Felipe Aluja Jaramillo M.D.1, Diana Carolina Quiasúa Mejía M.D.2, Héctor Mauricio Martínez Ordúz M.D.1, César González Ardila M.D.3 1Radiology
Department, Fundación Universitaria Sanitas, Clínica Universitaria Colombia, Bogotá, Colombia. 2Dermatology Department, Hospital Universitario de la Samaritana, Bogotá, Colombia. 3Dermatology, Organización Sanitas Internacional, Bogotá, Colombia.
INTRODUCTION AND LEARNING OBJECTIVES: Ultrasound offers an appropriate alternative for the evaluation of the nail unit, allows a real time evaluation of each one of the components of the nail unit with an optimal visualization of these structures, allows the evaluation of the thickness of the components, the vascularity and blood flow by Doppler application. Also, the nail unit signs of disease and disorder such as psoriasis, systemic erythematous lupus, systemic sclerosis, other rheumatologic conditions and nail tumors, among others, may be assessed, not only in the diagnosis but also in the follow up. Presurgical evaluation, surgical follow up and some procedures such as biopsies may be done by this technique.
Normal Ultrasound. Longitudinal and transverse view. The nail unit is composed of the nail plate and the periungual tissues. The nail matrix, the nail bed, the proximal nail fold and the hyponychium compose the different units of the nail plate.
Onycholysis Picture. Separation of the nail plate from the nail bed. Ultrasound. Longitudinal and transverse views, demonstrates a separation of the distal edge of the nail bed affecting the medial edges (arrows), with thickenning of the nail plates (arrowhead).
Psoriasis
Onychomycosis Picture. Onycholysis, pachyonychia and chromonychia. Ultrasound. Longitudinal and transverse view. Increase in the thickness of the nail bed (arrows) greater than the one seen in psoriasis. There is also a diffuse thicknening of the nail plate (arrowhead) with acoustic shadow and fusion of the dorsal and ventral plates.
Picture. Pits and onycholysis. Ultrasound. Longitudinal and transverse view. Focal hyperechoic deposit located in the ventral plate (arrowhead), loss of the definition of the plates and wavy shape of the plates. Increased Doppler color vascularization.
Trauma Picture. Subungual hemorrhage. Sutures in the lateral edge of the nail plates. Ultrasound. Longitudinal and transverse view. Irregularity of the dorsal cortical of the distal phalanx related to fracture (arrow) and increased echogenicity of the proximal nail fold secondary to hematoma (arrowhead).
Exostosis Picture. Pseudoleukonychia, melanonychia with gray background colour. Ultrasound. Longitudinal and transverse view. Irregularity of the cortical bone (arrows) with hypoechoic areas mixed with ecogenic areas that produce posterior acoustic shadow related to subungual exostosis.
Subungual warts
Melanoma
Picture. Verrucouse papule in the hyponychium.
Picture. Melanonychia.
Ultrasound. Longitudinal and transverse view. Hypoechoic fusiform eccentric lesion (arrows), hypovascular, with exophytic component in the distal fold (arrowhead).
Ultrasound. Longitudinal and transverse view. Hypervascular ill-defined hypoechoic lesion (arrows) in the nail bed that spares the adyacent structures, with normal appareance of the nail plates and nail matrix.
Conclusion: Ultrasound is an excellent technique for evaluation of normal anatomy, diagnosis and follow up of patients with nail unit diseases. This is an alternative for other imaging methods and may be used for an accurate diagnosis approach. Is an appropriate and non invasive modality, widely available. Bibliography: Wortsman X, Jemec G. Ultrasound imaging of nails. Dermatol Clin. 2006;24:323–328. The authors have no González CP. Evaluación ecográfica del aparato ungueal. Rev Medica Sanitas. 2013;16(3):125-133. disclosure. Harai T, Fumiiri M. Ultrasonic observation of the nail matrix. Dermatol Surg. 1995;21:158-161. Contact: macario171@gmail.com Wortsman, Ximena, Jemec, Gregor (Eds.). Dermatologic Ultrasound With Clinical and Histological Correlations. Springer New York.2013, pp419-476.
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