Medical and Surgical Management of Nail Disorders: F117Molly Hinshaw, MD

Associate Professor of Dermatology & DermatopathologyUWHealth in Madison, WI

mhinshaw@dermatology.wisc.edu

DISCLOSURESI do not have any relevant relationships with industry.

DISCLOSURE OF RELATIONSHIPS WITH INDUSTRYDISCLOSURE OF RELATIONSHIPS WITH INDUSTRY

FOTOGRAFIA E FILMANDO SÃO ESTRITAMENTE PROIBIDOS EM TODAS AS SESSÕES EDUCACIONAIS

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PHOTOGRAPHY & VIDEOTAPING ARE STRICTLY PROHIBITED IN ALL EDUCATIONAL SESSIONS

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Session directors will be closely monitoring such occurrences.

Case

• F in her 50s presented with a 2 month history of a lesion of the left nail matrix

Biopsy Proven Pyogenic Granuloma (PG) • First visit: punch biopsy, dx PG confirmed, immediately recurred • RTC 1 weeks later, shave with light cautery (Epilady, 3Hz), bx=PG• Recurred the next day• Punch removal, gelfoam, did not submit• Recurred 3wks later, repeat shave• Started Timolol, did not recur

1st

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1st Visit

2nd

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Pyogenic granuloma the quest for optimum treatment: Audit of treatment of 408 cases*A.V. Giblin*, A.J.P. Clover, A. Athanassopoulos, P.G. Budny. J Plast, Reconstr & Aesthetic Surg 2007; 60:130-5.

• Retrospective study• No mention of which on upper or lower extremity were in nail unit• 80% treated with excision (326 lesions), 3.7% recurrence rate• 19% treated with curettage, shave excision, cautery or combination,

10.3 % recurrence rate with these treatments • Overall recurrence rate 5% • 20 lesions recurred, 50% of these were on fingers, 35% head/neck• Authors conclusion: The preferred treatment for PG is excision with

linear closure

Management of PG: Options

• Surgical: excision, shave, cautery, curettage• Procedural: cryotherapy, pulsed dye laser • Medical: silver nitrate, imiquimod, timolol• Combination• What is best?

β-Adrenergic receptor expression in vascular tumorsKaren M Chisholm, Kay W Chang, Mai T Truong, Shirley Kwok, Rob B West1 and Amy E Heerema-McKenney. Modern Pathol 2012; 25: 1446-51.

• Propranolol emerged as effective Rx for infantile hemangiomas (IH)• Β-adrenergic receptor antagonist thought to cause vasoconstriction

by its effect on nitric oxide, block angiogenesis by its effect on VEGF, and induce apoptosis

• Authors previously found βARs on 1 IH that responded to propranolol• Now sought to eval βAR expression on a variety of vascular tumors

using tissue microarray• The array was immunostained for B2-AR, B2-ARP, and B3-AR & results

scored for intensity of endothelial cell expression as: Negative, Weak +, Strong +

• All phases of IH had strong expression of all 3 receptors with the exception of weak expression of B2-AR in the proliferative phase

• Small number of PGs with staining adequate for interpretation, weak staining 50% of cases

1st Case Report of PG Rx with Topical Beta Blocker: Timolol 0.5% gel

• Lesion developed 4 mo prior, friable, had bled. No Bx. • βblockers inc. topicals used for IHs, therefore decided to try for PG• Resolved after 1 mo of Rx, no recurrence at 8 mo phone follow-up

PG in a 5 month old treated with timolol

Take Home Points: Pyogenic Granuloma (PG)

• PG is a biopsy diagnosis. Must exclude melanoma, NMSC esp adults• Frequent problem in pts on retinoids, EGFR inhibitors, etc.• Pathogenesis unknown, disordered angiogenesis, βAR expression• Limited studies on Tx for PG, most frequently used Tx are destructive• In the nail, do no harm, limit scarring• Timolol for PG was first described in 2014• Is a consideration in adults for recurrent biopsy proven PG (?bx kids)• Studies comparing treatments for PG including beta blockers needed

Thank You!

Molly Hinshaw, MDAssociate Professor of Dermatology & Dermatopathology

UWHealth in Madison, WImhinshaw@dermatology.wisc.edu