Further reading

Nail disorders are rarely subjected to thorough histopathological investigation. In contrast to skin, the nail is not easy to biopsy and many physicians as well as patients are therefore reluctant to undertake this procedure. To obtain relevant results it is necessary to consider the following:

1 Nail changes usually reflect a pathological process of the matrix or (much less frequenly) of the nail bed. The biopsy must contain a relevant piece of matrix.

2 Some changes that are obvious to the naked eye may almost be invisible in a microscopic section. This is not infrequently the case in nail pigmentations (see Chapter 7).

3 Nail clippings are useful for the diagnosis of onychomycosis and a few other conditions. However, as in routine mycology, subungual keratotic material usually harbours the greatest amount of fungal elements.

4 The nail organ often reacts differently from normal epidermis.

5 Nail specimens are difficult to handle and process in the histopathological laboratory. Tears and folds are the rule rather than the exception.

There are particular reaction patterns that differ in the nail from those of common epidermis:

• A granular layer is always pathological in the matrix and nail bed and leads to onycholysis.

• Irritation that would cause parakeratosis in the epidermis often induces pathological orthokeratinization.

• Spongiosis is often seen in disorders that would not cause spongiosis in skin, e.g. in psoriasis or lichen planus.

• Changes in the nail plate are most often non-specific; they may suggest a diagnosis but do not provide proof.

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