lipoma, 55
Longitudinal melanonychia, 5, 87
Lotions, 89
Luliconazole, 20
Lyme disease, 26
M
Majocchi’s granuloma, 19
Melanoma, 53, 59
Melanonychia, 45
Moccasin tinea pedis, 18
Moisturizers, 32
Molluscum contagiosum, 24
Morbilliform drug eruptions, 81
Morgellons disease, 68
Morphea, 50
Mycosis fungoides, 59, 60
Myxoid cyst, 12
Necrobiosis lipoidica, 74
Neurobromas, 55
Neurobromatosis, 55
O
Ointments, 89
Onychogryphosis, 5
Onycholysis, 6, 7
Onychomadesis, 1
Onychomycosis, 11
Onychorrhexis, 2
Oral antifungals, 91
Oxiconazole, 20
P
Palmoplantar keratoderma (PPK), 31
Palpable purpura, 73
Papulosquamous, 35
Perforating folliculitis, 74
Periodic acid Schiff (PAS), 20
Periungual viral warts, 10
Pigmentation disorders
post-inammatory hyperpigmentation, 43
Pitted keratolysis, 23
Plantar verruca, 90
Plantar verrucae, 24
Porokeratoses, 32
Porokeratosis, 75
Poroma, 55
Post-inammatory hypopigmentation, 44
Powders, 89
Pressure ulcer, 80
Pretibial myxedema, 75, 76
Prurigo nodularis, 67
Psoriasis, 2, 3, 35, 91
Psoriatic arthritis, 91
Punch biopsy, 84, 85
Pyoderma gangrenosum, 79
Pyogenic granuloma, 11, 56
N
Naftitine, 20
Nail biopsy, 87
Nail color changes
green nails, 6
leukonychia, 5
longitudinal melanonychia, 5, 6
Yellow nail syndrome, 7
Nail lichen planus, 9
Nail matrix nevi, 13
Nail plate changes
Beau’s lines, 1
onychomadesis, 1
onychorrhexis, 2
trachyonychia, 3
Nail psoriasis, 9
Nail shape and size changes
anonychia, 3
clubbing, 4
koilonychia, 3
pincer nails, 4
R
Retronychia, 9
S
Scabies, 26
Scale, 29
Scars, 46
Seborrheic keratoses, 56
Sertaconazole, 20
Shave biopsy, 83
Sickle cell ulcer, 79
Skin of color, 43, 45
Sprays, 89
Squamous cell carcinoma (SCC), 59
Staphylococcus aureus, 21
Stasis dermatitis, 40, 41
Stucco keratoses, 57
Subungual exostosis, 13
Subungual hematoma, 8
Subungual melanoma, 14
Index
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95
Subungual squamous cell carcinoma (SCC), 13
Supercial fungal infections
dermatophytes, 17
interdigital tinea pedis, 18
laboratory tests, 20
majocchi’s granuloma, 19
moccasin tinea pedis, 18
molds, 17
tinea incognito, 19
treatment, 20
vesiculobullous tinea
pedis, 18
yeast, 17
Systemic lupus
erythematosus, 50
Systemic sclerosis, 50
T
Tanorexia, 67
Tapes, 89
Tinea incognito, 18
Tinea nigra, 19
Tinea pedis, 17
Topical corticosteroid, 90
Topical nail therapies, 91
Trachyonychia, 2
Trans-epidermal water loss (TEWL), 32
Trichophyton rubrum, 17
U
Ulcers
arterial, 77
calciphylaxis, 80
diabetic, 78
diagnosis, 77
pressure, 80
pyoderma gangrenosum, 79
sickle cell ulcer, 79
venous, 78
V
Venous stasis ulcer, 78
Venous ulcers, 78
Vesiculobullous tinea pedis, 18
Vitiligo, 44, 45, 51
X
Xerosis, 29
Y
Yellow nail syndrome, 6
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