Green nail syndrome | |
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Other names | Chloronychia, Goldman–Fox syndrome [1] [2] |
Chloronychia affecting the nail of the ring finger | |
Specialty | Dermatology |
Green nail syndrome is an infection that can develop in individuals whose hands are frequently submerged in water resulting in discolouration of the nails from shades of green to black. [3] [4] It may also occur as transverse green stripes that are ascribed to intermittent episodes of infection. [3] It is usually caused by the bacteria Pseudomonas aeruginosa [5] and is linked to hands being constantly moist or exposed to chemicals, or in individuals who have damaged or traumatised nails. [6] There are several activities and nail injuries or conditions that are linked to higher risk of contracting the condition.
Green nail syndrome (chloronychia or Goldman-Fox syndrome [7] ) is characterised by discolouration of the infected nail, inflammation of the skin around the nail known as paronychia, and an odour resembling fruit. [3] The colour may range from light or blueish green or yellow-green to darker green or black. [8] [3] Nails may be separated from the nail bed (onycholysis) [3] and may have green stripes from repeated infections. [3] Chronic fungal infection (onychomycosis) may also be present. [4]
Green nail syndrome is caused when the nail is exposed to a bacterial organism, which leads to opportunistic infection. [9] Pseudomonas aeruginosa, the most common cause but not the only one, [10] is frequently found in nature including in water sources, humans, animals and soil. [9] [10] These bacteria do not normally survive on dry, healthy skin, but can thrive in moist conditions. [9] The seal between the nail and finger acts as a physical barrier to prevent infection, however hyper-hydration or destruction of the epidermis can impair the barrier, allowing the bacteria to colonise.[ medical citation needed ]The nail turns green due to the bacteria secreting pigments such as pyocyanin [3] [4] and pyoverdin. [9]
Green nail syndrome occurs rarely in healthy individuals, but can occur in the immunocompromised or those whose hands are frequently immersed in water or who have other nail problems. [5] The elderly and people who have had trauma to a finger or nail are at greater risk of contracting green nail syndrome. [1]
Green nail syndrome has been linked to manicures, [11] heat, dermatitis, ulcerations, occlusions and excess sweating.[ medical citation needed ]Higher risk of contracting the infection is also linked to soccer players and military personnel due to the prolonged periods of time in which they exercise while wear tight fitting shoes [12] as well as immunosuppressed persons and those with a weakened epidermis barrier.
Pseudomonas can be transferred among clients in a nail salon if appropriate hygiene standards are not practiced, allowing transfer of the bacteria to clients. [13] Artificial nails may be a contributing factor, and their use can result in diagnostic delay. [8]
A man working in a job where he was regularly mixing chemicals developed green nails secondary to exposure to chemicals; he mostly wore latex gloves, but sometimes did not, and the type of gloves he used was inadequate, resulting in a constantly moist environment. [14]
Cloronychia may be transferred to patients in clinics by medical practitioners, even when they are wearing gloves. [6]
Diagnosis can typically be made from a physical examination of the nail, although cultures are sometimes needed. [8] Nail scrapings [15] can be performed to rule out fungal infections. [4]
Green nails may also be seen with Proteus mirabilis infection, in psoriasis, or because of use of triphenylmethane dyes [3] or other stains and lacquers or chemical solutions. [8] [4] Melanoma is an infrequent differential diagnosis, which must be ruled out in hard-to-treat cases. [4] Other differential diagnoses include hematoma and fungal infections (onychomycosis). [8]
Preventative measures should be implemented by those who are most at risk of contracting green nail syndrome due to their predisposition or lifestyle and workplace choices. Wearing waterproof gloves or rubber boots can be effective in preventing prolonged exposure of the nails to water. Avoiding trauma that could lead to the destruction of the epidermis seal is on the nails is a priority in preventing green nail syndrome recurrences.[ medical citation needed ]
As of 2020, there have not been controlled, blinded studies on the treatment of green nail syndrome [16] and there are no treatment guidelines as of 2021. [8] Keeping the nails dry and avoiding excessive immersion of the nails are key. [11] In some cases, surgical removal of the infected nail may be required, [16] as a last choice. [8] The patient is advised to avoid further trauma to the infected nail regardless of the treatment they received. [12]
Oral antibiotics are rarely necessary, helpful [4] or recommended by all practitioners. [3] Moderate cases of green nail syndrome may be prescribed topical antibiotics (silver sulfadiazine, gentamicin, ciprofloxacin, bacitracin and polymyxin B). [16] Oral antibiotics are sometimes used if other therapies fail. [16] Tobramycin eye drops are sometimes used. [16]
The least invasive treatment includes soaking the nail in alcohol and regularly trimming the nail back,[ medical citation needed ] to dry out the area and prevent bacterial colonization. [15] Some at-home treatments include soaking the nails in vinegar (diluted with water 1:1) or a chlorine bleach solution (diluted with water 1:4) at regular intervals. [4]
Goldman–Fox syndrome was first described in 1944 by Leon Goldman, a dermatology professor at the University of Cincinnati, and Harry Fox. [2] [7] [17]
A biofilm is a syntrophic community of microorganisms in which cells stick to each other and often also to a surface. These adherent cells become embedded within a slimy extracellular matrix that is composed of extracellular polymeric substances (EPSs). The cells within the biofilm produce the EPS components, which are typically a polymeric combination of extracellular polysaccharides, proteins, lipids and DNA. Because they have a three-dimensional structure and represent a community lifestyle for microorganisms, they have been metaphorically described as "cities for microbes".
Waterhouse–Friderichsen syndrome (WFS) is defined as adrenal gland failure due to bleeding into the adrenal glands, commonly caused by severe bacterial infection. Typically, it is caused by Neisseria meningitidis.
Pseudomonas is a genus of Gram-negative bacteria belonging to the family Pseudomonadaceae in the class Gammaproteobacteria. The 313 members of the genus demonstrate a great deal of metabolic diversity and consequently are able to colonize a wide range of niches. Their ease of culture in vitro and availability of an increasing number of Pseudomonas strain genome sequences has made the genus an excellent focus for scientific research; the best studied species include P. aeruginosa in its role as an opportunistic human pathogen, the plant pathogen P. syringae, the soil bacterium P. putida, and the plant growth-promoting P. fluorescens, P. lini, P. migulae, and P. graminis.
Folliculitis is the infection and inflammation of one or more hair follicles. The condition may occur anywhere on hair-covered skin. The rash may appear as pimples that come to white tips on the face, chest, back, arms, legs, buttocks, or head.
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Multiple drug resistance (MDR), multidrug resistance or multiresistance is antimicrobial resistance shown by a species of microorganism to at least one antimicrobial drug in three or more antimicrobial categories. Antimicrobial categories are classifications of antimicrobial agents based on their mode of action and specific to target organisms. The MDR types most threatening to public health are MDR bacteria that resist multiple antibiotics; other types include MDR viruses, parasites.
Paronychia is an inflammation of the skin around the nail, which can occur suddenly, when it is usually due to the bacterium Staphylococcus aureus, or gradually when it is commonly caused by the fungus Candida albicans. The term is from Greek: παρωνυχία from para 'around', onyx 'nail', and the abstract noun suffix -ia.
Onychomycosis, also known as tinea unguium, is a fungal infection of the nail. Symptoms may include white or yellow nail discoloration, thickening of the nail, and separation of the nail from the nail bed. Fingernails may be affected, but it is more common for toenails. Complications may include cellulitis of the lower leg. A number of different types of fungus can cause onychomycosis, including dermatophytes and Fusarium. Risk factors include athlete's foot, other nail diseases, exposure to someone with the condition, peripheral vascular disease, and poor immune function. The diagnosis is generally suspected based on the appearance and confirmed by laboratory testing.
Pseudomonas aeruginosa is a common encapsulated, Gram-negative, aerobic–facultatively anaerobic, rod-shaped bacterium that can cause disease in plants and animals, including humans. A species of considerable medical importance, P. aeruginosa is a multidrug resistant pathogen recognized for its ubiquity, its intrinsically advanced antibiotic resistance mechanisms, and its association with serious illnesses – hospital-acquired infections such as ventilator-associated pneumonia and various sepsis syndromes. P. aeruginosa is able to selectively inhibit various antibiotics from penetrating its outer membrane - and has high resistance to several antibiotics, according to the World Health Organization P. aeruginosa poses one of the greatest threats to humans in terms of antibiotic resistance.
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