Those of us at DERMfoot are acutely aware and sensitive to the national and global impact of COVID-19. We want to assure everyone planning to attend DERMfoot 2020 that their health and safety is our top priority. DERMfoot is taking COVID-19 seriously and is fully engaged and prepared to host a successful 2020 Seminar, April 16th - 19th, at the Sheraton Tysons Hotel in Tysons, Virginia. As this unprecedented situation is changing every day, we remain watchful while planing DERMfoot 2020.

The DERMfoot Executive Board is taking all necessary precautions to ensure a safe environment for attendees. We are continually monitoring developments concerning the coronavirus and staying abreast of reports and travel advisories from the Centers for Disease Control and Prevention (CDC), the World Health Organization (WHO), and the European Centre for Disease Prevention and Control. We are working with the Sheraton Tysons Hotel to put the appropriate measures in place to ensure you have an engaging and enjoyable learning experience in a healthy environment.

We encourage attendees to monitor the various health organizations tracking and responding to COVID-19. We have provided informational links below, which will direct you to important details released by the CDC and WHO. 

Continual updates will be provided via www.DERMfoot.com, e-mail, and the DERMfoot AttendeeHub mobile app push notifications. 

We look forward to seeing you in April!
Acral Lentiginous Melanoma Interview with Susan Taylor, MD
Associate Professor of Dermatology
Perelman School of Medicine
Vice President-Elect American Academy of Dermatology
Founder, Skin of Color Society
Image: medicalnewstoday.com
Image: aimatmelanoma.org
Image: pcds.org.uk
Q: Why is Acral Lentiginous Melanoma important in persons of color?

Dr. Taylor : Acral lentiginous melanoma (ALM) is the predominant form of melanoma occurring in persons of color, accounting for more than 60% of melanoma cases, whereas in Caucasians it accounts for approximately 10% of cases. The high percentage of ALM in non-white populations is due to the overall low incidence of sun-related melanoma in these populations.  There is increased morbidity and mortality from ALM in people of color compared to Caucasians. They are more likely to have thicker lesions and more advanced disease at the time of diagnosis. They have a poorer prognosis with the 5 and 10 year survival rated for people of color with ALM 80.3% and 67.5% respectively as compared to 91.3 % and 87.5% for all cutaneous melanomas combined.

Q: How do they form on the palms and soles if the area is shielded from the light?

Dr. Taylor: Not all melanomas are induced by ultraviolet light. ALM on the palms and soles are non-UVR-related melanomas. It is not clear why melanomas form on the palms and soles. One theory is that trauma or mechanical stress might induce DNA damage leading to melanoma. Recent whole exome/genome studies of melanoma support the hypothesis that non-UVR-derived melanomas have different genetic causal pathways not related to UVR exposure. Our group is looking at morphological differences in melanocytes in acral skin of people of color as well as differences in oxidative stress-related mutations.

Q: Is trauma an instigator of this condition? If not, what is?

Dr. Taylor: Trauma and mechanical stress may indeed be an instigator of ALM. A study demonstrated that most ALM in their series were on the heel of the foot, an area with peek pressures.

Q: What is the best way to prevent this form of cancer ?

Dr. Taylor: Until we understand the cause(s) of ALM, we will be unable to implement prevention strategies. However, currently the most effective strategy is early diagnosis. Towards that end, education and diagnostic tools such as dermoscopy and the BRAAFF checklist are proving to be helpful.
Does Nail Polish and Fungus Go Together?
By Annette Joyce D.P.M.
April showers bring more than just May flowers each year to the podiatry office. Spring tends to mark the beginning of nail fungus season and habitual pedicures. It seems there may be a symbiotic relationship between these common female rituals and onychomycosis, but how can we be certain? Many patients who first discover the unsightly look of a fungal toenail come to their podiatrist for a cure, and then to their pedicurist for a quick fix. Nail polish is the hallmark of a cosmetically acceptable solution to hide that dreaded fungal toe infection.  
 
So, what advice can a “Let’s fix your feet” kind of doc give to these patients asking about a personal lifestyle choice - To wear nail policy this season- or not??
 
Q: Does Nail Polish Harbor Fungus?
 
The literature suggests Yes and No. In a recent review article by Klafke GB et al 1 , T. Rubrum was used to inoculate a red and white polish, a base coat and a top coat. Fungal growth was not seen in the red, white or base coat after 60 days incubation. However, the top coat did produce viable cultures in all brands tested.This study concurs with a prior study of Goncalves et al 2 , in which the top coat was hypothesized to act as a fomite in the transmission of onychomycosis (OM). The theory is that top coats are rich in mineral and soy oil and do not contain toxic chemicals like toluene, xylene, formaldehyde, chromium and nickel, that often exist in standard nail polishes and base coats. Bottom line, bring your own top coat to be safe.
 
Q: Can prescription antifungals be used with nail polish and still produce results?
 
That depends. There are currently 3 commonly prescribed topical brand name antifungals on the market-Jublia, Penlac, and Kerydin. All 3 are indicated for treating T. Rubrum and T. Mentagrophytes, common pathogens in OM. Studies have been performed on both Jublia and Kerydin to test whether or not combining nail polish and these topical medications will alter the clinical outcome for our patients. Penlac has not been studied with nail polish and the package insert strictly prohibits use with nail polish.
 
In a 2015 study, Vlahovic et al 3 , evaluated in vitro penetration of up to 4 layers of brand nail polish with two commonly prescribed antifungals- tavaborale (Kerydin) and efinaconazole (Jublia). The study suggested that concomitant use of nail polish does not affect the penetration of tavaborale beneath the nailbed ,where the infection commonly resides. In another study, efinaconazole did penetrate through unpolished and polished nails. However, the nail poish became “tacky” and possibly undesirable in appearance Ziechner et al 4 .
 
In 2016, Vlahovic et al 5 , published a followup study to further evaluate the appearance of nail polish in the presence of the same antifungals- tavaborale and efinaconazole. This study demonstrated that nail polish color remains intact after a once-daily application of tavaborale 5% to non-diseased, cadaver nails, for 7 days. No color transfer was apparent to the applicator, brush, or watercolor paper. Conversely, efinaconazole-treated nails showed changes in both color and appearance as well as transfer of the color ( ie pigment bleeding) immediately after application, making this a somewhat less desirable alternative for keeping your nails fungus free and Rouge Noir red.
 
References:
1.    Klafke GB, da Silva RA, de Pellegrin KY, Xavier MO. Analysis of the role of nail polish in the transmission of onychomycosis. An Bras Dermatol. 2018; 93(6):930-1.
2.    Goncalves MG, Castilino EM, Games CT, Brizzatti NS, Almeida MTG, Nail Polishes: Vehicle for transmission of onychomycosis? In: Abstracts of the 18th Congress of the International Society for Human and Animal Mycology, 11-15 Jun 2012, Berlin, Germany, Mycoses 2012:55:95-338.
3.    Vlahovic T, Merchant T, Chanda S, Zane L, Coronado D. In vitro nail penetration of tavaborale topical solution , 5% through nail polish on ex vivo human fingernails. J Drugs Dermatol. 2015; 14: 675-678.
4.    Zeichner JA Stein GL, Korotzer A. penetration of (14C)-efinaconazole topical solution, 10% does not appear to be influenced by nail polish. J Clin Aesthet Dermatol. 2-14; 7:34-36.
5.    Vlahovic T, Coronado D, Chanda S, Merchant T, Zane L. Evaluation of the appearance of nail polish following nail treatment of ex vivo Human nails with topical solution of tavaborale and efinaconazole. Jan 2016, JDD Vol 15:(1) 89-94.
Metastatic Melanoma
By Bryan Markinson, DPM

Associate Professor of Orthopedics and Chief of Podiatric
Medicine and Surgery     

Instructor Division of Dermatologic Surgery Department of Dermatology Mount Sinai School of Medicine

Board of Medical Advisors – International Foot and Ankle Foundation for Education and Research - Appointed
These photos are of four recent patients who presented with the lesions shown. In the upper left corner, the lesion is a solid mass that grew to the shown size and stabilized at that size for the past two years. Ultrasound revealed the mass to be a solid tumor. Excision of the lesion was carried out. Histologic diagnosis was a fibroma.

The lower left lesion overlies the distal interphalangeal joint of the toe, lateral to the midline. Note the concavity of the nail plate corresponding directly to the location and the width of the lesion. This lesion is a mucoid cyst that is impinging on the nail matrix, casing the nail plate deformity.
The upper right photo is a male patient in his late forties who was diagnosed with HIV infection several years prior. Due to insurance issues, he stopped his ant-retroviral therapy for the past two years. The patient noted the lesion on his third toe about three weeks prior to a small red area, which rapidly grew. The lesion was removed on the next visit. The diagnosis was HIV related Kaposi's sarcoma. The patient was referred to the infectious disease service, where therapy for HIV was reinstituted.

The bottom right photo depicts a patient of mine for whom I performed a second toe amputation two years prior to invasive nail bed melanoma. She was sentinel lymph node-negative at that time. She had regular oncology follow up when a PET scan done at the two-year mark revealed activity on the dorsum of the foot corresponding to a very small subcutaneous lesion shown circled in the photo. This was not present on the most recent follow up with me a few months prior. The medical oncologist sent the patient back to me for diagnosis. The lesion was a small soft nodule directly under the skin, easily excised. It exhibited no pigment. Histologic diagnosis was metastatic melanoma, representing an in-transit metastasis of the original nail bed lesion. The patient was then started on adjuvant therapy.
Patient Presents with Nail Pigmentation
by Joel Morse, DPM


A 53-year-old black female presents to the office with a chief concern of incurvated dark nails with a history of failed treatment for fungal toenails. She recalled that she was placed on Terbinafine by her dermatologist – 11 months ago, and there is still discoloration over the entire nail plate on all of the nails. It turned out that no fungal nail culture was performed before the initiation of treatment.

A workup of the patient was performed with a history and physical examination, and a nail culture found no evidence of fungal hyphae. The diagnosis was Racial Melanonychia – a type of nail pigmentation seen in those with pigmented skin. Melanonychia frequently has a racial predilection. It occurs among more than 50% of black Africans, approximately 10% of Japanese, and among peoples of Mediterranean origin. (1)
Longitudinal pigmentation of the nail is a common presenting problem in general podiatry. However, it is not something the patient always brings to your attention. You need to look for it.

Nail pigmentation changes include longitudinal bands, transverse bands, and diffuse darkening. At times there is overlap between the diffuse darkening and the longitudinal bands. Longitudinal Melanonychia is referenced more often in the literature because it is seen with nail melanoma, which is deadly. The other causes of nail pigmentation are less known; however, with the fact that the population of persons with pigmented skin is increasing in the world, it is incumbent on us to understand nail pathology in those individuals. Be aware that there is much overlap between benign nail pigmentation and subungual malignant melanoma. Do not get caught.

Melanonychia:
Melanonychia is defined by the presence of melanin within the nail plate. It appears more often as a longitudinal brown-black band starting from the matrix and extending to the free edge of the nail plate. Less often, the pigmentation can involve the whole nail plate or present as a transverse band. (2). There are many causes of discoloration of the nail plate. Longitudinal Melanonychia is the buzz word here.

Melanonychia results from production of melanin by melanocytes of the nail matrix, where melanocytes are usually quiescent but may become active and start melanin synthesis. Melanonychia has three main causes: simple melanocytic activation (increased activation (with a normal number) of melanocytes, benign melanocyte proliferations (lentigo, nevus), and malignant melanocyte proliferation (melanoma). When matrix nevi present as melanonychia, the pigment-producing nevus cells incorporate melanin into the nascent nail plate onychocytes, producing true brown nail plate discoloration(3).
For Supporting Lower Extremity Dermatology
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