Purulent-necrotic surgical onychopatology (nail pathology), author’s view: some problems of diagnostics and complex treatment of complicated And combined cases

Abstract

The aim of the work: to research and improve the effectiveness of complex treatment of chronic and combined purulent-necrotic patho­logy of the distal hands and foot, in particular “surgical onychopathology”, by optimizing clinical diagnosis, development of individual sequences of complex surgical procedure, creating effective schemes of anti-relapse measures and prevention of secondary incarnations.

Materials and Methods. The research was performed at Danylo Halytskyi Lviv National Medical University clinical bases. Over a 15-year period (2006–2020) in 1838 patients, 5–92 years old, 1007 men and 831 women some nosological forms, clinical variants and features of the pathological process were studied. 757 cases of onychodestruction were prospectively investigated. Clinical and morphological material by classical (descriptive) and correlation statistics methods were processed. The design of the study included the adherence to the principles of confidentiality and respect for the patient’s personality, the concept of informed consent and other provisions, clauses of moral and ethical norms and principles of bioethics.

Results and Discussion. The largest observations of non-mycotic and mycotic-associated purulent-necrotic chronic and combined pathology of the hand and foot a subset of middle-aged people were stated. The age distribution showed a prevalence (in total samples) of middle-aged and elderly people, especially in sub-samples with mycotic dermatophyte (trichophytic) lesions. Recurrence ingrown toenails and subungual hyperkeratosis with secondary nail ingrowth determined due to compression by hyperkeratoid masses and dermatophytoma of the central part of the nail, deformity and incarnation in patients 50–70 years old were diagnosed. 45.05 % of cases of ingrown nails were approved and 21.87 % – complicated dermatophytic onychomycosis. Some purulent combined cases and necrotic variants of onychodestruction, as well as polyonychomycosis that are typical for elderly and senile patients (χ2=24.12, p=0.028) were stated. Most cases in patients with complicated onychomycosis (χ2=20.87, p<0.01) with secondary deformity of mycotically altered nail (χ2=17.35, p=0.022), some nail ingrowth in soft tissue (χ2=15.36, p<0.05) were diagnosed. In 48 % of mycotic lesions subsamples were incurved and ingrowing the one nail, 27 % – two nails, in the other 25 % of the partial prospective sample – more than 2 nail plates. During the pathomorphological study, some complicated, torpid, chronic variants, as well as recurrent cases of some purulent-necrotic pathology of the hand and foot, patho- and morphogenesis of destructive onychomycosis were simultaneously studied and specified. Secondary infection, joining the mycotic “surgical onychopathology”, bacterial superinfection etc determines the formation of low- or asymptomatic subungual panaritium of mixed etiology. Secondary chronic osteomyelitis of the distal phalanx was found in 5 % of all inpatients. A significant cases of unsatisfactory treatment results in combined lesions is determined by inadequate choice or technical violations (mistakes) of surgical procedure, in ca­ses of leaving some nail spicules and unsuccessful resection (χ2=4.22). Some recurrence when Dupuytren’s method of removing nails and other known surgical procedure (χ2=13.47, p=0.02), at refusal of carrying out simultaneous interventions on paronychial and subungual structures were observed. Surgical treatment should include anti-incarnation corrective measures, χ2=12,11, p=0.024; which significantly reduces the risk of recurrence, χ2=28.17, p<0.01. Block-shaped eponychectomy, some methods of minimally invasive affected nails mobilization and dissection were proposed and implemented. The maximum recurrence rate of polyonychomycosis was observed within 12–15 months, χ2=25.52, p=0.018, in the case of systemic therapy – for the third year after treatment, χ2=13.47, p=0.023. Removal of affected nails in patients with destructive complicated onychomycosis, combined lesions should be performed through onycholized structures.