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Nail Splinter Hemorrhage

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61. Psoriatic Arthritis (Follow-up)

with psoriatic arthritis, may include the following: Beau lines Leukonychia Onycholysis Oil spots Subungual hyperkeratosis Splinter hemorrhages Spotted lunulae Transverse ridging Cracking of the free edge of the nail Uniform nail pitting Extra-articular features are observed less frequently in patients with psoriatic arthritis than in those with rheumatoid arthritis (RA) but may include the following: Synovitis affecting flexor tendon sheaths, with sparing of the extensor tendon sheath Subcutaneous nodules (...) at the attachment of the Achilles tendon and the plantar fascia to the calcaneus with the development of insertional spurs Dactylitis with sausage digits is seen in as many as 35% of patients Skin lesions include scaly, erythematous plaques; guttate lesions; lakes of pus; and erythroderma Psoriasis may occur in hidden sites, such as the scalp (where psoriasis frequently is mistaken for dandruff), perineum, intergluteal cleft, and umbilicus Psoriatic nail changes, which may be a solitary finding in patients

2014 eMedicine.com

62. Psoriatic Arthritis (Follow-up)

with psoriatic arthritis, may include the following: Beau lines Leukonychia Onycholysis Oil spots Subungual hyperkeratosis Splinter hemorrhages Spotted lunulae Transverse ridging Cracking of the free edge of the nail Uniform nail pitting Extra-articular features are observed less frequently in patients with psoriatic arthritis than in those with rheumatoid arthritis (RA) but may include the following: Synovitis affecting flexor tendon sheaths, with sparing of the extensor tendon sheath Subcutaneous nodules (...) at the attachment of the Achilles tendon and the plantar fascia to the calcaneus with the development of insertional spurs Dactylitis with sausage digits is seen in as many as 35% of patients Skin lesions include scaly, erythematous plaques; guttate lesions; lakes of pus; and erythroderma Psoriasis may occur in hidden sites, such as the scalp (where psoriasis frequently is mistaken for dandruff), perineum, intergluteal cleft, and umbilicus Psoriatic nail changes, which may be a solitary finding in patients

2014 eMedicine.com

63. Psoriatic Arthritis (Follow-up)

with psoriatic arthritis, may include the following: Beau lines Leukonychia Onycholysis Oil spots Subungual hyperkeratosis Splinter hemorrhages Spotted lunulae Transverse ridging Cracking of the free edge of the nail Uniform nail pitting Extra-articular features are observed less frequently in patients with psoriatic arthritis than in those with rheumatoid arthritis (RA) but may include the following: Synovitis affecting flexor tendon sheaths, with sparing of the extensor tendon sheath Subcutaneous nodules (...) at the attachment of the Achilles tendon and the plantar fascia to the calcaneus with the development of insertional spurs Dactylitis with sausage digits is seen in as many as 35% of patients Skin lesions include scaly, erythematous plaques; guttate lesions; lakes of pus; and erythroderma Psoriasis may occur in hidden sites, such as the scalp (where psoriasis frequently is mistaken for dandruff), perineum, intergluteal cleft, and umbilicus Psoriatic nail changes, which may be a solitary finding in patients

2014 eMedicine.com

64. Dermatologic Manifestations of Cardiac Disease (Follow-up)

a common pathogenetic mechanism for baldness and coronary atherosclerosis. Petechiae Petechiae are found most frequently on the conjunctivae, palate, buccal mucosa, and upper extremities. They are found in persons with infective endocarditis. Splinter Hemorrhages Splinter hemorrhages are subungual, linear, dark-red streaks that may appear in persons with infective endocarditis. Roth Spots Roth spots are oval, retinal hemorrhages with a clear, pale center. Differential diagnoses include connective (...) Clubbing (Hypertrophic Osteoarthropathy) Definition represents a localized drumsticklike swelling of the distal segments of fingers and toes, particularly over the extensor surface. It is caused by connective tissue proliferation leading to increases in the sponginess of the soft tissue at the base of the nails due to stimulation by a humoral substance that causes dilation of the vessels of the fingertip or toe tip. [ ] Differential diagnosis Clubbing, as illustrated below, is seen in persons

2014 eMedicine.com

65. Dermatologic Manifestations of Gastrointestinal Disease (Follow-up)

macular or papular, sharply demarcated telangiectases on the face, lips, palate, tongue, ears, chest, or extremities, with occasional presentation under nails. The age of onset for the telangiectases is most often the third decade of life, although earlier presentations may occur during adolescence. Although the distribution of lesions and associated bleeding diathesis are clinically suggestive of hereditary hemorrhagic telangiectasia, it may occasionally be difficult to distinguish from similar (...) [ ] Esophagitis Scleroderma GI bleeding Hereditary hemorrhagic telangiectasia Cirrhosis Liver disease secondary to alcohol or other factors Vesicles/blisters/erosions Esophageal webs Epidermolysis bullosa Esophageal erosion Pemphigus vulgaris Pyloric atresia Junctional epidermolysis bullosa Hepatitis Porphyria cutanea tarda Malabsorption Dermatitis herpetiformis and celiac sprue Velvety hyperpigmented plaques, tripe palms, mucosal hyperplasia Gastric cancer Malignant acanthosis nigricans Yellowish papules

2014 eMedicine.com

66. Dermatologic Manifestations of Hematologic Disease (Follow-up)

, purpura, ecchymoses, painful skin nodules, and subungual splinter hemorrhages. Livedo reticularis is a presenting sign in up to 40% of patients with the diagnosis of SLE. [ ] Skin changes defined as livedo reticularis are violaceous, red or blue, reticular, or mottled pattern of the skin of the arms, legs, and the trunk. They are not reversible with rewarming. [ ] Noninflammatory vascular thrombosis is the most frequent finding in skin lesions of patients with antiphospholipid syndrome. Differential (...) as palpable purpura, is a characteristic lesion of cryoglobulinemia types II and III. The lesions are nonpruritic and transient. Mixed cryoglobulinemias present with the classic Melzer triad of purpura, arthralgias, and weakness in 25-30% of patients. Other cutaneous manifestations include polyarteritis nodosa–like lesions, splinter hemorrhages, and palmar erythema. [ ] Laboratory detection and analysis of monoclonal immunoglobulins or light chains are performed by using serum or urine protein

2014 eMedicine.com

67. Antiphospholipid Antibody Syndrome (Follow-up)

. The purplish hue is from stasis in the small vessel beds. Muddy discoloration and mild diffuse swelling of the fingers observed as part of the Raynaud phenomenon, which is associated with antiphospholipid antibody syndrome. At room temperature, this patient still has decreased capillary refill and cold fingers despite treatment with pentoxifylline. The discoloration extends proximally onto the palms and turns blue-purple when exposed to cold. Linear splinter hemorrhages are found under the nails of fingers (...) : Deterrence/Prevention See the list below: Adequate medical therapy Patient education Monitoring for new events Monitoring for drug adverse effects and toxicity Previous Next: Complications Hemorrhage may occur as a result of overaggressive therapy. Rethrombosis may occur as a result of inadequate therapy. Catastrophic antiphospholipid antibody syndrome can lead to death (50% mortality rate). Previous Next: Prognosis The long-term prognosis varies and depends on the tissue damage incurred and the organ

2014 eMedicine Pediatrics

68. Antiphospholipid Antibody Syndrome (Overview)

-purple when exposed to cold. Linear splinter hemorrhages are found under the nails of fingers and toes. These may be solitary or multiple and appear intermittently. One set of suggested algorithms for the workup and treatment of patients with antiphospholipid antibody syndrome. This should not be considered dogmatic because laboratory evaluation is not standardized and treatment remains empiric and controversial. Laboratory testing is not recommended in healthy asymptomatic individuals with no risk

2014 eMedicine Pediatrics

69. Foreign Body Removal, Wound

and at the bases of fingers or toes are useful anesthetic application options to consider prior to an extensive evaluation or removal attempt. Removal of a nail through the hand or foot is aided by blocking the relevant nerve distributions prior to an attempt. [ , ] Field blocks that surround the site of a splinter or staple entrance are essential for pain management during the procedure. A digital nerve block facilitates the removal of a fishhook through a finger and also helps in postprocedure pain (...) ; MASQUERADING AS PHARYNGOTONSILLITIS. Niger J Med . 2015 Oct-Dec. 24 (4):380-3. . Teng M, Doniger SJ. Subungual wooden splinter visualized with bedside sonography. Pediatr Emerg Care . 2012 Apr. 28(4):392-4. . Bumpus K, Maier MA. The ABC's of wound care. Curr Cardiol Rep . 2013 Apr. 15(4):346. . Halaas GW. Management of foreign bodies in the skin. Am Fam Physician . 2007 Sep 1. 76(5):683-8. . Freeman BJ, Ainscow DA. Nail gun injury: an update. Injury . 1994 Mar. 25(2):110-1. . O'Brien M, Hutton KA

2014 eMedicine.com

70. Psoriatic Arthritis (Diagnosis)

with psoriatic arthritis, may include the following: Beau lines Leukonychia Onycholysis Oil spots Subungual hyperkeratosis Splinter hemorrhages Spotted lunulae Transverse ridging Cracking of the free edge of the nail Uniform nail pitting Extra-articular features are observed less frequently in patients with psoriatic arthritis than in those with rheumatoid arthritis (RA) but may include the following: Synovitis affecting flexor tendon sheaths, with sparing of the extensor tendon sheath Subcutaneous nodules (...) at the attachment of the Achilles tendon and the plantar fascia to the calcaneus with the development of insertional spurs Dactylitis with sausage digits is seen in as many as 35% of patients Skin lesions include scaly, erythematous plaques; guttate lesions; lakes of pus; and erythroderma Psoriasis may occur in hidden sites, such as the scalp (where psoriasis frequently is mistaken for dandruff), perineum, intergluteal cleft, and umbilicus Psoriatic nail changes, which may be a solitary finding in patients

2014 eMedicine.com

71. Psoriatic Arthritis (Diagnosis)

with psoriatic arthritis, may include the following: Beau lines Leukonychia Onycholysis Oil spots Subungual hyperkeratosis Splinter hemorrhages Spotted lunulae Transverse ridging Cracking of the free edge of the nail Uniform nail pitting Extra-articular features are observed less frequently in patients with psoriatic arthritis than in those with rheumatoid arthritis (RA) but may include the following: Synovitis affecting flexor tendon sheaths, with sparing of the extensor tendon sheath Subcutaneous nodules (...) at the attachment of the Achilles tendon and the plantar fascia to the calcaneus with the development of insertional spurs Dactylitis with sausage digits is seen in as many as 35% of patients Skin lesions include scaly, erythematous plaques; guttate lesions; lakes of pus; and erythroderma Psoriasis may occur in hidden sites, such as the scalp (where psoriasis frequently is mistaken for dandruff), perineum, intergluteal cleft, and umbilicus Psoriatic nail changes, which may be a solitary finding in patients

2014 eMedicine.com

72. Psoriatic Arthritis (Diagnosis)

with psoriatic arthritis, may include the following: Beau lines Leukonychia Onycholysis Oil spots Subungual hyperkeratosis Splinter hemorrhages Spotted lunulae Transverse ridging Cracking of the free edge of the nail Uniform nail pitting Extra-articular features are observed less frequently in patients with psoriatic arthritis than in those with rheumatoid arthritis (RA) but may include the following: Synovitis affecting flexor tendon sheaths, with sparing of the extensor tendon sheath Subcutaneous nodules (...) at the attachment of the Achilles tendon and the plantar fascia to the calcaneus with the development of insertional spurs Dactylitis with sausage digits is seen in as many as 35% of patients Skin lesions include scaly, erythematous plaques; guttate lesions; lakes of pus; and erythroderma Psoriasis may occur in hidden sites, such as the scalp (where psoriasis frequently is mistaken for dandruff), perineum, intergluteal cleft, and umbilicus Psoriatic nail changes, which may be a solitary finding in patients

2014 eMedicine.com

73. Infective Endocarditis (Diagnosis)

signs of IE are found in as many as 50% of patients. They include the following: Petechiae: Common, but nonspecific, finding Subungual (splinter) hemorrhages: Dark-red, linear lesions in the nail beds Osler nodes: Tender subcutaneous nodules usually found on the distal pads of the digits Janeway lesions: Nontender maculae on the palms and soles Roth spots: Retinal hemorrhages with small, clear centers; rare Signs of neurologic disease, which occur in as many as 40% of patients, include the following (...) [ ] : Embolic stroke with focal neurologic deficits: The most common neurologic sign Intracerebral hemorrhage Multiple microabscesses Other signs of IE include the following: Splenomegaly Stiff neck Delirium Paralysis, hemiparesis, aphasia Conjunctival hemorrhage Pallor Gallops Rales Cardiac arrhythmia Pericardial rub Pleural friction rub Subacute native valve endocarditis The symptoms of early subacute native valve endocarditis (NVE) are usually subtle and nonspecific; they include the following: Low-grade

2014 eMedicine.com

74. Antiphospholipid Antibody Syndrome (Diagnosis)

-purple when exposed to cold. Linear splinter hemorrhages are found under the nails of fingers and toes. These may be solitary or multiple and appear intermittently. One set of suggested algorithms for the workup and treatment of patients with antiphospholipid antibody syndrome. This should not be considered dogmatic because laboratory evaluation is not standardized and treatment remains empiric and controversial. Laboratory testing is not recommended in healthy asymptomatic individuals with no risk

2014 eMedicine Pediatrics

75. Antiphospholipid Antibody Syndrome (Treatment)

antibody syndrome. At room temperature, this patient still has decreased capillary refill and cold fingers despite treatment with pentoxifylline. The discoloration extends proximally onto the palms and turns blue-purple when exposed to cold. Linear splinter hemorrhages are found under the nails of fingers and toes. These may be solitary or multiple and appear intermittently. One set of suggested algorithms for the workup and treatment of patients with antiphospholipid antibody syndrome. This should

2014 eMedicine Pediatrics

76. Endocarditis (Diagnosis)

of IE are found in as many as 50% of patients. They include the following: Petechiae: Common, but nonspecific, finding Subungual (splinter) hemorrhages: Dark-red, linear lesions in the nail beds Osler nodes: Tender subcutaneous nodules usually found on the distal pads of the digits Janeway lesions: Nontender maculae on the palms and soles Roth spots: Retinal hemorrhages with small, clear centers; rare Signs of neurologic disease, which occur in as many as 40% of patients, include the following (...) [ ] : Embolic stroke with focal neurologic deficits: The most common neurologic sign Intracerebral hemorrhage Multiple microabscesses Other signs of IE include the following: Splenomegaly Stiff neck Delirium Paralysis, hemiparesis, aphasia Conjunctival hemorrhage Pallor Gallops Rales Cardiac arrhythmia Pericardial rub Pleural friction rub Subacute native valve endocarditis The symptoms of early subacute native valve endocarditis (NVE) are usually subtle and nonspecific; they include the following: Low-grade

2014 eMedicine Emergency Medicine

77. Endocarditis (Overview)

are found in as many as 50% of patients. They include the following: Petechiae: Common, but nonspecific, finding Subungual (splinter) hemorrhages: Dark-red, linear lesions in the nail beds Osler nodes: Tender subcutaneous nodules usually found on the distal pads of the digits Janeway lesions: Nontender maculae on the palms and soles Roth spots: Retinal hemorrhages with small, clear centers; rare Signs of neurologic disease, which occur in as many as 40% of patients, include the following [ ] : Embolic (...) stroke with focal neurologic deficits: The most common neurologic sign Intracerebral hemorrhage Multiple microabscesses Other signs of IE include the following: Splenomegaly Stiff neck Delirium Paralysis, hemiparesis, aphasia Conjunctival hemorrhage Pallor Gallops Rales Cardiac arrhythmia Pericardial rub Pleural friction rub Subacute native valve endocarditis The symptoms of early subacute native valve endocarditis (NVE) are usually subtle and nonspecific; they include the following: Low-grade fever

2014 eMedicine Emergency Medicine

78. Psoriatic Arthritis (Treatment)

with psoriatic arthritis, may include the following: Beau lines Leukonychia Onycholysis Oil spots Subungual hyperkeratosis Splinter hemorrhages Spotted lunulae Transverse ridging Cracking of the free edge of the nail Uniform nail pitting Extra-articular features are observed less frequently in patients with psoriatic arthritis than in those with rheumatoid arthritis (RA) but may include the following: Synovitis affecting flexor tendon sheaths, with sparing of the extensor tendon sheath Subcutaneous nodules (...) at the attachment of the Achilles tendon and the plantar fascia to the calcaneus with the development of insertional spurs Dactylitis with sausage digits is seen in as many as 35% of patients Skin lesions include scaly, erythematous plaques; guttate lesions; lakes of pus; and erythroderma Psoriasis may occur in hidden sites, such as the scalp (where psoriasis frequently is mistaken for dandruff), perineum, intergluteal cleft, and umbilicus Psoriatic nail changes, which may be a solitary finding in patients

2014 eMedicine.com

79. Psoriatic Arthritis (Treatment)

with psoriatic arthritis, may include the following: Beau lines Leukonychia Onycholysis Oil spots Subungual hyperkeratosis Splinter hemorrhages Spotted lunulae Transverse ridging Cracking of the free edge of the nail Uniform nail pitting Extra-articular features are observed less frequently in patients with psoriatic arthritis than in those with rheumatoid arthritis (RA) but may include the following: Synovitis affecting flexor tendon sheaths, with sparing of the extensor tendon sheath Subcutaneous nodules (...) at the attachment of the Achilles tendon and the plantar fascia to the calcaneus with the development of insertional spurs Dactylitis with sausage digits is seen in as many as 35% of patients Skin lesions include scaly, erythematous plaques; guttate lesions; lakes of pus; and erythroderma Psoriasis may occur in hidden sites, such as the scalp (where psoriasis frequently is mistaken for dandruff), perineum, intergluteal cleft, and umbilicus Psoriatic nail changes, which may be a solitary finding in patients

2014 eMedicine.com

80. Fingernail psoriasis reconsidered: A case-control study. (PubMed)

examination. The disease severity was measured by the NAPSI.Mean NAPSI score in patients and control subjects was 26.6 and 3.6, respectively. Most items included in the NAPSI were specific for nail psoriasis. Onycholysis and splinter hemorrhages were most frequently observed. Leukonychia was more frequent in control subjects. Longitudinal ridges and Beau lines are not included in the NAPSI but are significantly more frequently seen in patients than in control subjects.Limited sample size (...) was a limitation.The NAPSI was able to discriminate patients with fingernail psoriasis from healthy control subjects. Onycholysis and splinter hemorrhages were the most prevalent fingernail changes in psoriatic patients. Leukonychia was more frequently observed in control subjects, which raises the question of whether leukonychia should remain in the NAPSI. On the other hand, longitudinal ridges and Beau lines occurred more frequently in psoriasis but are not included in the NAPSI.Copyright © 2013 American Academy

2013 Journal of American Academy of Dermatology

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