Case Report
Open Access
Retronychia Treated with Proximal Nail Avulsion; two
Cases Successfully Treated with this Technique and the
First cases of Retronychia Occurring After Chemical
Matricectomy
Michelle Gatica-Torres and Judith Dominguez-Cherit*
Department of Dermatology, Instituto Nacional de Ciencias Medicas y Nutricion "Salvador Zubiran", Mexico City, Mexico
*Corresponding author: Judith Dominguez-Cherit, Department of Dermatology, Instituto Nacional de Ciencias Medicas y Nutricion "Salvador Zubiran",
Mexico City, Mexico. Vasco de Quiroga 15 Col. Sección XVI, Tlalpan, Mexico City, 14000. Tel: +52 55 5487 0900; E-mail:
@
Received: December 19, 2015; Accepted: December 25, 2015; Published: December 30, 2015
Citation: Gatica-Torres M, Domínguez-Cherit J (2015) Retronychia Treated with Proximal Nail Avulsion; two Cases Successfully
Treated with this Technique and the First cases of Retronychia Occurring After Chemical Matricectomy. Clin Res Dermatol Open
Access 2(3): 1-3. http://dx.doi.org/10.15226/2378-1726/2/3/00123
Introduction
Retronychia refers to a proximal in growth of the nail causing
persistent proximal nail fold paronychia. Previously reported
cases have treated this condition with total nail avulsion with
satisfactory outcomes [1].
We describe three cases of retronychia; a chronic case where total nail avulsion had to be performed since the inflammation persisted after proximal nail avulsion and the first two cases of retronychia on an early clinical stage successfully treated with partial nail avulsion. We also describe the first two cases of retronychia appearing after a chemical matricectomy, occurring on the same patient.
We describe three cases of retronychia; a chronic case where total nail avulsion had to be performed since the inflammation persisted after proximal nail avulsion and the first two cases of retronychia on an early clinical stage successfully treated with partial nail avulsion. We also describe the first two cases of retronychia appearing after a chemical matricectomy, occurring on the same patient.
Case 1
A 15-year-old male patient presented with deformity of the
distal interphalangeal joint of the second finger of the left hand
with a lateral depressible bulging on the joint area. He had
suffered an ulnar fracture 2 months before. The nail exhibited
distal onycholysis, a prominent white lunula, paronychia of the
proximal nail fold and a deep pink transverse line over the lunula,
similar to the onychodermal band (Figure 1). This caused pain
and decreased manual dexterity. Retronychia on an early clinical
stage was diagnosed and surgery was performed. Under digital
block anesthesia and tourniquet placement, the proximal portion
of the nail plate was resected, revealing a thick and doublelayered
proximal nail. The procedure led to resolution of pain
and subsequent nail growth was normal.
Case 2
An 18-year-old man suffered a stump on his left toe,
subsequently having periungual inflammation and excruciating
pain. He consulted a podiatry that performed a unilateral phenol
matricectomy that didn't improve the patient's symptoms. He then developed granulation tissue on the proximal nailfold,
paronychia and worsening pain (Figure 2). 3 months later,
curettage of nail fold granulation tissue and avulsion of the
proximal portion of the nail plate was done under local anesthesia,
leaving the distal portion of the plate on its place. The patient was
reassessed a week later without showing great improvement so
we proceeded to perform avulsion of the remaining plate. After 3
days the patient had no pain and 9 months later he had a normal
growing nail (Figure 3). After two years, the patient developed
onychocriptosis, affecting the lateral nail fold of the contralateral
toe, which was treated with partial phenolization of the nail
matrix. After four weeks, the patient developed inflammation on
the proximal nail fold with protruding granulation tissue (Figure
4). We successfully performed a partial proximal nail avulsion,
encountering a double-layered nail plate (Figure 5). The patient
responded excellently to this procedure.
Figure 1: Early retronychia exhibiting deformity of the distal interphalangeal
joint, distal onycholysis, a prominent white lunula, paronychia
of the proximal nail fold and a deep pink transverse line over the lunula.
Figure 2: Late stage retronychia with granulation tissue on the proximal
nailfold and marked paronychia.
Figure 3: Nine months after the total avulsion the nail had a normal
growth with some yellow discoloration and mild pachyonychia..
Discussion
Onychocryptosis or unguius incarnatus is an inflammatory
condition where the nail plate or a spicule grows towards the
periungual tissue, typically the lateral nail fold. It’s most commonly
seen with a bad nail trimming technique in adolescents. Proximal
in growth of the nail is less common and although not many cases
and series have been published, it´s not as uncommon as it seems
[2]. De Berker et al first described 3 cases of proximal in growing
nails and gave this condition the name of retronychia in 1999.
According to the first description of this pattern of nail in growth,
published by the same author a few years later, patients with
retronychia manifest two cardinal features: proximal paronychia
and elevation of the proximal nail plate [1]. Other common
clinical features include, thickening of the proximal portion of
the nail plate, a proximal plate with multiple layers, yellow nails, granulation tissue arising from the traumatized proximal nail fold
and distal onycholysis [3, 4]. Toes are affected the vast majority
of the time and hands are infrequently affected [1].
Figure 4: Retronychia exhibiting inflammation of the proximal nail fold
with granulation tissue.
Figure 5: Proximal avulsion of the nail plate with a thick and doublelayered
plate.
Little is known about the exact mechanism by which
retronychia is caused. Trauma; as in Case 2, and a systemic
insult; as in Case 1, have both been implicated in the pathologic
mechanism of retronychia. Distal recurrent trauma, commonly
from footwear, detaches the plate from its bed and from the
matrix, causing disruption of the longitudinal growth of the
nail [3]. As the new nail grows it pushes the old plate upwards
and backwards. Baumgartner and Haneke [4] described 5 cases
where distal onycholysis was a common denominator allowing
the nail to have back-and-forth and tilting movements which
magnifies the trauma to the proximal nail fold. One of our cases
had distal onycholysis, while in the other case the distal plate
remained firmly attached to the nail bed, as the cases described by
de Berker [1]. To our knowledge, the development of retronychia
after a matricectomy hasn’t been reported previously.
The diagnosis of retronychia is made by the clinical findings described above. This condition is frequently misdiagnosed as infectious paronychia [4]. Since quality of life is diminished by this condition because of pain, dermatologist should be able to diagnose retronychia in early stages in order to provide patients an appropriate treatment.
Differential diagnosis of this condition should include soft tissue infections, inflammatory conditions with periungual involvement such as psoriasis and nail tumors, for instance, squamous cell carcinoma, melanoma or metastases from malignant tumors, particularly if this is associated to nail dystrophy and onychomadesis.
Nail avulsion is nowadays the first-line treatment, since it is inexpensive, fast and easy to perform with excellent results [6]. Partial nail avulsion should be considered in order to have a faster recovery period. If an underlying nail is found during avulsion, viability of the nail should be carefully assessed. Any signs of non-viability should encourage the surgeon to remove it [5]. Superimposed infection should be managed with topical or systemic antibiotics, according to its severity.
The diagnosis of retronychia is made by the clinical findings described above. This condition is frequently misdiagnosed as infectious paronychia [4]. Since quality of life is diminished by this condition because of pain, dermatologist should be able to diagnose retronychia in early stages in order to provide patients an appropriate treatment.
Differential diagnosis of this condition should include soft tissue infections, inflammatory conditions with periungual involvement such as psoriasis and nail tumors, for instance, squamous cell carcinoma, melanoma or metastases from malignant tumors, particularly if this is associated to nail dystrophy and onychomadesis.
Nail avulsion is nowadays the first-line treatment, since it is inexpensive, fast and easy to perform with excellent results [6]. Partial nail avulsion should be considered in order to have a faster recovery period. If an underlying nail is found during avulsion, viability of the nail should be carefully assessed. Any signs of non-viability should encourage the surgeon to remove it [5]. Superimposed infection should be managed with topical or systemic antibiotics, according to its severity.
Conclusion
Chronic proximal paronychia and elevation of the proximal
nail plate should raise suspicion of retronychia [7]. Patients
usually have history of trauma or a systemic acute insult that
abruptly stop the nail growth. The new nail then pushes the old
plate upwards and backwards, leading to trauma of the proximal
nail fold [5].Nail avulsion improves the patient’s symptoms and
is usually curative. When retronychia is diagnosed on an early
stage, the avulsion could be conservative, keeping the distal
portion of the plate. The prognosis of these patients is favorable
if surgical treatment is performed.
- De Berker DA, Richert B, Duhard E, Piraccini BM, André J, Baran R. Retronychia: proximal ingrowing of the nail plate. J Am Acad Dermatol. 2008;58(6):978–983. doi: 10.1016/j.jaad.2008.01.013.
- Piraccini BM, Richert B, de Berker DA, Tengattini V, Sgubbi P, Patrizi A, et al. Retronychia in children, adolescents, and young adults: a case series. J Am Acad Dermatol. 2014;70(2):388-390. doi: 10.1016/j. jaad.2013.09.029.
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- Baumgartner M, Haneke E. Retronychia: diagnosis and treatment. Dermatol Surg. 2010;36(10):1610–1614. doi:10.1111/j.1524- 4725.2010.01693.x.
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- Cabete J, Lencastre A. Recognizing and treating retronychia. Int J Dermatol. 2015;54(1):e51-52.doi: 10.1111/ijd.12635.
- Zaraa I, Kort R, Mokni M, Ben Osman A. Retronychia: a rare cause of chronic paronychia. Dermatol Online J. 2012;18(6):9.