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epidermis&#44; papillary dermis&#44; and sparing the reticular dermis&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> As in the skin&#44; there is an influx of neutrophils &#40;considered a major criterion for the diagnosis of nail psoriasis&#41;&#44; psoriasiform hyperplasia of the epidermis&#44; dilated and tortuous venules filling the dermal papillae&#44; and perivascular lymphoid infiltrate in the underlying adventitial dermis&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Focal parakeratosis can form in the dorsal&#44; intermediate or ventral portions of the nail plate&#44; producing pitting&#44; true leukonychia&#44; or onycholysis&#44; respectively&#46; When the entire matrix is affected&#44; there may be marked dystrophy&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">However&#44; certain characteristics are distinct in the nail unit&#58; while in the hyponychium&#44; there is a loss of the granulosa layer normally present&#59; in the matrix and nail bed there is hypergranulosis&#46; Spongiosis may occur&#44; forming prominent serum crusts on papillae top&#44; due to hypervascularization&#44; increased vascular permeability in the dermal papillae&#44; and blockage of exudate elimination caused by apposition of the nail&#46; In addition&#44; hemorrhage spots in the granulosa and corneal layer can be seen&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;5</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">As onychomycosis and psoriasis share some histological features&#44; Grover et al&#46; recommended that negative periodic acid-schiff immunohistochemical &#40;PAS&#41; reactions for fungi should be included as an additional diagnostic criterion&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Longitudinal and 3-mm punch biopsies are currently the most used techniques for the investigation of nail disorders&#46; In the longitudinal technique&#44; one incision is made through the nail bed&#44; the entire matrix&#44; and the proximal nail fold&#46; The second incision parallel to the initial one&#44; no more than 3-mm from the first&#44; is made in the lateral nail fold&#46; The tissue between the two incisions is excised from the underlying bone and the defect is then sutured&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;5</span></a> Expected complications include reduction in nail width&#44; malalignment of the axis of the regrowing nail&#44; scarring of the nail bed&#44; onycholysis&#44; or growth of nail spicules&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">A punch biopsy can be performed in any area of the nail apparatus&#46; Partial avulsion of the nail plate may or may not be necessary&#46; The 3-mm punch is used&#44; rotating it down to the bone&#44; and the base of the fragment is cut with sharp iris scissors&#46; The resulting defect does not require suturing&#46; In the bed region&#44; biopsy collection rarely generates dystrophy&#44; but it can result in onycholysis&#46; In the proximal matrix&#44; there is a risk of onychodystrophy&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;7</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">In both techniques&#44; onycholysis and nail dystrophy may appear&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;7</span></a> Incidentally&#44; low clinicopathological correlations may occur&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6</span></a> The tangential excision &#40;TB&#41; biopsy technique is well-known for diagnosing longitudinal melanonychia&#46; Former studies have demonstrated that the thickness obtained is sufficient for the differential diagnosis of the various processes that manifest with melanonychia and the morbidity is lower&#44; compared to more invasive techniques&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#8211;10</span></a> There are two advantages of using TB&#46; First&#44; with TB&#44; it is possible to obtain a sample with a width greater than that of 3-mm&#44; allowing for an increased number of tissue sections&#46; This could aid in the histopathological evaluation of inflammatory diseases characterized by superficial histopathological changes&#44; such as psoriasis&#46; Second&#44; by using the TB technique&#44; deep tissue is spared&#44; reducing the risk of cicatricial onychodystrophies&#46; The authors aimed to evaluate the results of the nail tangential excision biopsy technique for the histopathological diagnosis of psoriasis&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Methods</span><p id="par0050" class="elsevierStylePara elsevierViewall">This is prospective descriptive work&#46; The study proceeded after approval from the Institutional Research Ethics Committee &#40;CAEE&#58; 55474521&#46;1&#46;0000&#46;5404&#41;&#46; Between 2021 and 2022&#44; 13 patients with a diagnosis hypothesis of nail psoriasis were selected during the nail disease clinic care&#46; The following nail changes were considered&#58; onycholysis&#44; splinter hemorrhages&#44; subungual hyperkeratosis&#44; salmon patches&#47;oil spots&#44; and pitting&#46; Signed informed consent forms included the risk of onychodystrophy&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Biopsies were obtained from the nail with the most prominent involvement&#44; preferably from the nail bed&#46; The same nail specialist and dermatologist performed the procedures&#46; Aseptic surgical technique with distal block anesthesia without vasoconstrictor and tourniquet were used&#46; The nail plate was detached using a number 15 scalpel blade to maintain the integrity of the epithelium at the time of nail avulsion&#46; Then&#44; the nail was partially cut with pliers&#44; and tangential excision was performed on the nail bed or matrix &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Finally&#44; the tourniquet was removed&#44; and the occlusive dressing was applied&#46; A representative diagram of the nail complex was drawn on filter paper&#44; on which the removed specimen was placed&#44; in the location corresponding to its removal&#44; with the epithelium facing upwards&#46; This procedure prevents the laminar sample from curling during fixation and improves histopathological analysis&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">Then&#44; the paper was folded to wrap the material&#44; it was stapled&#44; and immersed in 10&#37; buffered formaldehyde&#46; The removed nail plate was placed in a dry polypropylene tube &#40;Eppendorf&#41;&#46; Both samples were sent to histological processing at the Pathology Department&#46; In the laboratory&#44; the sample was removed from the filter paper and placed inside a groove produced in a thin slice of <span class="elsevierStyleItalic">Solanum tuberosum</span> &#40;English potato&#41;&#44; to assure proper histological inclusion&#46; Both &#40;potato and surgical material&#41; were dehydrated&#44; diaphanized&#44; and embedded in paraffin&#44; as a single material&#44; and were subsequently paraffin-embedded&#44; cut at various levels&#44; and stained&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> The nail plate was softened with potash&#44; washed&#44; cut&#44; fixed&#44; and processed for histological analysis&#46; The patients were instructed on how to perform local cleaning 48&#8239;hours after the procedure and to use analgesics and systemic antibiotics for seven days&#46; There was clinical follow-up for a minimum period of 6 to 12 months&#44; until complete nail growth&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">The specimens were blindly analyzed by one dermatopathologist and one dermatologist&#46; The following variables were evaluated&#58; subungual hyperparakeratosis&#44; serous and&#47;or neutrophilic exudate&#44; and hemorrhage in the stratum corneum&#44; hypo-&#47;hypergranulosis&#44; papillomatosis&#44; spongiosis&#44; hyperplasia of the epidermis&#44; dilated dermal papillae vessels&#44; type and location of the inflammatory infiltrate in the papillary or adventitial dermis&#46; A search for fungi was carried out in all samples using PAS-stain&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Results</span><p id="par0070" class="elsevierStylePara elsevierViewall">Biopsies were obtained from twelve fingers and one toe of 13 different patients &#40;five men and eight women&#41;&#46; One of the samples presented unequivocal findings of nail lichen planus &#40;lichenoid lymphoid infiltrate&#44; with dermo-epidermal cleft and absence of dilated dermal papillae vessels&#41;&#46; Clinically&#44; there was dystrophy of all hand nails&#44; with onycholysis&#44; subungual hyperkeratosis&#44; splinter hemorrhages&#44; red spots on the nail bed and lunula&#44; and longitudinal striae &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">The main clinical features of the remaining 12 samples were onycholysis &#40;9&#47;12&#41;&#44; splinter hemorrhages &#40;9&#47;12&#41;&#44; oil spot &#40;8&#47;12&#41;&#44; salmon patch &#40;7&#47;12&#41;&#44; pitting &#40;7&#47;12&#41; and subungual hyperkeratosis &#40;5&#47;12&#41;&#46; Only one of the 12 patients had pitting as an isolated change so TB was obtained from the nail matrix&#46; The others had nail changes predominantly related to nail bed &#40;<a class="elsevierStyleCrossRefs" href="#fig0015">Figs&#46; 3 and 4</a>&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">Nail matrix TB allowed the identification of vascular ectasia within papillary dermis&#44; although other histological features of psoriasis were missing&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Five patients concomitantly had psoriasis skin lesions&#46; Of these&#44; three showed discrete nail changes&#44; only one presented a salmon patch with onycholysis&#44; one presented subungual hyperkeratosis with splinter hemorrhages&#44; and one presented isolated pitting&#46; In these three&#44; the histological changes of TB and nail plate were insufficient to meet the criteria for a diagnosis of psoriasis&#46; The TB samples&#39; width ranged from 1&#46;1&#8239;cm to 0&#46;3&#8239;cm in width&#44; which were equal to or greater than those that would be obtained using the 3-mm punch or longitudinal biopsies&#46; Still&#44; their thickness ranged from 0&#46;1 to 0&#46;15&#8239;cm&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">In four out of 13 patients&#44; the adventitial dermis was not taken and&#44; in one patient&#44; neither was the papilla&#46; The histological findings in the 12 samples were &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#58; absence of spongiosis &#40;12&#47;12&#41;&#44; presence of dilated papillae vessels &#40;11&#47;11&#41;&#44; parakeratosis &#40;11&#47;12&#41;&#44; regular epidermal hyperplasia of the epidermis &#40;9&#47;12&#41;&#44; hypogranulosis focal &#40;5&#47;12&#41;&#44; thinning of the epidermis in the suprapapillary region &#40;5&#47;12&#41;&#44; Munro&#8217;s microabscess &#40;4&#47;12&#41; and focal hypergranulosis &#40;3&#47;12&#41;&#46; Sending the nail plate was important for fungal research&#46; In one case&#44; it was possible to identify&#44; in one focus&#44; a small number of septate filamentous fungi&#46; The presence of septate filamentous fungi in nail plates could be attributed to a primary fungal infection or secondary fungal infection of psoriasis&#46; Psoriasis and dermatophytosis have a lot of common histopathological findings&#46; However&#44; the presence of parakeratosis on the papillae&#44; hypogranulosis&#44; thinning of the suprapapillary epidermis&#44; and increased density of dermal vessels allowed diagnostic confirmation of concomitant psoriasis&#46;</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">Through nail plate histopathological evaluation&#44; additional findings suggestive of psoriasis were recorded&#44; such as the top of the superficialized papillae&#44; suprapapillary intracorneal serous exudate&#44; parakeratosis&#44; and intracorneal neutrophils&#46; Assessment of the nail plate contributed to the final diagnosis in three out of 12 cases &#40;<a class="elsevierStyleCrossRef" href="#fig0030">Fig&#46; 6</a>&#41;&#46;</p><elsevierMultimedia ident="fig0030"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">In summary&#44; by obtaining the 13 TB cases&#44; it was possible to define the diagnosis of lichen planus in one and psoriasis in 9&#46; In the remaining 3&#44; sufficient criteria were not met to achieve the diagnosis&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">The time to resume daily activities was up to seven days&#46; Nail dystrophy was not observed in any patient after six months to one year of follow-up &#40;<a class="elsevierStyleCrossRefs" href="#fig0035">Figs&#46; 7 and 8</a>&#41;&#46;</p><elsevierMultimedia ident="fig0035"></elsevierMultimedia><elsevierMultimedia ident="fig0040"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Discussion</span><p id="par0110" class="elsevierStylePara elsevierViewall">In the approach to inflammatory nail diseases&#44; obtaining a biopsy is extremely important for defining the diagnosis&#44; planning treatment&#44; and estimating the prognosis&#46; However&#44; dermatologists are reluctant to biopsy the nail&#44; due to the risk of dystrophies&#44; lack of prior training in nail surgery and&#44; not rarely&#44; inconclusive histopathological findings&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6&#44;13&#8211;15</span></a> In 1999&#44; Haneke demonstrated the efficacy and safety of TB for the diagnosis and treatment of nail melanonychia&#44; avoiding permanent onychodystrophies&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Di Chiacchio et al&#46; reported that with this technique it is possible to obtain specimens with sufficient thickness for differential diagnosis between hypermelanosis&#44; lentigo&#44; junctional or compound nevus&#44; and in situ melanoma&#44; as all the histopathological changes are restricted to the epidermis or upper part of the dermis&#46; They also found that the procedure induced minimal damage to the matrix&#44; with excellent aesthetic results&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Since then&#44; the use of this technique remained restricted to the elucidation of melanonychia diagnosis&#46; In psoriasis and lichen planus&#44; the main inflammatory nail diseases&#44; histological changes are seen in the superficial layers of the nail bed&#47;matrix&#46; Therefore&#44; the possibility of also using TB in the diagnosis of these diseases may encourage dermatologists to collect more biopsies and&#44; consequently&#44; define the diagnosis in a greater number of patients&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Punch biopsy&#44; without prior avulsion of the plate&#44; would be the ideal technique indicated for the investigation of inflammatory nail diseases&#44; due to better preservation of the superficial tissue morphology&#46; However&#44; it is a difficult task to introduce the punch through the nail plate&#44; maintaining the adhesion of the plate to the bed&#47;matrix during the rotation of the instrument&#46; Shearing often occurs&#46; Furthermore&#44; the idea is to soften the nail plate by using alkali before fixation&#44; to optimize the histological preparations&#46; This procedure and the delay in fixing the specimen can damage elements of the nail bed&#47;matrix&#44; which would help to define the diagnosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#8211;15</span></a> Careful detachment of the nail plate with a scalpel blade&#44; in TB&#44; proved to be effective in maintaining the integrity of the epithelium&#46; In the present study&#44; sending the overlying plate separately allowed additional microscopic evaluation&#44; without interfering with the histopathological processing&#46; The most frequent histomorphological findings in these samples were&#58; the absence of spongiosis &#40;12&#47;12&#41;&#44; dilated papillae vessels &#40;11&#47;11&#41;&#44; and parakeratosis &#40;11&#47;12&#41; &#40;<a class="elsevierStyleCrossRefs" href="#fig0025">Figs&#46; 5&#44; 9 and 10</a>&#41;&#46; Grover et al&#46; highlighted the findings of hyperkeratosis with parakeratotic areas &#40;91&#37;&#41;&#44; and dilated vessels&#44; in all patients with a confirmed clinical diagnosis of psoriasis&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><elsevierMultimedia ident="fig0045"></elsevierMultimedia><elsevierMultimedia ident="fig0050"></elsevierMultimedia><p id="par0120" class="elsevierStylePara elsevierViewall">The authors found full clinical-histological correlation in 75&#37; &#40;9&#47;12&#41; of patients&#44; a higher rate than those already reported&#44; whether in samples obtained by longitudinal or punch biopsies&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6</span></a> Hanno et al&#46; detected histomorphological findings that met the criteria for a specific nosological diagnosis in only 40&#37; of the studied cases&#59; of the six patients with clinical suspicion of psoriasis and the seven suggestive of lichen planus&#44; in only four and three patients&#44; respectively&#44; the diagnoses were confirmed&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Grover et al&#46; studied 22 patients with a clinical diagnosis of nail psoriasis&#44; collected samples through longitudinal and punch techniques&#44; and achieved a clinicopathological correlation of 54&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Perhaps the highest rate of clinical-histological correlation in the studied patients was due to the greater sampling in the width of the excised tissue&#44; made possible by TB&#44; associated with the care used in the technique&#44; from sample collection to histological reading&#44; in addition to the inclusion of additional histological criteria&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Hanno et al&#46; &#40;1986&#41; proposed the histological criteria to be considered for diagnosis of nail psoriasis&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Hyperkeratosis&#44; with parakeratosis&#44; intracorneal serous exudate&#44; a granular layer of irregular thickness&#44; and psoriasiform hyperplasia of the epidermis of the nail bed&#44; with dilation of the papillary blood vessels were described as minor criteria&#46; The finding of neutrophils on the bed epithelium surface&#44; with parakeratotic scales adhered to the nail plate&#44; was considered the major criterion&#46; To confirm the diagnosis of nail psoriasis&#44; the major criterion would be necessary&#44; with or without an associated minor criterion&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> In 2005&#44; Grover et al&#46; proposed an additional criterion&#58; negative PAS-stain for fungi&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> However&#44; the concomitance of nail psoriasis and onychomycosis is possible and described&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> Indeed&#44; neutrophil aggregates seem to be more common in onychomycosis and parakeratosis&#44; and more frequent in psoriasis&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> The authors postulate that the value neutrophils exudate as a major and mandatory criterion for diagnosis&#44; may be the main obstacle to the best clinicopathological correlation of former studies&#46; In the samples the authors analyzed&#44; a good clinical-histological correlation was obtained when using the following criteria&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">-</span><p id="par0130" class="elsevierStylePara elsevierViewall">Mandatory criterion&#58; dilatated dermal papillae vessels &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#59;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">-</span><p id="par0135" class="elsevierStylePara elsevierViewall">Secondary criteria &#40;at least three&#41;&#58; absence of spongiosis&#44; presence of parakeratosis&#44; psoriasiform epidermal hyperplasia&#44; focal thinning of the granular layer and suprapapillary epidermis&#44; and intra- or subcorneal neutrophils exudate &#40;<a class="elsevierStyleCrossRefs" href="#fig0025">Figs&#46; 5&#44; 9 and 10</a>&#41;&#46;</p></li></ul></p><p id="par0140" class="elsevierStylePara elsevierViewall">Additional nail plate analysis supported a diagnosis of psoriasis in three of 12 cases&#44; and in six cases&#44; the analysis of the subungual tissue was essential for the diagnosis&#46; Thus&#44; only a nail clipping specimen would be insufficient for diagnosis in the majority of patients&#46; Even so&#44; the authors emphasize that the nail plate must be analyzed&#44; as it can provide additional information&#44; in addition to allowing fungal research &#40;<a class="elsevierStyleCrossRef" href="#fig0030">Fig&#46; 6</a>&#41;&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">If the clinical findings are subtle&#44; with discreet pitting&#44; salmon patch&#44; or isolated subungual hyperkeratosis&#44; a histological analysis may be inconclusive&#46; In these cases&#44; the authors suggest clinical follow-up and biopsy indication if there are other associated clinical signs&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">In patients with subungual hyperkeratosis&#44; the TB of the nail bed must be a little deeper&#44; due to the risk of not reaching the dermis&#46; In the matrix&#44; a superficial tangential biopsy is sufficient to obtain adequate sampling of the papillary dermis&#46; Since many patients with nail psoriasis present with mixed clinical findings of nail bed and matrix involvement&#44; it is preferable and sufficient to obtain a biopsy of the nail bed&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Limitations</span><p id="par0155" class="elsevierStylePara elsevierViewall">In three of the 12 included patients&#44; the clinical and&#44; consequently&#44; histological nail changes were subtle &#40;one of them only had a salmon patch with onycholysis&#44; another subungual hyperkeratosis with splinter hemorrhages&#44; and the last&#44; isolated pitting&#41;&#46; Also&#44; in one patient TB sample&#44; the dermal papilla was not taken&#44; although sufficient histological changes were found in the epidermis and nail plate to reach a psoriasis diagnosis&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Conclusion</span><p id="par0160" class="elsevierStylePara elsevierViewall">The TB technique was found to be a good option for diagnosing the main inflammatory nail diseases because&#44; through it&#44; larger and thinner samples&#44; short postoperative recovery time&#44; and low risk of onychodystrophy were achieved&#46; TB allowed for defining the diagnosis&#44; especially when sufficient clinical elements were associated with histomorphological findings&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Financial support</span><p id="par0165" class="elsevierStylePara elsevierViewall">This work was carried out with the support of the Coordination for the Improvement of Higher Education Personnel - Brazil &#40;CAPES&#41; - Financing code 001&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Authors&#8217; contributions</span><p id="par0170" class="elsevierStylePara elsevierViewall">Laura Bertanha&#58; Participated in generating and analyzing the data&#59; wrote the majority of the original draft of the paper&#44; reviewed the pertinent raw data on which the results and conclusions of this study are based and approved the final version of this paper&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Ingrid Iara Damas&#58; Participated in generating data&#44; writing the paper and approved the final version of this paper&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">Rafael Fantelli Stelini&#58; Participated in generating data&#44; writing the paper&#44; reviewed the pertinent raw data on which the results and conclusions of this study are based and approved the final version of this paper&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">Maria Let&#237;cia Cintra&#58; Participated in designing&#44; generating and analyzing the data&#59; wrote the paper and reviewed the pertinent raw data on which the results and conclusions of this study are based and approved the final version of this paper&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">Nilton Di Chiacchio&#58; Participated in generating data&#44; writing the paper&#44; reviewed the pertinent raw data on which the results and conclusions of this study are based and approved the final version of this paper&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conflicts of interest</span><p id="par0195" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Histopathology can be crucial for diagnosis of inflammatory nail diseases&#46; Longitudinal excision and punch biopsies are the most used techniques to obtain the tissue sample&#46; However&#44; there is a low clinical-histopathological correlation&#44; besides the risk of nail dystrophy&#46; Tangential excision biopsy &#40;TB&#41; is a well-established technique for the investigation of longitudinal melanonychia&#46; TB could also be used to evaluate diseases in which histopathological changes are superficial&#44; as in psoriasis&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Objective</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">To study the value of TB in the histopathological diagnosis of nail psoriasis&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Methods</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">This is a prospective and descriptive study of the clinical-histopathological findings of samples from the nail bed or matrix and nail plate of 13 patients with clinical suspicion of nail psoriasis&#46; Biopsies were obtained through partial nail avulsion and TB&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">In nine patients&#44; the hypothesis of psoriasis was confirmed by histopathology&#59; in one&#44; the criteria for diagnosing nail lichen planus were fulfilled&#46; The tissue sample of only one patient did not reach the dermal papillae&#44; and&#44; in four of 13 patients&#44; the adventitial dermis was not sampled&#46; No patient developed onychodystrophy after the procedure&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Study limitations</span><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">In three patients&#44; the clinical and&#44; consequently&#44; histopathological nail changes were subtle&#46; Also&#44; in one patient&#8217;s TB didn&#8217;t sample the dermal papillae&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Conclusions</span><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">TB is a good option to assist in the histopathological diagnosis of nail psoriasis&#44; especially when appropriate clinical elements are combined&#46; Using this technique&#44; larger and thinner samples&#44; short postoperative recovery time&#44; and low risk of onychodystrophy are obtained&#46;</p></span>"
        "secciones" => array:6 [
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          2 => array:2 [
            "identificador" => "abst0015"
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          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Results"
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          4 => array:2 [
            "identificador" => "abst0025"
            "titulo" => "Study limitations"
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          5 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "Conclusions"
          ]
        ]
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Study conducted at the Department of Pathological Anatomy&#44; Medical Sciences College&#44; Universidade Estadual de Campinas&#44; Campinas&#44; SP&#44; Brasil&#59; Department of Dermatology&#44; Hospital do Servidor P&#250;blico Municipal de S&#227;o Paulo&#44; S&#227;o Paulo&#44; SP&#44; Brasil&#46;</p>"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Longitudinal tangential biopsy technique &#8211; &#40;A&#41; Onychoscopy&#58; regular onycholysis with salmon patch and dilated linear vessels&#59; &#40;B&#41; Partial detachment of the nail plate with a number 15 scalpel blade&#44; in the demarcated region&#59; &#40;C&#41; Partial cutting of the plate with pliers&#59; &#40;D&#41; Slightly thicker tangential biopsy of the nail bed &#40;sample measuring 0&#46;7&#8239;&#215;&#8239;0&#46;2&#8239;&#215;&#8239;0&#46;1&#8239;cm&#41;&#46;</p>"
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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Lichen planus &#8210; &#40;A&#41; All fingernails affected&#58; regular onycholysis&#44; subungual hyperkeratosis and onychodystrophy&#59; &#40;B&#41; Onychoscopy&#58; red spots on the lunula&#44; subungual hyperkeratosis and irregular striated leukonychia&#59; &#40;C&#41; Nail bed with significant lymphoid infiltrate within the dermal papillae&#59; &#40;D&#41; lichenoid lymphoid infiltrate fills the papilla&#44; with a subepidermal cleft&#46; Hematoxilina &#38; eosin&#44; &#215;100 &#40;C&#41; and &#215; 400 &#40;D&#41;&#46;</p>"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Nail psoriasis &#8210; &#40;A&#41; Regular onycholysis with salmon patch on several digits&#59; &#40;B&#41; Onychoscopy&#58; regular onycholysis with salmon patch&#59; &#40;C&#41; Coarse nail pittings&#46;</p>"
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Nail psoriasis &#8210; &#40;A&#41; Regular onycholysis with salmon patch on several digits&#59; &#40;B&#41; Compact subungual hyperkeratosis&#44; seen on the free nail edge&#59; &#40;C&#41; Onychoscopy&#58; regular onycholysis with salmon patch and punctate leukonychia&#46;</p>"
        ]
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          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Psoriasis &#40;nail bed&#41; &#8210; &#40;A&#41; Psoriasiform hyperplasia of the epidermis&#44; hypervascularized papillary dermis and thinning of the suprapapillary stratum spinosum&#59; &#40;B and C&#41; Thinning of the suprapapillary stratum spinosum&#44; highly vascularized papillae and absence of spongiosis&#59; &#40;D&#41; Parakeratosis and intracorneal neutrophils exudate&#46; Hematoxilina &#38; eosin&#44; 40 &#40;A&#41; and &#215;400 &#40;B&#8210;D&#41;&#46;</p>"
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          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Psoriasis &#40;nail plate&#41; &#8210; &#40;A&#41; Papillomatosis &#40;the tops of the papillae superficialized from the bed &#8211; red arrows&#41;&#59; &#40;B&#41; Intracorneal serous exudate on the top of the papillae &#40;blue arrows&#41;&#44; with parakeratosis &#40;black arrows&#41;&#59; &#40;C&#41; Keratinocyte nuclei &#40;parakeratosis &#8210; black arrows&#41; and rare neutrophils &#40;yellow arrows&#41;&#46; Hematoxilina &#38; eosin&#44; &#215;100 &#40;A&#44; B&#41; and &#215;400 &#40;C&#41;&#46;</p>"
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          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Nail psoriasis -before and after tangential biopsy &#8210; &#40;A&#41; Onychoscopy of the area to be biopsied- regular onycholysis with salmon patches and splinter hemorrhages&#59; &#40;B&#41; 7-day postoperative period &#8210; excellent bed healing&#59; &#40;C&#41; 30-days post-operative period &#8211; complete nail recovery&#46;</p>"
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          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Nail psoriasis -before and after tangential biopsy &#8210; &#40;A and B&#41; Onychoscopy of the area to be biopsied - regular onycholysis with oil spot&#44; splinter hemorrhages and compact subungual hyperkeratosis&#59; &#40;C&#41; Immediate pre-operative period&#59; &#40;D&#41; 30-days post-operative &#8211; complete nail recovery&#46;</p>"
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Nail psoriasis &#8210; &#40;A&#41; All fingernails with regular onycholysis&#44; salmon patch&#44; some oil spots&#44; subungual hyperkeratosis and splinter hemorrhages&#59; &#40;B&#41; Onychoscopy&#58; distal leukonychia and splinter hemorrhages&#59; &#40;C&#41; High papillae vascular density&#59; &#40;D&#41; Area of hypogranulosis&#44; on the left&#44; and area of hypergranulosis&#44; on the right&#46; Hematoxilina &#38; eosin &#215;100 &#40;C&#41; and &#215;400 &#40;D&#41;&#46;</p>"
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Nail psoriasis &#8210; &#40;A&#41; Regular onycholysis on all fingernails&#44; some with oil spots&#44; subungual hyperkeratosis&#44; and total dystrophy&#59; &#40;B&#41; Neutrophilis exudate amidst superficial keratinocytes &#40;red arrow&#41;&#59; neutrophils within parakeratotic scale &#40;yellow arrows&#41;&#46; Hematoxilina &#38; eosin&#44; &#215;400&#46;</p>"
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    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:17 [
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                            1 => "B&#46;M&#46; Mathes"
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            5 => array:3 [
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Original Article
Role of tangential biopsy in the diagnosis of nail psoriasis
Laura Bertanhaa,b,
Corresponding author
labertanha@yahoo.com.br

Corresponding author.
, Ingrid Iara Damasa, Rafael Fantelli Stelinia, Maria Letícia Cintraa, Nilton Di Chiacchiob
a Department of Pathological Anatomy, Medical Sciences College, Universidade Estadual de Campinas, Campinas, SP, Brazil
b Dermatology Service, Hospital do Servidor Público Municipal de São Paulo, São Paulo, SP, Brazil
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Longitudinal tangential biopsy technique &#8211; &#40;A&#41; Onychoscopy&#58; regular onycholysis with salmon patch and dilated linear vessels&#59; &#40;B&#41; Partial detachment of the nail plate with a number 15 scalpel blade&#44; in the demarcated region&#59; &#40;C&#41; Partial cutting of the plate with pliers&#59; &#40;D&#41; Slightly thicker tangential biopsy of the nail bed &#40;sample measuring 0&#46;7&#8239;&#215;&#8239;0&#46;2&#8239;&#215;&#8239;0&#46;1&#8239;cm&#41;&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Clinical changes in nail disorders are not only limited but also are shared by different types of processes&#46; Onycholysis&#44; for example&#44; can be a manifestation of different diseases such as lichen planus&#44; onychomycosis&#44; or nail psoriasis&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> In the case of suspected inflammatory diseases of the nails&#44; without associated skin involvement&#44; a nail biopsy is necessary to assist in accurate diagnosis and specific treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Involvement of the nail matrix in psoriasis manifests as nail plate pitting&#44; thinning&#44; onychorrhexis&#44; red dots on the lunula&#44; and true leukonychia&#46; In the nail bed&#44; the &#39;oil spot&#8217; or &#39;salmon stain&#39; changes&#44; subungual hyperkeratosis&#44; onycholysis&#44; and splinter hemorrhages can be identified&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Pittings&#44; subungual hyperkeratosis&#44; and onycholysis are the most common findings&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The clinical diagnosis can be corroborated using a dermatoscope&#44; enabling clearer identification of the erythematous halo next to onycholysis&#46; It also highlights dilated&#44; elongated&#44; and tortuous capillaries in hyponychium and nail bed&#44; in addition to compact subungual hyperkeratosis on the free edge&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Histopathological changes in nail psoriasis are limited to the nail plate or horny layer&#44; epidermis&#44; papillary dermis&#44; and sparing the reticular dermis&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> As in the skin&#44; there is an influx of neutrophils &#40;considered a major criterion for the diagnosis of nail psoriasis&#41;&#44; psoriasiform hyperplasia of the epidermis&#44; dilated and tortuous venules filling the dermal papillae&#44; and perivascular lymphoid infiltrate in the underlying adventitial dermis&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Focal parakeratosis can form in the dorsal&#44; intermediate or ventral portions of the nail plate&#44; producing pitting&#44; true leukonychia&#44; or onycholysis&#44; respectively&#46; When the entire matrix is affected&#44; there may be marked dystrophy&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">However&#44; certain characteristics are distinct in the nail unit&#58; while in the hyponychium&#44; there is a loss of the granulosa layer normally present&#59; in the matrix and nail bed there is hypergranulosis&#46; Spongiosis may occur&#44; forming prominent serum crusts on papillae top&#44; due to hypervascularization&#44; increased vascular permeability in the dermal papillae&#44; and blockage of exudate elimination caused by apposition of the nail&#46; In addition&#44; hemorrhage spots in the granulosa and corneal layer can be seen&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;5</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">As onychomycosis and psoriasis share some histological features&#44; Grover et al&#46; recommended that negative periodic acid-schiff immunohistochemical &#40;PAS&#41; reactions for fungi should be included as an additional diagnostic criterion&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Longitudinal and 3-mm punch biopsies are currently the most used techniques for the investigation of nail disorders&#46; In the longitudinal technique&#44; one incision is made through the nail bed&#44; the entire matrix&#44; and the proximal nail fold&#46; The second incision parallel to the initial one&#44; no more than 3-mm from the first&#44; is made in the lateral nail fold&#46; The tissue between the two incisions is excised from the underlying bone and the defect is then sutured&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;5</span></a> Expected complications include reduction in nail width&#44; malalignment of the axis of the regrowing nail&#44; scarring of the nail bed&#44; onycholysis&#44; or growth of nail spicules&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">A punch biopsy can be performed in any area of the nail apparatus&#46; Partial avulsion of the nail plate may or may not be necessary&#46; The 3-mm punch is used&#44; rotating it down to the bone&#44; and the base of the fragment is cut with sharp iris scissors&#46; The resulting defect does not require suturing&#46; In the bed region&#44; biopsy collection rarely generates dystrophy&#44; but it can result in onycholysis&#46; In the proximal matrix&#44; there is a risk of onychodystrophy&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;7</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">In both techniques&#44; onycholysis and nail dystrophy may appear&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;7</span></a> Incidentally&#44; low clinicopathological correlations may occur&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6</span></a> The tangential excision &#40;TB&#41; biopsy technique is well-known for diagnosing longitudinal melanonychia&#46; Former studies have demonstrated that the thickness obtained is sufficient for the differential diagnosis of the various processes that manifest with melanonychia and the morbidity is lower&#44; compared to more invasive techniques&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#8211;10</span></a> There are two advantages of using TB&#46; First&#44; with TB&#44; it is possible to obtain a sample with a width greater than that of 3-mm&#44; allowing for an increased number of tissue sections&#46; This could aid in the histopathological evaluation of inflammatory diseases characterized by superficial histopathological changes&#44; such as psoriasis&#46; Second&#44; by using the TB technique&#44; deep tissue is spared&#44; reducing the risk of cicatricial onychodystrophies&#46; The authors aimed to evaluate the results of the nail tangential excision biopsy technique for the histopathological diagnosis of psoriasis&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Methods</span><p id="par0050" class="elsevierStylePara elsevierViewall">This is prospective descriptive work&#46; The study proceeded after approval from the Institutional Research Ethics Committee &#40;CAEE&#58; 55474521&#46;1&#46;0000&#46;5404&#41;&#46; Between 2021 and 2022&#44; 13 patients with a diagnosis hypothesis of nail psoriasis were selected during the nail disease clinic care&#46; The following nail changes were considered&#58; onycholysis&#44; splinter hemorrhages&#44; subungual hyperkeratosis&#44; salmon patches&#47;oil spots&#44; and pitting&#46; Signed informed consent forms included the risk of onychodystrophy&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Biopsies were obtained from the nail with the most prominent involvement&#44; preferably from the nail bed&#46; The same nail specialist and dermatologist performed the procedures&#46; Aseptic surgical technique with distal block anesthesia without vasoconstrictor and tourniquet were used&#46; The nail plate was detached using a number 15 scalpel blade to maintain the integrity of the epithelium at the time of nail avulsion&#46; Then&#44; the nail was partially cut with pliers&#44; and tangential excision was performed on the nail bed or matrix &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Finally&#44; the tourniquet was removed&#44; and the occlusive dressing was applied&#46; A representative diagram of the nail complex was drawn on filter paper&#44; on which the removed specimen was placed&#44; in the location corresponding to its removal&#44; with the epithelium facing upwards&#46; This procedure prevents the laminar sample from curling during fixation and improves histopathological analysis&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">Then&#44; the paper was folded to wrap the material&#44; it was stapled&#44; and immersed in 10&#37; buffered formaldehyde&#46; The removed nail plate was placed in a dry polypropylene tube &#40;Eppendorf&#41;&#46; Both samples were sent to histological processing at the Pathology Department&#46; In the laboratory&#44; the sample was removed from the filter paper and placed inside a groove produced in a thin slice of <span class="elsevierStyleItalic">Solanum tuberosum</span> &#40;English potato&#41;&#44; to assure proper histological inclusion&#46; Both &#40;potato and surgical material&#41; were dehydrated&#44; diaphanized&#44; and embedded in paraffin&#44; as a single material&#44; and were subsequently paraffin-embedded&#44; cut at various levels&#44; and stained&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> The nail plate was softened with potash&#44; washed&#44; cut&#44; fixed&#44; and processed for histological analysis&#46; The patients were instructed on how to perform local cleaning 48&#8239;hours after the procedure and to use analgesics and systemic antibiotics for seven days&#46; There was clinical follow-up for a minimum period of 6 to 12 months&#44; until complete nail growth&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">The specimens were blindly analyzed by one dermatopathologist and one dermatologist&#46; The following variables were evaluated&#58; subungual hyperparakeratosis&#44; serous and&#47;or neutrophilic exudate&#44; and hemorrhage in the stratum corneum&#44; hypo-&#47;hypergranulosis&#44; papillomatosis&#44; spongiosis&#44; hyperplasia of the epidermis&#44; dilated dermal papillae vessels&#44; type and location of the inflammatory infiltrate in the papillary or adventitial dermis&#46; A search for fungi was carried out in all samples using PAS-stain&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Results</span><p id="par0070" class="elsevierStylePara elsevierViewall">Biopsies were obtained from twelve fingers and one toe of 13 different patients &#40;five men and eight women&#41;&#46; One of the samples presented unequivocal findings of nail lichen planus &#40;lichenoid lymphoid infiltrate&#44; with dermo-epidermal cleft and absence of dilated dermal papillae vessels&#41;&#46; Clinically&#44; there was dystrophy of all hand nails&#44; with onycholysis&#44; subungual hyperkeratosis&#44; splinter hemorrhages&#44; red spots on the nail bed and lunula&#44; and longitudinal striae &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">The main clinical features of the remaining 12 samples were onycholysis &#40;9&#47;12&#41;&#44; splinter hemorrhages &#40;9&#47;12&#41;&#44; oil spot &#40;8&#47;12&#41;&#44; salmon patch &#40;7&#47;12&#41;&#44; pitting &#40;7&#47;12&#41; and subungual hyperkeratosis &#40;5&#47;12&#41;&#46; Only one of the 12 patients had pitting as an isolated change so TB was obtained from the nail matrix&#46; The others had nail changes predominantly related to nail bed &#40;<a class="elsevierStyleCrossRefs" href="#fig0015">Figs&#46; 3 and 4</a>&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">Nail matrix TB allowed the identification of vascular ectasia within papillary dermis&#44; although other histological features of psoriasis were missing&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Five patients concomitantly had psoriasis skin lesions&#46; Of these&#44; three showed discrete nail changes&#44; only one presented a salmon patch with onycholysis&#44; one presented subungual hyperkeratosis with splinter hemorrhages&#44; and one presented isolated pitting&#46; In these three&#44; the histological changes of TB and nail plate were insufficient to meet the criteria for a diagnosis of psoriasis&#46; The TB samples&#39; width ranged from 1&#46;1&#8239;cm to 0&#46;3&#8239;cm in width&#44; which were equal to or greater than those that would be obtained using the 3-mm punch or longitudinal biopsies&#46; Still&#44; their thickness ranged from 0&#46;1 to 0&#46;15&#8239;cm&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">In four out of 13 patients&#44; the adventitial dermis was not taken and&#44; in one patient&#44; neither was the papilla&#46; The histological findings in the 12 samples were &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#58; absence of spongiosis &#40;12&#47;12&#41;&#44; presence of dilated papillae vessels &#40;11&#47;11&#41;&#44; parakeratosis &#40;11&#47;12&#41;&#44; regular epidermal hyperplasia of the epidermis &#40;9&#47;12&#41;&#44; hypogranulosis focal &#40;5&#47;12&#41;&#44; thinning of the epidermis in the suprapapillary region &#40;5&#47;12&#41;&#44; Munro&#8217;s microabscess &#40;4&#47;12&#41; and focal hypergranulosis &#40;3&#47;12&#41;&#46; Sending the nail plate was important for fungal research&#46; In one case&#44; it was possible to identify&#44; in one focus&#44; a small number of septate filamentous fungi&#46; The presence of septate filamentous fungi in nail plates could be attributed to a primary fungal infection or secondary fungal infection of psoriasis&#46; Psoriasis and dermatophytosis have a lot of common histopathological findings&#46; However&#44; the presence of parakeratosis on the papillae&#44; hypogranulosis&#44; thinning of the suprapapillary epidermis&#44; and increased density of dermal vessels allowed diagnostic confirmation of concomitant psoriasis&#46;</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">Through nail plate histopathological evaluation&#44; additional findings suggestive of psoriasis were recorded&#44; such as the top of the superficialized papillae&#44; suprapapillary intracorneal serous exudate&#44; parakeratosis&#44; and intracorneal neutrophils&#46; Assessment of the nail plate contributed to the final diagnosis in three out of 12 cases &#40;<a class="elsevierStyleCrossRef" href="#fig0030">Fig&#46; 6</a>&#41;&#46;</p><elsevierMultimedia ident="fig0030"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">In summary&#44; by obtaining the 13 TB cases&#44; it was possible to define the diagnosis of lichen planus in one and psoriasis in 9&#46; In the remaining 3&#44; sufficient criteria were not met to achieve the diagnosis&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">The time to resume daily activities was up to seven days&#46; Nail dystrophy was not observed in any patient after six months to one year of follow-up &#40;<a class="elsevierStyleCrossRefs" href="#fig0035">Figs&#46; 7 and 8</a>&#41;&#46;</p><elsevierMultimedia ident="fig0035"></elsevierMultimedia><elsevierMultimedia ident="fig0040"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Discussion</span><p id="par0110" class="elsevierStylePara elsevierViewall">In the approach to inflammatory nail diseases&#44; obtaining a biopsy is extremely important for defining the diagnosis&#44; planning treatment&#44; and estimating the prognosis&#46; However&#44; dermatologists are reluctant to biopsy the nail&#44; due to the risk of dystrophies&#44; lack of prior training in nail surgery and&#44; not rarely&#44; inconclusive histopathological findings&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6&#44;13&#8211;15</span></a> In 1999&#44; Haneke demonstrated the efficacy and safety of TB for the diagnosis and treatment of nail melanonychia&#44; avoiding permanent onychodystrophies&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Di Chiacchio et al&#46; reported that with this technique it is possible to obtain specimens with sufficient thickness for differential diagnosis between hypermelanosis&#44; lentigo&#44; junctional or compound nevus&#44; and in situ melanoma&#44; as all the histopathological changes are restricted to the epidermis or upper part of the dermis&#46; They also found that the procedure induced minimal damage to the matrix&#44; with excellent aesthetic results&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Since then&#44; the use of this technique remained restricted to the elucidation of melanonychia diagnosis&#46; In psoriasis and lichen planus&#44; the main inflammatory nail diseases&#44; histological changes are seen in the superficial layers of the nail bed&#47;matrix&#46; Therefore&#44; the possibility of also using TB in the diagnosis of these diseases may encourage dermatologists to collect more biopsies and&#44; consequently&#44; define the diagnosis in a greater number of patients&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Punch biopsy&#44; without prior avulsion of the plate&#44; would be the ideal technique indicated for the investigation of inflammatory nail diseases&#44; due to better preservation of the superficial tissue morphology&#46; However&#44; it is a difficult task to introduce the punch through the nail plate&#44; maintaining the adhesion of the plate to the bed&#47;matrix during the rotation of the instrument&#46; Shearing often occurs&#46; Furthermore&#44; the idea is to soften the nail plate by using alkali before fixation&#44; to optimize the histological preparations&#46; This procedure and the delay in fixing the specimen can damage elements of the nail bed&#47;matrix&#44; which would help to define the diagnosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#8211;15</span></a> Careful detachment of the nail plate with a scalpel blade&#44; in TB&#44; proved to be effective in maintaining the integrity of the epithelium&#46; In the present study&#44; sending the overlying plate separately allowed additional microscopic evaluation&#44; without interfering with the histopathological processing&#46; The most frequent histomorphological findings in these samples were&#58; the absence of spongiosis &#40;12&#47;12&#41;&#44; dilated papillae vessels &#40;11&#47;11&#41;&#44; and parakeratosis &#40;11&#47;12&#41; &#40;<a class="elsevierStyleCrossRefs" href="#fig0025">Figs&#46; 5&#44; 9 and 10</a>&#41;&#46; Grover et al&#46; highlighted the findings of hyperkeratosis with parakeratotic areas &#40;91&#37;&#41;&#44; and dilated vessels&#44; in all patients with a confirmed clinical diagnosis of psoriasis&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><elsevierMultimedia ident="fig0045"></elsevierMultimedia><elsevierMultimedia ident="fig0050"></elsevierMultimedia><p id="par0120" class="elsevierStylePara elsevierViewall">The authors found full clinical-histological correlation in 75&#37; &#40;9&#47;12&#41; of patients&#44; a higher rate than those already reported&#44; whether in samples obtained by longitudinal or punch biopsies&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6</span></a> Hanno et al&#46; detected histomorphological findings that met the criteria for a specific nosological diagnosis in only 40&#37; of the studied cases&#59; of the six patients with clinical suspicion of psoriasis and the seven suggestive of lichen planus&#44; in only four and three patients&#44; respectively&#44; the diagnoses were confirmed&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Grover et al&#46; studied 22 patients with a clinical diagnosis of nail psoriasis&#44; collected samples through longitudinal and punch techniques&#44; and achieved a clinicopathological correlation of 54&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Perhaps the highest rate of clinical-histological correlation in the studied patients was due to the greater sampling in the width of the excised tissue&#44; made possible by TB&#44; associated with the care used in the technique&#44; from sample collection to histological reading&#44; in addition to the inclusion of additional histological criteria&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Hanno et al&#46; &#40;1986&#41; proposed the histological criteria to be considered for diagnosis of nail psoriasis&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Hyperkeratosis&#44; with parakeratosis&#44; intracorneal serous exudate&#44; a granular layer of irregular thickness&#44; and psoriasiform hyperplasia of the epidermis of the nail bed&#44; with dilation of the papillary blood vessels were described as minor criteria&#46; The finding of neutrophils on the bed epithelium surface&#44; with parakeratotic scales adhered to the nail plate&#44; was considered the major criterion&#46; To confirm the diagnosis of nail psoriasis&#44; the major criterion would be necessary&#44; with or without an associated minor criterion&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> In 2005&#44; Grover et al&#46; proposed an additional criterion&#58; negative PAS-stain for fungi&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> However&#44; the concomitance of nail psoriasis and onychomycosis is possible and described&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> Indeed&#44; neutrophil aggregates seem to be more common in onychomycosis and parakeratosis&#44; and more frequent in psoriasis&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> The authors postulate that the value neutrophils exudate as a major and mandatory criterion for diagnosis&#44; may be the main obstacle to the best clinicopathological correlation of former studies&#46; In the samples the authors analyzed&#44; a good clinical-histological correlation was obtained when using the following criteria&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">-</span><p id="par0130" class="elsevierStylePara elsevierViewall">Mandatory criterion&#58; dilatated dermal papillae vessels &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#59;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">-</span><p id="par0135" class="elsevierStylePara elsevierViewall">Secondary criteria &#40;at least three&#41;&#58; absence of spongiosis&#44; presence of parakeratosis&#44; psoriasiform epidermal hyperplasia&#44; focal thinning of the granular layer and suprapapillary epidermis&#44; and intra- or subcorneal neutrophils exudate &#40;<a class="elsevierStyleCrossRefs" href="#fig0025">Figs&#46; 5&#44; 9 and 10</a>&#41;&#46;</p></li></ul></p><p id="par0140" class="elsevierStylePara elsevierViewall">Additional nail plate analysis supported a diagnosis of psoriasis in three of 12 cases&#44; and in six cases&#44; the analysis of the subungual tissue was essential for the diagnosis&#46; Thus&#44; only a nail clipping specimen would be insufficient for diagnosis in the majority of patients&#46; Even so&#44; the authors emphasize that the nail plate must be analyzed&#44; as it can provide additional information&#44; in addition to allowing fungal research &#40;<a class="elsevierStyleCrossRef" href="#fig0030">Fig&#46; 6</a>&#41;&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">If the clinical findings are subtle&#44; with discreet pitting&#44; salmon patch&#44; or isolated subungual hyperkeratosis&#44; a histological analysis may be inconclusive&#46; In these cases&#44; the authors suggest clinical follow-up and biopsy indication if there are other associated clinical signs&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">In patients with subungual hyperkeratosis&#44; the TB of the nail bed must be a little deeper&#44; due to the risk of not reaching the dermis&#46; In the matrix&#44; a superficial tangential biopsy is sufficient to obtain adequate sampling of the papillary dermis&#46; Since many patients with nail psoriasis present with mixed clinical findings of nail bed and matrix involvement&#44; it is preferable and sufficient to obtain a biopsy of the nail bed&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Limitations</span><p id="par0155" class="elsevierStylePara elsevierViewall">In three of the 12 included patients&#44; the clinical and&#44; consequently&#44; histological nail changes were subtle &#40;one of them only had a salmon patch with onycholysis&#44; another subungual hyperkeratosis with splinter hemorrhages&#44; and the last&#44; isolated pitting&#41;&#46; Also&#44; in one patient TB sample&#44; the dermal papilla was not taken&#44; although sufficient histological changes were found in the epidermis and nail plate to reach a psoriasis diagnosis&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Conclusion</span><p id="par0160" class="elsevierStylePara elsevierViewall">The TB technique was found to be a good option for diagnosing the main inflammatory nail diseases because&#44; through it&#44; larger and thinner samples&#44; short postoperative recovery time&#44; and low risk of onychodystrophy were achieved&#46; TB allowed for defining the diagnosis&#44; especially when sufficient clinical elements were associated with histomorphological findings&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Financial support</span><p id="par0165" class="elsevierStylePara elsevierViewall">This work was carried out with the support of the Coordination for the Improvement of Higher Education Personnel - Brazil &#40;CAPES&#41; - Financing code 001&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Authors&#8217; contributions</span><p id="par0170" class="elsevierStylePara elsevierViewall">Laura Bertanha&#58; Participated in generating and analyzing the data&#59; wrote the majority of the original draft of the paper&#44; reviewed the pertinent raw data on which the results and conclusions of this study are based and approved the final version of this paper&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Ingrid Iara Damas&#58; Participated in generating data&#44; writing the paper and approved the final version of this paper&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">Rafael Fantelli Stelini&#58; Participated in generating data&#44; writing the paper&#44; reviewed the pertinent raw data on which the results and conclusions of this study are based and approved the final version of this paper&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">Maria Let&#237;cia Cintra&#58; Participated in designing&#44; generating and analyzing the data&#59; wrote the paper and reviewed the pertinent raw data on which the results and conclusions of this study are based and approved the final version of this paper&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">Nilton Di Chiacchio&#58; Participated in generating data&#44; writing the paper&#44; reviewed the pertinent raw data on which the results and conclusions of this study are based and approved the final version of this paper&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conflicts of interest</span><p id="par0195" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Histopathology can be crucial for diagnosis of inflammatory nail diseases&#46; Longitudinal excision and punch biopsies are the most used techniques to obtain the tissue sample&#46; However&#44; there is a low clinical-histopathological correlation&#44; besides the risk of nail dystrophy&#46; Tangential excision biopsy &#40;TB&#41; is a well-established technique for the investigation of longitudinal melanonychia&#46; TB could also be used to evaluate diseases in which histopathological changes are superficial&#44; as in psoriasis&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Objective</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">To study the value of TB in the histopathological diagnosis of nail psoriasis&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Methods</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">This is a prospective and descriptive study of the clinical-histopathological findings of samples from the nail bed or matrix and nail plate of 13 patients with clinical suspicion of nail psoriasis&#46; Biopsies were obtained through partial nail avulsion and TB&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">In nine patients&#44; the hypothesis of psoriasis was confirmed by histopathology&#59; in one&#44; the criteria for diagnosing nail lichen planus were fulfilled&#46; The tissue sample of only one patient did not reach the dermal papillae&#44; and&#44; in four of 13 patients&#44; the adventitial dermis was not sampled&#46; No patient developed onychodystrophy after the procedure&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Study limitations</span><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">In three patients&#44; the clinical and&#44; consequently&#44; histopathological nail changes were subtle&#46; Also&#44; in one patient&#8217;s TB didn&#8217;t sample the dermal papillae&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Conclusions</span><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">TB is a good option to assist in the histopathological diagnosis of nail psoriasis&#44; especially when appropriate clinical elements are combined&#46; Using this technique&#44; larger and thinner samples&#44; short postoperative recovery time&#44; and low risk of onychodystrophy are obtained&#46;</p></span>"
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Article information
ISSN: 03650596
Original language: English
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