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Case study
A previously healthy man, 43 years of age, was referred to the dermatology department with a one-year history of fingernail onychomycosis. His condition was refractory to oral antifungal treatment (terbinafine 250 mg QD for three months). On physical examination, nail pitting and onycholysis affecting seven fingernails was noted (Figure 1A). He also had mild erythematous silvery-white scaly patches in the left external ear canal (Figure 1B) and slight, fine scaling of the scalp, which was associated with mild pruritus. No other skin lesions were detected.
Question 1
What is the most likely diagnosis for this patient?
Question 2
How do you diagnose this disease?
Question 3
Are there other possible diagnoses?
Question 4
What may be the implications of nail involvement in this disease?
Question 5
How do you manage this patient?
Answer 1
The most likely diagnosis in this case is psoriasis with mainly fingernail involvement - nail psoriasis. Although nail psoriasis occurs as an isolated symptom in only 5-10% of patients, it is present in approximately 50% of patients with psoriasis.1
This patient presented with nail plate depressions (nail pitting) and nail detachment from the nail bed (onycholysis), two of the most common features of nail psoriasis. However, these features alone are not specific enough to make this diagnosis as they can be present in several other conditions.2 The combination of the nail pitting and onycholysis with the silvery-white, scaly patches in the external ear canal and scalp (classical signs of skin psoriasis) makes nail psoriasis the most likely diagnosis in this case.
Answer 2
It is easier to...