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ลักษณะโครงสร้างของเล็บ
   Nail Anatomy

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 ความผิดปกติของเล็บจากยิสต์และแบคทีเรีย  Bacteria & Yeast      

Bacteria and yeast can infect the skin structures around the nail and cause a  variety 
of acute and chronic infections. Infection of the lateral or proximal nail folds is called paronychia. Acute paronychia is usually caused by Staphylococcus aureus. Chronic paronychia is caused by many different bacteria and yeasts such as candida.

Pseudomonas is a bacteria that thrives in a warm moist environment. It grows if a
space is created between the under surface of the nail plate and the nail bed. The bacteria makes a green pigment and stains the nail plate.

The buttons on the left lead to descriptions of these diseases.

 

 

Chronic paronychia evolves slowly and presents initially with tenderness and 
mild swelling about the proximal and lateral nailfolds. Individuals whose hands are repeatedly exposed to moisture (e.g., bakers, dishwashers, and dentists) are at greatest risk. Manipulation of the cuticle accelerates the process. Typically, many or all fingers are involved simultaneously. The cuticle separates from the nail plate, leaving the space between the proximal nailfold and the nail plate exposed to infection.

Many organisms, both pathogens and contaminants, thrive in this warm, moist intertriginous space. The skin about the nail becomes pale red, tender or painful, 
and swollen. Occasionally a small quantity of pus can be expressed from under the proximal nailfold.

A culture of this material may grow Candida or gram-positive and gram-negative organisms. The nail plate is not infected and maintains its integrity, although its surface becomes brown and rippled. There is no subungual thickening such as that present in some fungal infections. The process is chronic and responds very slowly to treatment. Psoriasis of the fingers may present in a similar form.

Treatment

Every attempt must be made to keep the hands dry. One should avoid using medicines with an ointment base, because they are too occlusive and interfere with the necessary drying process. Patients should refrain from washing dishes and from washing their own hair. Rubber or plastic gloves are of some value, but moisture accumulates in them with prolonged use.

Oral antibiotics do not penetrate this distal site in sufficient concentration. Furthermore, the variety of organisms is too numerous to respond to a single oral agent. The most effective treatment is to place one or two drops of 3% thymol in 70% ethanol, which must be compounded by a pharmacist, at the proximal nailfold and to wait for this liquid to flow by capillary action into the space created by the absent cuticle. Slight elevation of the proximal nailfold with a flat toothpick facilitates penetration. This should be repeated two or three times a day for weeks, until the cuticle is re-formed. The cuticle may never re-form in patients with long-standing inflammation.

 Fluconazole (150 mg/day) for 1 to 4 weeks may control chronic inflammation.  Short courses of fluconazole may have to be repeated as the infection recurs.

 

 

 

Acute paronychia
The rapid onset of painful, bright red swelling of the proximal and lateral nailfold may occur spontaneously or may follow trauma or manipulation. Superficial infections present with an accumulation of purulent material behind the cuticle. Staphylococcus is the most common organism but contamination by other bacteria and yeast is possible.

Treatment

The small abscess is drained by inserting the pointed end of a comedone extractor or similar instrument between the proximal nailfold and the nail plate. Pain is abruptly relieved. A diffuse, painful swelling suggests deeper infection, and cases that do not respond to antistaphylococcal antibiotics may require deep incision. Acute paronychia rarely evolves into chronic paronychia

 

 

 

Pseudomonas
Repeated exposure to soap and water causes maceration of the hyponychium and softening of the nail plate. Separation of the nail plate (onycholysis) exposes a damp, macerated space between the nail plate and the nail bed, which is a fertile site for the growth of Pseudomonas.

The nail plate assumes a green-black color. There is little discomfort or inflammation. This presentation may be confused with subungual hematoma, but the absence of pain with Pseudomonas infection establishes the diagnosis. Applying a few drops of a one part chlorine bleach/four parts water mixture under the nail three times a day controls the infection.



 

 

 

 

 

 

 ความผิดปกติของเล็บจากการถูกกระแทก Trauma      
Trauma to the nail unit can produce a variety of changes to the nail plate, nail bed and skin surrounding the nail. These changes may be easily confused with other nail diseases. Some of the most common changes can be seen by pushing the buttons on the left

Onycholysis

Onycholysis, the painless separation of the nail from the nail bed, is common. Separation usually begins at the distal groove and progresses irregularly and proximally, causing part or most of the plate to become separated (Figure 25-20). The nonadherent portion of the nail is opaque with a white, yellow, or green tinge. The causes of onycholysis include psoriasis, trauma, Candida or Pseudomonas infections, internal drugs,24 PUVA photochemotherapy,25 contact with chemicals, maceration from prolonged immersion, and allergic contact dermatitis (e.g., to nail hardener).26,27

When other signs of skin disease are absent, onycholysis is most frequently seen in women with long fingernails. With normal activity, the extended nail inadvertently strikes objects and acts as a lever to pry the nail from the nail bed. Forcing a stylus between the nail plate and bed while manicuring can cause separation. Photoonycholysis may occur with the use of tetracycline antibiotics.

Treatment

All of the separated nail is removed, and the fingers are kept dry. Removing the separated nail eliminates the lever, and dryness discourages infection. One should not cover the cut nails; occlusion promotes maceration. Any form of manipulation should be discouraged.

 

 

 

HangNail
Splitting or peeling of the skin around the nail  is called a hangnail. It occurs in predisposed people especially during the cold, dry winter months. It is often resistant to treatment and causes chronic pain.

Treatment

Avoid frequent hand washing and exposure  to activites that involve frequent contact with water. Heavy moisturizers such as Aquaphore ointment are soothing and promote healing.

 

 

 

Subungual hematoma

Anatomy of the nail bed
The nail bed consists of parallel longitudinal ridges with small blood vessels at their base. Bleeding induced by trauma or vessel disease, such as lupus, occurs in the depths of these grooves, producing the splinter hemorrhage pattern viewed through the nail plate and illustrated in the pictures above.

Subungual hematoma

Subungual hematoma may be caused by trauma to the nail plate, which causes immediate bleeding and pain. The quantity of blood may be sufficient to cause separation and loss of the nail plate. The traditional method of puncturing the nail with a red-hot paperclip tip remains the quickest and most effective method of draining the blood. Trauma to the proximal nailfold causes hemorrhage that may not be apparent for days. The nail plate may emerge from the nailfold with blood stains that remain until the nail grows out.

 

 

White spots or bands

White spots (leukonychia punctata) in the nail plate, a very common finding, possibly result from cuticle manipulation or other mild forms of trauma. The spots or bands may appear at the lunula or may appear spontaneously in the nail plate and subsequently disappear or grow with the nail.

 

 

Habit-tic deformity
Habit-tic deformity is a common finding and is caused by biting or picking a section of the proximal nailfold of the thumb with the index fingernail. The resulting defect consists of a longitudinal band of horizontal grooves that often have a yellow discoloration. The band extends from the proximal nailfold to the tip of the nail.This should not be confused with the nail rippling that occurs with chronic paronychia or chronic eczematous inflammation of the proximal nailfold. The ripples of chronic inflammation appear as rounded waves,in contrast to the closely spaced, sharp grooves produced by continual manipulation.

The method of formation is demonstrated for the patient. Some patients are not aware of their habit, and others who admit to nail picking may not realize that they have created the defect. Patients who discontinue manipulation are able to grow relatively normal nails; there are those, however, who find it impossible to stop.





 

 

 

 

 

  ความผิดปกติของเล็บจากโรคสะเก็ดเงิน Psoriasis  

Psoriasis of the nails

Nail involvement  occurs simultaneously with skin disease but may occur as an isolated finding and be confused with several other disease. Psoriasis of the nails is often misdiagnosed as a fungal infection.

The incidence of nail involvement in psoriasis varies from 10% to 50%.  There are several characteristic changes that occur. One or all of these changes may be present . Pitting, onycholysis (nail plate separation, discoloration, subungual thickening, and nail-plate alterations take place.

Pitting

Pitting, or sharply defined ice picklike depressions in the nail plate, is the most common finding. The number, distribution, pattern, and depth vary. Pitting is observed in normal nails and with alopecia areata, but, in general, psoriatic pits are deeper. Pits form as the nail substance is shed, which is a process analogous to the shedding of psoriatic skin scale.

   


Onycholysis, subungual debris, nail plate distortion

Onycholysis
Separation of the nail from the nail bed, or onycholysis, is common. Onycholysis is frequently accompanied by yellow discoloration. Separation begins at the distal groove or under the nail plate and may involve several nails.

Onycholysis occurs as an isolated finding in women with long fingernails. Minor trauma causes the separation. Yeast often grows in the space between the nail plate and nail bed

Subungual debris and plate distortion

Psoriasis of the hyponychium results in the accumulation of yellow, scaly debris that elevates the nail plate. The debris is commonly mistaken for nail fungus infection. Severe psoriasis of the matrix and nail bed results in grossly malformed nails, and nail-bed splinter hemorrhages are common .

 


Nail plate surface distortions
Psoriasis of the nail matrix  results in many different patterns of distortion. Isolated inflammatory lesions of the proximal matrix cause pits. Diffuse inflammation of the anterior matrix causes the pattern illustrated here. The entire surface is rough and distorted. Patients with this isolated finding think that they just have ruff nail and are unaware of the etiology. A careful search for subtle signs of psoriasis in other body areas (e.g. scalp scale, gluteal pinking)  is indicated.

 

 

 

Oil spot lesions
Oil spot lesions are caused by separation of the nail from the nail bed. Serum and  cellular debris accumulate and become trapped in this space. The yellow color is highly characteristic. This nail also has a few pits on the surface.





 

 


 






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