Successful Treatment of Traumatic Onychodystrophy and Associated Pterygium Unguis With Fractionated Carbon Dioxide Laser: Case Report and Review of the Literature

November 2016 | Volume 15 | Issue 11 | Case Report | 1461 | Copyright © 2016

Derek Ho BS,a,b Andrew Mamalis MD MS,a,b and Jared Jagdeo MD MSa,b,c

aDermatology Service, Sacramento VA Medical Center, Mather, CA bDepartment of Dermatology, University of California Davis, Sacramento, CA cDepartment of Dermatology, State University of New York Downstate Medical Center, Brooklyn, NY

Abstract

Onychodystrophy is a common, chronic malformation of the nail that is aesthetically displeasing and can signi cantly impact patient quality-of-life. Onychodystrophy can be associated with pterygium unguis that contributes to pain and appears as a V-shaped exten- sion of the proximal nail fold skin. Treatment options are limited, and topical or intralesional corticosteroids have minimal ef cacy and cause signi cant patient discomfort. Surgical revision of onychodystrophy is complex, and symptomatic or aesthetic improvements are difficult to achieve. There is limited published literature on laser treatment of noninfectious onychodystrophy or associated pterygium unguis. We present a case of a 68-year-old man with a 10-year history of painful traumatic onychodystrophy with associated pterygium unguis, who was successfully treated after three treatments of fractionated carbon dioxide (CO2) laser. Additionally, we review the medical literature on laser treatment of noninfectious onychodystrophy and pterygium unguis. To our knowledge, this is the first reported successful treatment of painful traumatic onychodystrophy and associated pterygium unguis using fractionated CO2 laser. We hope clinicians consider this treatment modality to relieve pain and improve aesthetics associated with traumatic onychodystrophy and associated pterygium unguis. We envision additional research investigating the mechanism of action of fractionated CO2 laser may con rm this treatment option for the management of traumatic onychodystrophy and associated pterygium unguis. J Drugs Dermatol. 2016;15(11):1461-1464.

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INTRODUCTION

Onychodystrophy is a common, chronic malformation of the nail characterized by abnormalities of the nail plate, color, or texture.1 Onychodystrophy is aesthetically displeasing and can significantly impact patient quality-of-life. The etiology of onychodystrophy may be secondary to infectious diseases (most commonly onychomycosis), inflammatory diseases, trauma, or idiopathic causes. Onychodystrophy can be associated with pterygium unguis that contributes to pain and appears as a V-shaped extension of the proximal nail fold skin and adheres to the nail bed. Pterygium unguis results from scarring between the proximal nail fold and matrix.2,3 While treatment of infectious onychodystrophy involves antifungal agents, treatment of noninfectious etiologies, such as traumatic onychodystrophy, or associated pterygium unguis is challenging.1 Treatment options are limited, and topical or intralesional corticosteroids have minimal ef cacy and cause significant patient discomfort. Surgical revision of onychodystrophy is complex, and symptomatic or aesthetic improvements are dif cult to achieve.4 Furthermore, associated pterygium unguis is often refractory to both topical and systemic therapies making it dif cult to treat. There is limited published literature on laser treatment of noninfectious onychodystrophy or associated pterygium unguis.We present a case of a 68-year-old man with a 10-year history of painful traumatic onychodystrophy with associated pterygium unguis, who was successfully treated after three treatments of fractionated carbon dioxide (CO2) laser. Additionally, we review the medical literature on laser treatment of noninfectious ony- chodystrophy and pterygium unguis.

CASE REPORT

Our patient presented to clinic for pain and poor aesthetic appearance of onychodystrophy with associated pterygium unguis of the right hand third digit (Figure 1A).The patient reported nail changes began 10 years prior following direct trauma to the nail, and since then the dystrophic nail was painful and often snagged clothing and fabric. On physical examination, there was splitting of the nail and a midline pterygium extending from the proximal fold to the distal edge and contributing to a raised longitudinal ridge where the patient’s pain was localized. Histologic evaluation of the nail demonstrated changes consistent with traumatic onychitis and Periodic acid–Schiff (PAS) stain was negative for fungal organisms. Prior to seeking medical treatment, the patient tried keeping the nail well trimmed but reported minimal pain relief. The patient underwent three treatments with DEKA SmartXide DOT HP

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