Nail biopsy

Nail biopsy

1. DR.YUGANDAR NAIL BIOPSY

2. Nail Biopsy Two Primary reasons to perform biopsy - Confirm diagnosis of disease - Remove neoplasm or correct deformity (d/t pain )

3. 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

4. Nail Biopsy Indications: Differentiate b/w inflammatory & infective disorders affecting nail unit To establish diagnosis of one or 20- nail dystrophy

5. Nail Biopsy To establish cause of longitudinal pigmented streaks Differentiate Subungual hematoma & Malignat melanoma

6. Nail Biopsy Indications: Differentiate benign & malignant tumours To identify the cause of pain ( eg Glomus tumour ) Contraindications: Severe uncontrolled diabete Severe Peripheral vascular diseases

7. Nail Biopsy Biopsies of nail : Nail Plate Nail bed Nail Matrix Nail fold Nail unit Biopsy ( Combined Biopsy of LNF,Lateral Nail Matrix & PNF )

8. Different types of nail biopsy

9. Site & technique of nail biopsy for common nail disorders

10. Site & technique of nail biopsy for common nail disorders

11. All biopsy or excision should be taken down to bone ( No subcutaneous tissue in nail)

12. 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

13. 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,Previous diagnostic tests,

14. Nail Biopsy Cutaneous H/O- H/O Nail Condition (Duration,Progression,Exposure,Trauma) Previous Malignancies,Fungal,Bacterial infections,Psoriasis,Lichen planus Occupation,Hobbies

15. Nail Biopsy Examination: All 20 nails,good lighting & magnification Mucous membranes,hair & Scalp Perpheral pulses

16. Nail Biopsy Laboratory tests: X-ray,Mycology,Microbiology

17. 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

18. 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

19. 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

20. 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

21. Nail Biopsy Penrose drains English nail splitter,clippers Disposable biopsy punches

22. Nail Biopsy Instruments Double action nail nipper & Freer Eleavator on left side of tray

23. Fine Curved ( Castro Veijo’s ) scissors,Fine Curved ( Jewellers ) forceps,Nail spatula ,Nail splitter & Disposable Biopsy Punches

24. Freer Eleavator – Proximal nail Plate avulsion English Nail splitter used to divide nail plate prior nail avulsion Nail Biopsy Instruments

25. 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

26. Nail Biopsy Lidocaine with adreanaline combination for digital anesthesia still controversy

27. Nail Biopsy Digital Anesthesia: Distal nail blocks Distal digital block Distal anesthesia through PNF Distal anesthesia through hyponychium

28. Nail Biopsy Proximal digital blocks Transthecal digital blocks Regional blocks

29. 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

30. 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 )

31. Nail Biopsy Different Digital sites of injection for Ring block

32. Site of Lidocaine injections for wing & digital block

33. 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

34. Advantages Disadvantages Immediate effect < 1 min Low risk of neurovascular compromise Induces compression hemostasis Local injection Relatively painful May cause inadequate coverage & swelling of surgical field in large surgeries Nail Biopsy Distal Digital Block

35. Distal Digital Block

36. Median Distal Block

37. 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

38. Dorsal View Ventral View Proximal Digital block

39. 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

40. Tourniquet Sterile Glove used as Tourniquet

41. 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

42. Penrose drain Sterile glove with artery forceps Tourniquet

43. Patterns of Nail Biopsy Nail Avulsion Nail bed biopsy Matrix biopsy Lateral Longitudinal nail biopsy 2. Transverse matrix biopsy 3.Matrix shave

44. 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

45. 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

46. Proximal hemiavulsion of nail plate Procedure: The origin of the nail and its proximal lateral aspects are undermined with a septum elevator. In nails with a shallow lateral nail fold, a nail splitter may be inserted and the nail transversely bisected. 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.

47. Nail Avulsion After Partial Nail Avulsion Nail bed can be seen & biopsed along longitudinal access

48. Nail Avulsion Freer Eleavator inserted under nail plate Loosened nail plate is grabed with hemostat & removed

49. Nail Avulsion Digital block has been performed

50. Nail Avulsion Apply rubber band

51. Nail Avulsion Release eponychium and lateral side

52. Nail Avulsion Cut complete nail (proceed under the cuticle), when the proximal edge is cut a 'give' can be felt

53. Nail Avulsion Grasp as much nailplate into needledriver or hemostat

54. Nail Avulsion Continue cutting undernath cuticle

55. Nail Avulsion Remove nailplate by gentle traction and rotating outward

56. Distal Nail Avulsion Proximal Nail Avulsion Nail Avulsion

57. 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

58. Removal of Nail Plate

59. 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

60. 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

61. Nail Bed Biopsy It may reattach or at least provide a natural dressing during the early healing phase. No Scarring from biopsy

62. Nail Bed Biopsy Suspected nail bed glomus tumour

63. Nail Bed Biopsy Subungual glomus tumour seen as a bluish mass after nail plate avulsion

64. Nail Bed Biopsy Excision of tumour done Nail bed incisons are oriented longitudinally

65. Nail Bed Biopsy > 3 mm size needs to be sutured

66. Punch Biopsy Fusiform Biopsy Nail Bed Biopsy

67. 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

68. 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

69. 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

70. Nail Matrix Biopsy

71. 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

72. 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

73. 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

74. 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

75. Lateral Longitudinal Nail biopsy A Large Lateral Longitudinal biopsy is closed with sutures designed to reconstruct lateral nail fold

76. Lateral Longitudinal Nail biopsy Area to be excised outlined,The incision is linear medially & curved laterally

77. Lateral Longitudinal Nail biopsy The incision is carried down to periosteum & tissue is lifted up with sharp scissors

78. Lateral Longitudinal Nail biopsy The separated specimen forhistopathologic examination

79. Lateral Longitudinal Nail biopsy The defect is sutured back

80. Lateral Longitudinal Nail biopsy Lateral portions of nail unit excised enbloc Includes Hyponychium,nail plate,nail matrix,nail bed & PNF

81. 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

82. 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

83. 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.

84. 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 specimen The nail plate is replaced to prevent contact between the wound and ventral aspect of the nail fold suture repair is not required.

85. Matrix shave or tangential biopsy

86. 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.

87. Proximal nail fold biopsy Method of removing small lesion from the PNF

88. 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.

89. 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.

90. 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

91. 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

92. Crescentic nail fold biopsy Crescentic shave of distal PNF & Cuticle as Rx of Ch Paronychia

93. 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.

94. 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

95. 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

96. 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

97. 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 )

98. Nail Biopsy Advantages: Never scarring,Easy Procedure Useful in Isolated nail manifestaions Gives a definitive diagnosis of onychomycosis Most useful in longitudinal melanonychia & suspected malignant melanoma Therapeutic benefit in glomus tumour

99. 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

100. Nail Plate Nail bed epithelium N. Matrix Hyponychium N. Bed dermis

101. Nail Plate Nail bed epithelium N. Matrix Hyponychium N. Bed dermis

102. 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

103. Nail Plate biopsy with adherent nail plate epithelium showing evidence of subungual wart Marked papillomatosis of nail bed epithelium

104. Onychomycosis Fungal Pseudohyphae seen in a nail plate biopsy

105. 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

106. Psoriasis Nail unit biopsy showing Parakeratosis Hypergranulosis Parakeratotic abscess Serum crusting

107. Psoriasis Spongitic Pustule seen in Epidermis Absence of Granular layer,Acanthosis of Epidermis,Vascular Changes

108. Lichen Planus Basal layer dissolution & band like infiltrate in epidermis can be seen

109. Hyperkeratosis & Superficial Lymphocytic infiltrate Band like superficial lymphocytic infiltrate along with vacuolar degenration Lichen Planus

110. Melanonychia Pigment laden cells in dermis & Epidermal pigmentation – Melanocytes activation

111. Nail clippings show Budding yeasts Candida

112. 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

113. Thank you Have a nice day