• In recent years, the usefulness of trichoscopy (scalp dermoscopy) (videodermatoscopy) has been reported for diagnosing hair loss diseases. This method allows viewing of the hair and scalp at X20 to X160 magnifications. Characteristic trichoscopy features of alopecia areata are black dots, tapering hairs (exclamation mark hairs), broken hairs, yellow dots, and short vellus hairs. In androgenetic alopecia (AGA), hair diameter diversity (HDD), perifollicular pigmentation/peripilar sign, and yellow dots are trichoscopically observed. In all cases of AGA and female AGA, HDD, more than 20%, which corresponds to vellus transformation, can be seen. In cicatricial alopecia (CA), the loss of orifices, a hallmark of CA, and the associated changes including perifollicular erythema or scale and hair tufting were observed. Different hair shafts variation such as vellus, terminal, micro-exclamation mark type, monilethrix, Netherton type, and pili annulati hairs can be seen . The number of hairs in one pilosebaceous unit can be assessed. Healthy Hair follicles variation healthy, empty, fibrotic ("white dots"), filled with hyperkeratotic plugs ("yellow dots"), or containing dead hair ("black dots"). Abnormalities of scalp skin color or structure include honeycomb-type hyperpigmentation, perifollicular discoloration (hyperpigmentation), and scaling are also seen with the help of trichoscopy.
This is a powerpoint presentation on the epidermal keratinization and its associated disorders, presented by Dr. Jerriton, Dermatology resident of SVMCH, Pondicherry.
Dermoscopy or epiluminescence microscopy
A simple, noninvasive method to examine the subsurface features of the skin.
Structures seen
Epidermis
Dermoepidermal junction
Superficial dermis
3 types of dermoscope
1.Nonpolarized devices
2.Polarized devices
3.Hybrid devices
Dermoscopy is used in:
1.Evaluating pigmented skin lesions
2.Evaluating nonpigment skin lesions
3.Entomodermoscopy
4.Trichoscopy
5.Onychoscopy
different dermoscopic patterns are used to diagnose the dermatological diseases are
1. melanocytic patterns:
Pigmentary patterns: typical pigment pattern, atypical pigment patter, pseudonetwork
dots and globules
Blue white veil
star brust pattern
2, Non melanocytic pattern:
milia like cyst
comedo like opening
3. vascular patterns:
lacunae
arborizing vessels
comma like vessels
corkscrew vessel
red dots
glomerular vessels
linear vessels
etc
• In recent years, the usefulness of trichoscopy (scalp dermoscopy) (videodermatoscopy) has been reported for diagnosing hair loss diseases. This method allows viewing of the hair and scalp at X20 to X160 magnifications. Characteristic trichoscopy features of alopecia areata are black dots, tapering hairs (exclamation mark hairs), broken hairs, yellow dots, and short vellus hairs. In androgenetic alopecia (AGA), hair diameter diversity (HDD), perifollicular pigmentation/peripilar sign, and yellow dots are trichoscopically observed. In all cases of AGA and female AGA, HDD, more than 20%, which corresponds to vellus transformation, can be seen. In cicatricial alopecia (CA), the loss of orifices, a hallmark of CA, and the associated changes including perifollicular erythema or scale and hair tufting were observed. Different hair shafts variation such as vellus, terminal, micro-exclamation mark type, monilethrix, Netherton type, and pili annulati hairs can be seen . The number of hairs in one pilosebaceous unit can be assessed. Healthy Hair follicles variation healthy, empty, fibrotic ("white dots"), filled with hyperkeratotic plugs ("yellow dots"), or containing dead hair ("black dots"). Abnormalities of scalp skin color or structure include honeycomb-type hyperpigmentation, perifollicular discoloration (hyperpigmentation), and scaling are also seen with the help of trichoscopy.
This is a powerpoint presentation on the epidermal keratinization and its associated disorders, presented by Dr. Jerriton, Dermatology resident of SVMCH, Pondicherry.
Dermoscopy or epiluminescence microscopy
A simple, noninvasive method to examine the subsurface features of the skin.
Structures seen
Epidermis
Dermoepidermal junction
Superficial dermis
3 types of dermoscope
1.Nonpolarized devices
2.Polarized devices
3.Hybrid devices
Dermoscopy is used in:
1.Evaluating pigmented skin lesions
2.Evaluating nonpigment skin lesions
3.Entomodermoscopy
4.Trichoscopy
5.Onychoscopy
different dermoscopic patterns are used to diagnose the dermatological diseases are
1. melanocytic patterns:
Pigmentary patterns: typical pigment pattern, atypical pigment patter, pseudonetwork
dots and globules
Blue white veil
star brust pattern
2, Non melanocytic pattern:
milia like cyst
comedo like opening
3. vascular patterns:
lacunae
arborizing vessels
comma like vessels
corkscrew vessel
red dots
glomerular vessels
linear vessels
etc
Subspecialty of dermatology and pathology focused on performing and interpreting tests on human tissue samples to provide scientific data and consultative opinions to referring clinicians
about various genodermatoses and classified according to clinical presentation.
mentioned are introduction clinical features histology management of each disease.
Androgenetic alopecia (AGA) is a nonscarring progressive miniaturization of the hair follicle in genetically predisposed men and women, usually in a specific pattern distribution.
Multifactorial and polygenetic etiology.
Clinical features:
-History of hair loss is -
long standing
slowly progressing reduction of hair density, diameter
Miniaturization of hair
Diminished anagen hair and increased telogen hair
-Pattern of hair loss in male:
Hamilton- Norwood type: recession of frontal hair line, latter followed by a vertex thinning with progression until top of the scalp is completely bald.
-Pattern of hair loss in female:
Centrofrontal hair loss with preservation of frontal hair line
(Ludwig type) {figure - left}
Christmas tree pattern {figure- right}
-Family history of AGA often positive
In female
signs of hyperandrogenism should be evaluated
gynecological history
progesterone containing pills
-To exclude other causes history should be taken regarding-
Thyroid disease,
Surgery, infection in last 6months to 1 year
Drug history
Iron deficiency
Smoking
UV exposure
Hair color, cosmetics use.
Allergic contact dermatitis
Treatment:
Androgenic alopecia is naturally progressive , so main strategy is to prevent progression and increase hair density.
1.Topical minoxidil:
2% for female and 5% spray for male 1 ml twice daily or half cup foam once daily.
There is transitory telogen shedding within first 8 weeks observed.
Response should be assessed after 6 months.
If response occurs, will be continued as main stay of treatment.
2.Finasteride oral ad Dutasteride oral
1 mg finasteride per day prevents progression of AGA .
0.5 mg daily dutasteride is alternative.
Combination of topical minoxidil and finasteride is good option
Response evaluated after 6 months . not indicated in women. Contraindicated in pregnant and child bearing female.
3.Antiandrogen and estrogenic drugs:
Given in hyperandrogenism in female. Not indicated in male.
Spironolactone 100-200 mg daily
Cyproterone acetate can be used
4.Hair transplantation
5.Low-level laser therapy
6.Miscellaneous: low level of evidence.
Platelet rich plasma therapy and microneedling
Herbal preparations
Topical melatonin
Nutritional supplement of- biotin, copper, zinc, aminoacids, micronutrients
Subspecialty of dermatology and pathology focused on performing and interpreting tests on human tissue samples to provide scientific data and consultative opinions to referring clinicians
about various genodermatoses and classified according to clinical presentation.
mentioned are introduction clinical features histology management of each disease.
Androgenetic alopecia (AGA) is a nonscarring progressive miniaturization of the hair follicle in genetically predisposed men and women, usually in a specific pattern distribution.
Multifactorial and polygenetic etiology.
Clinical features:
-History of hair loss is -
long standing
slowly progressing reduction of hair density, diameter
Miniaturization of hair
Diminished anagen hair and increased telogen hair
-Pattern of hair loss in male:
Hamilton- Norwood type: recession of frontal hair line, latter followed by a vertex thinning with progression until top of the scalp is completely bald.
-Pattern of hair loss in female:
Centrofrontal hair loss with preservation of frontal hair line
(Ludwig type) {figure - left}
Christmas tree pattern {figure- right}
-Family history of AGA often positive
In female
signs of hyperandrogenism should be evaluated
gynecological history
progesterone containing pills
-To exclude other causes history should be taken regarding-
Thyroid disease,
Surgery, infection in last 6months to 1 year
Drug history
Iron deficiency
Smoking
UV exposure
Hair color, cosmetics use.
Allergic contact dermatitis
Treatment:
Androgenic alopecia is naturally progressive , so main strategy is to prevent progression and increase hair density.
1.Topical minoxidil:
2% for female and 5% spray for male 1 ml twice daily or half cup foam once daily.
There is transitory telogen shedding within first 8 weeks observed.
Response should be assessed after 6 months.
If response occurs, will be continued as main stay of treatment.
2.Finasteride oral ad Dutasteride oral
1 mg finasteride per day prevents progression of AGA .
0.5 mg daily dutasteride is alternative.
Combination of topical minoxidil and finasteride is good option
Response evaluated after 6 months . not indicated in women. Contraindicated in pregnant and child bearing female.
3.Antiandrogen and estrogenic drugs:
Given in hyperandrogenism in female. Not indicated in male.
Spironolactone 100-200 mg daily
Cyproterone acetate can be used
4.Hair transplantation
5.Low-level laser therapy
6.Miscellaneous: low level of evidence.
Platelet rich plasma therapy and microneedling
Herbal preparations
Topical melatonin
Nutritional supplement of- biotin, copper, zinc, aminoacids, micronutrients
Toe nail fungus medicine:- An Effective Medicine for Toe Nails FungusSara Anthony
If you have painful nails with yellow patches on it having foul odour, you are suffering from Toenail fungus. Don’t avoid this harmful disease take proper care and use Toenail fungus medicine.
Valuable clinical guide for soft tissue diode laser users with pre & post operative pics , useful , fully informative with tips helps my beloved coleagues to enjoy & profession the use of soft tissue dental laser #clinical_dental_laser #dental_laser #soft_tissue_laser
Flap Design, one from important topics in Oral Surgery Syllabus, student must be know:
Definition Incision and flap.
Principles of flap design.
Enumerate types of flap with advantages, disadvantages, indications...
Complications.
A periodontal flap is a section of gingiva and/mucosa that is surgically separated from the underlying tissue to provide visibility and the access to the bone and the root surface. The flap also allows the gingiva to be displaced to a different location in patients with mucogingival involvement.
In this PowerPoint presentation, the periodontal flap is described under the headings: indication, contraindications, classification of flaps, flap design, horizontal and vertical incisions and various flap technique such as modified widman flap, undisplaced flap, palatal flap, apically displaced flap, papilla preservation flap and distal molar surgery for maxillary and mandibular molars. It also contains healing after flap surgery.
A must read seminar on Dental Implants for Under-Graduates and Post-Graduates.
If you have any doubts regarding Dental Implants or any topic if you are unable to understand then do feel free to contact me on my Email address: Dr.anujparihar@gmail.com
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
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
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 )
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
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
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
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 )
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
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
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
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
43. Patterns of Nail Biopsy
Nail Avulsion
Nail bed biopsy
Matrix biopsy
1. 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:
1. The origin of the nail and its proximal lateral
aspects are undermined with a septum elevator.
2. In nails with a shallow lateral nail fold, a nail
splitter may be inserted and the nail transversely
bisected.
3. In nails with a deep lateral nail fold, a deep
transverse score is placed with a scalpel across the
nail halfway along its length.
4. The septum elevator is then fully inserted through
the transverse score to loosen,elevate proximal nail.
47. Nail Avulsion
After Partial Nail
Avulsion Nail bed can be
seen & biopsed along
longitudinal access
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
60. 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
61. 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
62. Nail Bed Biopsy
It may reattach or at least provide a natural dressing
during the early healing phase.
No Scarring from biopsy
68. 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
69. 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
70. 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
72. 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
73. 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
74. 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
75. 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
76. Lateral Longitudinal Nail biopsy
A Large Lateral Longitudinal
biopsy is closed with sutures
designed to reconstruct
lateral nail fold
77. Lateral Longitudinal Nail biopsy
Area to be excised
outlined,The
incision is linear
medially & curved
laterally
78. Lateral Longitudinal Nail biopsy
The incision is
carried down to
periosteum &
tissue is lifted
up with sharp
scissors
81. Lateral Longitudinal Nail biopsy
Lateral portions of nail
unit excised enbloc
Includes
Hyponychium,nail
plate,nail matrix,nail bed
& PNF
82. 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
83. 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
84. 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.
85. 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.
87. 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.
89. 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.
90. 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.
91. 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
92. 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
93. Crescentic nail fold biopsy
Crescentic shave of distal PNF & Cuticle as Rx of Ch Paronychia
94. 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.
95. 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
96. 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
97. 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
98. 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 )
99. 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
100. 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
104. 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
105. Nail Plate biopsy with adherent nail plate epithelium
showing evidence of subungual wart
Marked papillomatosis of nail bed epithelium
107. Nail clippings show septate hyphal
elements proven to be Trichophyton
sp with in nail plate keratin
90 % Toe nail infections with
Trichophyton,Microsporum,Epi
dermophyton 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
108. Psoriasis
Nail unit biopsy showing
Parakeratosis
Hypergranulosis
Parakeratotic abscess
Serum crusting
114. 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
