TELEDERMATOLOGY READER REPORT1
History
Chief complaint: presenting for diagnosis of a lesion.
History of present illness: A 33-year-old man presents with "changing surface of the right thumbnail" that has worsened over the last year, since his wife died. Prior treatment: none. His primary symptom: roughness. Prior biopsy: none. He has no personal or family history of skin cancer or melanoma. Other significant laboratory/study findings: none.
Image Quality Assessment
Fully satisfactory.
TELEDERMATOLOGY IMAGING READER REPORT
One image was provided of a right thumbnail that shows a central, longitudinal depression traversed by multiple horizontal depressions (Beau's lines). The central cuticle is mildly hyperpigmented, and the skin of the proximal nail fold is thickened. Although poorly visualized, the image is suggestive of another depression in the distal second nail.
INTERPRETATION OF IMAGES
Lesion A
Findings
The presented lesion and history are most consistent with the diagnosis of habit-tic deformity (Figure 1).
RECOMMENDATIONS
Skin Care and Treatment Recommendations
We recommend reassurance of the benign nature of this lesion to the patient. Treatment involves helping the patient determine a preferred method of avoiding self-trauma to the nail fold, which may combine mechanical and psychobehavioral components. The mechanical process of self-trauma may be impeded by regular application of tape, bandages, or cyanoacrylate adhesive (instant glue) over the proximal nail fold (Ring, 2010). Cognitive behavioral therapy may address underlying nervousness, including possible underlying anxiety disorders (such as obsessive-compulsive disorder). In refractory cases, selective serotonin reuptake inhibitors may be considered (Perrin & Lam, 2014).
RECOMMENDED FOLLOW-UP
Type of Visit
Return to primary provider for reassurance and to discuss treatment options.
CLINICAL PEARL
The pathogenesis is repeated self-trauma to the central nail fold, usually via manipulation with other fingernails. Examination often reveals an absent cuticle. Habit-tic deformity should be easily distinguished from a fungal infection by the lack of nail thickening, subungual debris, or onycholysis. A more rare diagnosis to consider is median canaliform dystrophy, which may be a subset of habit-tic deformity. Although they present similarly, median canaliform dystrophy usually has a normal-appearing cuticle and classically exhibits a fir-tree-like shape of ridges (rather than parallel transverse) within a central, longitudinal depression (Tosti & Piraccini, 2012).
REFERENCES