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DR.YUGANDAR
NAIL BIOPSY
Nail Biopsy
Two Primary reasons to perform biopsy- Confirm diagnosis of disease- Remove neoplasm or correct deformity (d/t
pain )
Nail Biopsy
Site : Proximal to Distal Growth of nail ,Matrix biopsies performed with long axis of biopsy in transverse direction to avoid scar,It Causes a split in nail
Nail Biopsy
Indications:
- Differentiate b/w inflammatory & infective
disorders affecting nail unit
- To establish diagnosis of one or 20- nail
dystrophy
Nail Biopsy
- To establish cause of longitudinal pigmented
streaks
- Differentiate Subungual hematoma &
Malignat melanoma
Nail Biopsy
Indications:
- Differentiate benign & malignant tumours
- To identify the cause of pain ( eg Glomus
tumour )
Contraindications:
- Severe uncontrolled diabete
- Severe Peripheral vascular diseases
Nail Biopsy
Biopsies of nail :- Nail Plate- Nail bed- Nail Matrix- Nail fold- Nail unit Biopsy ( Combined Biopsy of
LNF,Lateral Nail Matrix & PNF )
Different types of nail biopsy
Site & technique of nail biopsy for common nail disorders
Site & technique of nail biopsy for common nail disorders
All biopsy or excision should be taken down to bone ( No subcutaneous tissue in nail)
Relationship of nail matrix & surface
Proximal part of nail matrix forms dorsal surface, distal portion of matrix forms ventral portion
Surgery to distal matrix is preferable to proximal matrix
Nail Biopsy
Patient Evaluation Prior to Nail Biopsy:
History:
- Medical H/O- DM,CTD,BD,PVD,HTN
- Drug H/O- Use of
Anticoagulants,Salicylates,NSAIDs,Prev
ious diagnostic tests,
Nail Biopsy
- Cutaneous H/O-
H/O Nail Condition
(Duration,Progression,Exposure,Trauma)
Previous Malignancies,Fungal,Bacterial
infections,Psoriasis,Lichen planus
Occupation,Hobbies
Nail Biopsy
Examination:
- All 20 nails,good lighting & magnification
- Mucous membranes,hair & Scalp
- Perpheral pulses
Nail Biopsy
Laboratory tests:
- X-ray,Mycology,Microbiology
Nail Biopsy
Patient Evaluation Prior to Nail Biopsy:
Procedure & Risk discussion:-Possibility of permanent dystrophy- Possibility of no diagnosis-Length of time for nail to regrow-Bleeding,Pain,Infection
Nail Biopsy
Reaons : Why Matrix shoudn’t be
damaged in nail biopsy
- Nail thickness is directly related to
length or size of nail matrix
- The matrix is centre of nail formation &
the source of nail plate
- Nail growth is a direct function of rate
of turnover of matrix cells
Principles Guiding Nail Biopsy
When information obtained from other
sites like skin biopsy,avoid biopsy of
nail matrix
Avoid transecting nail matrix to prevent
split nail deformity
Suture defects in nail bed possible
Perform distal rather than proximal
nail matrix biopsy
Retain distal curvature of nail
Nail Biopsy
Instruments:
- Nail Eleavators,Freer Eleavators
- Pointed scissors,Curved iris scissors
- 30 gauge needles,Luer lok syringe
- Double-action nail splitter
- Single or double skin hooks
Nail Biopsy
- Penrose drains
- English nail splitter,clippers
- Disposable biopsy punches
Nail Biopsy Instruments
Double action nail nipper & Freer Eleavator on left side of tray
Fine Curved ( Castro Veijo’s ) scissors,Fine Curved ( Jewellers ) forceps,Nail spatula ,Nail splitter & Disposable Biopsy Punches
Freer Eleavator – Proximal nail Plate avulsion
English Nail splitter used to divide nail plate prior nail avulsion
Nail Biopsy Instruments
Nail Biopsy
Anesthesia:
Local anesthetic administered with via 30
gauge needle on Luer-Lok syringe
Anesthetics used :
- 2% lidocaine,
- Ropivacaine ,Bupivacaine used for regional
blocks
Nail Biopsy
Lidocaine with adreanaline combination for digital anesthesia still controversy
Nail Biopsy
Digital Anesthesia:
Distal nail blocks
1. Distal digital block
2. Distal anesthesia through PNF
3. Distal anesthesia through hyponychium
Nail Biopsy
Proximal digital blocks
Transthecal digital blocks
Regional blocks
Nail Biopsy
Most common form of anesthesia is Ring
Block ( Digital nerve block )
Injecting 1-2 ml at base of each digit on
dorsolateral aspect
> 5 ml anesthetic impair Circulation of digits
Nail Biopsy
After 10 mins injection,efficacy of block can be
assessed at digit tip with help of same needle
If anesthesia is incomplete,It can be
supplemented by small local injection of
anesthetic at site of biopsy or surgery ( it may
increase tissue turgor,fine manipulation
difficult )
Nail Biopsy
Different Digital sites of injection for Ring block
Site of Lidocaine injections for wing & digital block
Nail Biopsy
Distal Digital Block:
- Needle inserted 2-3mm proximal to junction
of PNF & LNF
- After raising skin to minimize pain,needle
inserted vertically down toward ventral
aspect
- While doing so 0.5 – 1 ml anesthetic agent
injected to cover dorsal & ventral digital
nerves
Advantages Disadvantages
Immediate effect < 1 min
Low risk of neurovascular compromise
Induces compression hemostasis
Local injectionRelatively painfulMay cause
inadequate coverage & swelling of surgical field in large surgeries
Nail Biopsy Distal Digital Block
Distal Digital Block
Median Distal Block
Nail Biopsy
Proximal Digital block:
- Needle is introduced at base of digit & wheal
raised
- Needle pushed in ventral direction injecting
anesthetic agent at dorsal & ventral digital
nerves
- 1 ml for each nerve of thumb,2ml for toe
- It takes 10-15 mins for full effect
Dorsal View Ventral View
Proximal Digital block
Nail Biopsy - Drapping
-With sterile glove on involved hand
- Tip of glove is cut off, finger that is
undergoing surgery
- Remaining open finger of glove then rolled
back down digit,Provides tourniquet when
reaches proximal part of finger
- Toe nail surgery foot is draped with
sterile towels secured by towel clamps
Tourniquet
Sterile Glove used as Tourniquet
Tourniquet
Ischaemia can be tolerated in a normal digit
for 20 min
The standard tourniquet for local anaesthetic
is the Penrose drain
An alternative is Sterile glove
Penrose drain Sterile glove with artery forceps
Tourniquet
Patterns of Nail Biopsy
Nail Avulsion
Nail bed biopsy
Matrix biopsy
1. Lateral Longitudinal nail biopsy
2. Transverse matrix biopsy
3.Matrix shave
Patterns of Nail Biopsy
Nail fold biopsy 1. Proximal Nail fold Biopsy 2. Transverse Nail fold biopsy 3. Crescentric Nail fold biopsy 4. Focal Nail fold biopsy
Nail Avulsion
Examine underlying tissues or to provide temporary relief in cases of soft-tissue trauma
Distal or ring block,Nail elevator are used,For a partial avulsion nail splitters are needed
Proximal hemiavulsion of nail plate Procedure:
1. The origin of the nail and its proximal lateral
aspects are undermined with a septum elevator.
2. In nails with a shallow lateral nail fold, a nail
splitter may be inserted and the nail transversely
bisected.
3. In nails with a deep lateral nail fold, a deep
transverse score is placed with a scalpel across
the nail halfway along its length.
4. The septum elevator is then fully inserted
through the transverse score to loosen,elevate
proximal nail.
Nail Avulsion
After Partial Nail Avulsion Nail bed can be seen & biopsed along longitudinal access
Nail Avulsion
Freer Eleavator inserted under nail plate
Loosened nail plate is grabed with hemostat & removed
Nail Avulsion
Digital block has been performed
Nail Avulsion
Apply rubber band
Nail Avulsion
Release eponychium and lateral side
Nail Avulsion
Cut complete nail (proceed under the cuticle), when the proximal edge is cut a 'give' can be felt
Nail Avulsion
Grasp as much nailplate into needledriver or hemostat
Nail Avulsion
Continue cutting undernath cuticle
Nail Avulsion
Remove nailplate by gentle traction and rotating outward
Distal Nail Avulsion Proximal Nail Avulsion
Nail Avulsion
Nail Biopsy
Nail Plate Biopsy:- It is performed using nail nipper for distal
part & 3- 4mm atleast - Nail plate may get suck in the punch- look
& remove it- Differentiate b/w onychomycosis and
psoriasis- Wounds no scarring
Removal of Nail Plate
Nail Biopsy
Nail Bed Biopsy:- Partial Nail plate avulsion is performed with
a 4mm punch or nail plate lifting- 3mm punch is used to take sample from nail
bed- Punch is moved deep,till it touches
periosteum,Base is separated by iris scissors
- Larger samples: Elliptical excision with a maximum width of 3mm taken with long axis of incision along long axis of nail
Nail Bed Biopsy
An alternative is to employ a double punch technique
6-mm hole can be made in the nail plate with a biopsy punch over the area of nail bed to be examined, and the nail bed sampled using a smaller punch.
Closure is not possible. After complete haemostasis, the original disc of nail plate can be returned after soaking in antiseptic
Nail Bed Biopsy
It may reattach or at least provide a natural dressing during the early healing phase.
No Scarring from biopsy
Nail Bed Biopsy
Suspected nail bed glomus tumour
Nail Bed Biopsy
Subungual glomus tumour seen as a bluish mass after nail plate avulsion
Nail Bed Biopsy
Excision of tumour done
Nail bed incisons are oriented longitudinally
Nail Bed Biopsy
> 3 mm size needs to be sutured
Punch Biopsy Fusiform Biopsy
Nail Bed Biopsy
Nail Bed Biopsy
After digital block with NPA or without NPA
3 mm Punch Biopsy obtained by passing vertially down until periosteum
Specimen is free with iris scissors
Nail Bed Biopsy- Double Punch Technique
After digital block 5-6 mm Punch is used to remove nail plate
3 mm punch used to obtain specimen in centre of previously created window
Nail Biopsy
Nail Matrix Biopsy:- Proximal Nail avulsion has to be performed
to visualize the matrix- The matrix sample is taken using a 3mm
punch or Longitudinal elliptical sample oriented horizontially to long axis of digit
Nail Matrix Biopsy
Nail Matrix Biopsy
After nail plate avulsion,releasing incisions in the PNF
The PNF is retracted with skin hooks to visualize of nail matrix
The PNF is replaced & sutured with steri strips
Nail Matrix Biopsy
Lateral incisions made at jn of PNF & LNF
PNF is lifted up & retracted with stay sutures
Adequate sized punch driven down up to periosteum
Punch biopsy specimen lifted up
Lateral Longitudinal Nail biopsy
It is definitive method for sampling all the tissues
of the nail unit
Incision starts in the lateral nail sulcus b/w the
nail & nail fold.distally upto distal
groove,Proximally the incision upto the first of the
transverse skin markings of the distal
interphalangeal joint
Medial margin of the ellipse is formed by an
incision
through the nail plate, which has been softened
by an antiseptic soak
Lateral Longitudinal Nail biopsy
Both incisions are down to bone and
separated by 3 mm at the widest point. The
specimen is separated from its attachment
from the distal point proximally
The nail can be lifted at the free edge with
forceps, allowing the bottom of the
specimen to be released with curved iris
scissors
A 3/0 or 4/0 monofi lament for suture
Lateral Longitudinal Nail biopsy
A Large Lateral Longitudinal biopsy is closed with sutures designed to reconstruct lateral nail fold
Lateral Longitudinal Nail biopsy
Area to be excised outlined,The incision is linear medially & curved laterally
Lateral Longitudinal Nail biopsy
The incision is carried down to periosteum & tissue is lifted up with sharp scissors
Lateral Longitudinal Nail biopsyThe separated specimen forhistopathologic examination
Lateral Longitudinal Nail biopsyThe defect is sutured back
Lateral Longitudinal Nail biopsy
Lateral portions of nail unit excised enbloc
Includes Hyponychium,nail plate,nail matrix,nail bed & PNF
Transverse Matrix biopsy
The PNF is refl ected following an oblique
incision at the junction with the LNFs &
gentle separation of the PNF from the
dorsal aspect of the nail plate
The matrix is then visualized by performing
a proximal hemi-avulsion
Transverse Matrix biopsy
A thin ellipse is taken from the distal matrix
with the distal margin of the excision
matching the shape of the lunula
Transverse Matrix biopsy
Crescentic or narrow elliptical transverse matrix biopsy, which can be performed after removal of the proximal half of the nail plate alone.
Matrix shave or tangential biopsy
A diagnostic shave biopsy from nail matrix in longitudinal melanonychia
Matrix exposed,with identification of origin of melanonychia
The origin is then scored with a scalpel, 1 mm
beyond the edge of the pathology It can also represent an excision
specimenThe nail plate is replaced to prevent
contact between the wound and ventral aspect of the nail fold
suture repair is not required.
Matrix shave or tangential biopsy
Proximal nail fold biopsy
Biopsy the PNF to investigate a local dermatosis, connective tissue disease or focal tumour
Preservation of the symmetry & curvature of the proximal nail fold is a priority
A distal wing block should be avoided, as the tissues will become turgid and difficult to manipulate.
Proximal nail fold biopsy
Method of removing small lesion from the PNF
Transverse nail fold biopsy
A transverse ellipse (for connective tissue disease), a 2-mm punch (far from the free edge) or a shave biopsy are simple nail fold procedures
The transverse ellipse and punch biopsies are down to the dorsal aspect of the nail plate
The matrix may require protection from cutting trauma and this can be achieved
by inserting a septum elevator between the nail fold and the nail.
Transverse nail fold biopsy
Postoperatively, a thin line may remain in the nail fold after the transverse biopsy
these techniques leave little or no scarring. There is no nail plate change.
Crescentic nail fold biopsy
crescentic incision is performed just proximal to the cuticle with the blade angled to direct trauma away from the proximal matrix
matrix protection provided by inserting a septum elevator
Distal fraction of the proximal nail fold (including the cuticle) can be removed, although the width of the specimen should not exceed 4–5 mm in the midline
Crescentic nail fold biopsy
The wound heals by secondary intention and a new cuticle usually reforms, depending upon the original problem
Excision of chronic paronychia resistant to routine therapy
Excision of digital mucus cysts occupying the most distal margin of the nail fold
Crescentic nail fold biopsy
Crescentic shave of distal PNF & Cuticle as Rx of Ch Paronychia
Focal nail fold biopsy
Focal pathology in the nail fold can be excised by a V-shaped incision into the nail fold
The excision is through the entire thickness of the nail fold, but should not penetrate underlying nail
Relaxing incisions are made at one or both of the lateral margins of the PNF
Wounds in the midline of the nail fold can leave some scarring, but the nail plate is usually unaffected.
Postoperative care
Keep the digit elevated at least at waist
height whenever possible
Sleep with a pillow under the hand or foot
that is treated today to decrease pain
Keep pressure off the biopsy site for at
least the first two days
If your procedure is performed on a toe,
then wear loose fitting shoes
Postoperative care
Keep the wound covered with thin layer of
antibiotic. This keeps air, water and other
irritants off of it and helps it heal faster
Proper dressing can reduce throbbing pain
& Complications
NSAIDs
Nail Biopsy
Complications:- Pain,Bleeding,Necrosis of wound edges,- Trauma to Nail Matrix causes Split nail,Thin
nails & Onycholysis- Pyogenic granuloma,Reflex sympathetic
dystrophy,- Deep infections such as
Osteomyelitis,Septic arthritis
Nail Biopsy
Suturing:- Biopsies with a diametre < 3 mm – not
require - PNF/LNF: Absorbable suture( Vicryl 4-0 for
toes, 5-0 for for fingers )- Nail Matrix : Absorbable suture ( Vicryl 6-
0 )- Nail Bed: Absorbable suture ( Vicryl 5-0 )
Nail BiopsyAdvantages:Never scarring,Easy ProcedureUseful in Isolated nail manifestaionsGives a definitive diagnosis of
onychomycosisMost useful in longitudinal melanonychia &
suspected malignant melanomaTherapeutic benefit in glomus tumour
Nail Biopsy
Disadvantages:
Cases where skin biopsy easily taken
Difficult in patient with DM,PVD
Lack of dermatopathologists
Cases in which nail pathology is likely
to be nonspecific
Lack of well defined histopathological
criteria for some nail diseases
Nail PlateNail bed epithelium
N. Matrix Hyponychium N. Bed dermis
Nail PlateNail bed epithelium
N. Matrix Hyponychium N. Bed dermis
Normal Nail unit HP showing nail matrix area
The nail plate arising over nail matrix area
The characteristic absence of granular layer of nail matrix
Nail Plate biopsy with adherent nail plate epithelium showing evidence of subungual wart
Marked papillomatosis of nail bed epithelium
Onychomycosis
Fungal Pseudohyphae seen in a nail plate biopsy
Nail clippings show septate hyphal elements proven to be Trichophyton sp with in nail plate keratin
90 % Toe nail infections with Trichophyton,Microsporum,Epidermophyton sp
PAS staining most sensitive test
Stain reveals fungal organisms located in lower stratum corneum
Distal subungual Onychomycosis is MC form,caused by T.rubrum
It invades hyponychium & LNF finally yellow,onycholysis,sub ungual hyperkeratosis
T.mentagrophytes identified in superficial white OM,located in superficial nail plate
Onychomycosis
Psoriasis
Nail unit biopsy showing
Parakeratosis Hypergranulosis Parakeratotic abscess Serum crusting
Psoriasis
Spongitic Pustule seen in Epidermis Absence of Granular layer,Acanthosis of Epidermis,Vascular Changes
Lichen Planus
Basal layer dissolution & band like infiltrate in epidermis can be seen
Hyperkeratosis & Superficial Lymphocytic infiltrate
Band like superficial lymphocytic infiltrate along with vacuolar degenration
Lichen Planus
Melanonychia
Pigment laden cells in dermis & Epidermal pigmentation – Melanocytes activation
Nail clippings show Budding yeasts
Candida
Scabies of Nail
Sarcoptes scabiei present in distal subungual hyperkeratotic debris found in hyponychium
Cause of persistent epidemics of scabies
Norwegian scabies severe involvement of nail folds
Scrapings of distal hyponychium- showing organism – Sarcoptes Scabiei
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