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High-resolution ultrasound with Doppler as a confirmatory diagnostic method in retronychia
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This condition had been present for four months and was resistant to topical and oral antibiotics. She had active secretion and complete loss of the union of the proximal fold in the affected nail, henceforth chronic paronychia was the original diagnosis (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). A high-resolution ultrasound with Doppler analysis of the nail apparatus was requested. The findings established the diagnosis of rethonychia (<a class="elsevierStyleCrossRef" href="#fig0010">Figs. 2</a>‒<a class="elsevierStyleCrossRef" href="#fig0020">4</a>). Then we decided to perform a surgical intervention.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">Retronychia is a disorder of the nail apparatus in which there is an abnormal growth of the nail plate within the proximal fold, leading to the formation of several generations of misaligned nail plates under the fold.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Retronychia affects middle-aged adults, mostly females.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> It is characterized by unilateral involvement and affects almost exclusively the hallux.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Repeated trauma, pregnancy, puerperium, use of tight footwear, and anatomical alterations such as fingers in claws or curved nails have been described as associated factors.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">After persistent minor traumas, the process begins with an interruption of the growth of the nail plate that leads to its misalignment and incomplete separation from the matrix, where the nail plate loses its fixation in the proximal part of the bed but remains attached to the matrix in the lateral aspects.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> The nail plate moves in a retrograde direction and becomes embedded in the proximal nail fold, leading to inflammation and large tissue formation.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The new nail plate will push the old one upwards, leading to abnormal growth and inflammation, thus becoming a vicious cycle, where up to four generations of nail plates can be superimposed under the proximal nail fold. Retronychia often manifests as a chronic paronychia that is resistant to antimicrobial therapy.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">6</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The diagnosis of retronychia is based primarily on clinical aspects and is confirmed by imaging methods. There are different imaging modalities to study the ungular apparatus, including simple radiography, ultrasound, and Magnetic Resonance Imaging (MRI).<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">7</span></a> Ultrasound has proven to be useful; it has the advantage that it is a non-invasive method, it is accessible and helps in surgical planning.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">8</span></a> The type of ultrasound used for the diagnosis in the case presented is a high-resolution method with Doppler analysis, which is different from classical ultrasound. It uses transducers with higher frequencies, up to 22 MHz, that provide a complete and real-time view of the ungular apparatus. It differs by the addition of Doppler analysis and requires a trained person. In the literature, there is evidence of the use of this type of ultrasound to evaluate nail diseases. High-resolution ultrasound proves to be a precise and complete tool where various characteristics of the ungual apparatus can be evaluated that leads to a high histological correlation of different nail conditions.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">9</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">MRI is also another option. It is excellent for the evaluation of tumors, especially vascular tumors. However, it is highly costly, and it also requires complete immobility of the affected limb, making it difficult to use in the pediatric population.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">7</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Ultrasound criteria for rethonychia have been described:<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1.</span><p id="par0040" class="elsevierStylePara elsevierViewall">Presence of a hypoechoic halo surrounding the origin of the nail plate.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2.</span><p id="par0045" class="elsevierStylePara elsevierViewall">Distance (≤ v5.1 mm) between the origin of the nail plate and the base of the distal phalanx (thumbs and first toes) or a difference in this distance ≥ 0.5 mm compared to the contralateral healthy finger.</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3.</span><p id="par0050" class="elsevierStylePara elsevierViewall">Proximal nail fold thickness ≥ 2.2 mm in men or ≥ 1.9 mm in women and/or a thickness ≥ 0.3 mm compared to the contralateral healthy finger.</p></li></ul></p><p id="par0055" class="elsevierStylePara elsevierViewall">If it is unilateral, it must meet these three criteria; if it is bilateral, it can meet any of the three criteria.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Other findings on ultrasound in retronychia are:<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a><ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">•</span><p id="par0065" class="elsevierStylePara elsevierViewall">Two or more overlapping nail plates.</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">•</span><p id="par0070" class="elsevierStylePara elsevierViewall">Increased blood flow in the dermis of the proximal fold and the nail bed.</p></li></ul></p><p id="par0075" class="elsevierStylePara elsevierViewall">Possible causes of chronic paronychia such as infections, neoplasms, systemic diseases, and medications should be ruled out.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">The mainstay of treatment is based on surgical avulsion, performing a proximal approach to the old nail plate and the possible underlying ingrown plates.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> High-potency topical steroids could be used in conjunction with a bandage to fix the nail to the bed.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">To prevent retronychia it is important to recommend patients to wear comfortable shoes, avoid repetitive trauma, and in case of foot deformities these should be corrected.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Financial support</span><p id="par0090" class="elsevierStylePara elsevierViewall">None declared.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Authors’ contribution</span><p id="par0095" class="elsevierStylePara elsevierViewall">Cristina Vélez Arroyave: Critical literature review; preparation and writing of the manuscript and study conception and planning.</p><p id="par0100" class="elsevierStylePara elsevierViewall">Laura Carvajal Betancur: Critical literature review; preparation and writing of the manuscript and study conception and planning.</p><p id="par0105" class="elsevierStylePara elsevierViewall">Ángela María Londoño García: Approval of the final version of the manuscript; effective participation in research orientation and study conception and planning.</p><p id="par0110" class="elsevierStylePara elsevierViewall">Leonard Pacheco Peñaranda: Approval of the final version of the manuscript; effective participation in research orientation and study conception and planning.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflicts of interest</span><p id="par0115" class="elsevierStylePara elsevierViewall">None declared.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Financial support" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Authors’ contribution" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Conflicts of interest" ] 3 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2021-05-19" "fechaAceptado" => "2021-07-20" "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "⋆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Study conducted at the Sonoderma Institution, Medellín, Colombia.</p>" ] ] "multimedia" => array:4 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 678 "Ancho" => 2175 "Tamanyo" => 112458 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">There is absence of plate growth due to complete loss of the union of the proximal fold.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 645 "Ancho" => 2175 "Tamanyo" => 98513 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Sonoanatomy of the nail apparatus in retronychia: nail plate (white), nail bed (green), nail matrix (orange), inflammatory halo (purple), extensor tendon (red), subcutaneous tissue (yellow), dermis (pink), epidermis (orange) and phalanx (gray).</p>" ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1785 "Ancho" => 2925 "Tamanyo" => 332403 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">(a) High-resolution skin ultrasound with Doppler analysis performed with a 22 Mhz translator showed thickening of the nail bed with hypoechoic appearance. It measured 4.4 mm and did not show any signs of hypervascularization on the Doppler exam. However, it did show a reduction in the space between the origin of the nail plate and the base of the distal phalanx: its measure was approximately 3.5 mm and presented a hypoechoic inflammatory halo. (b) Normal anatomy of the nail.</p>" ] ] 3 => array:8 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 821 "Ancho" => 2925 "Tamanyo" => 159475 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0020" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">(a) Power Doppler around the nail plate. 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