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although the condition is thought to be a complication of onychomadesis&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">3</span></a> Thus&#44; repeated injury to the distal end of the nail triggers onycholysis that would first break the continuity and then the alignment between the nail matrix and the nail plate&#46; By losing its proximal attachment to the nail bed and being subject to repeat injury&#44; the nail plate gradually moves backward until it embeds itself in the cul-de-sac of the PNF&#46; An inflammatory process with formation of granulation tissue is triggered in the cul-de-sac and nail bed&#44; thus accounting for the clinical signs of paronychia&#46; In addition&#44; the presence of inflammatory phenomena would prevent the attachment of the new growing nail plate to the proximal part of the nail bed&#44; thus leading again to onychomadesis&#44; backward movement&#44; and ingrowth into the PNF&#46; This process can thus generate a vicious cycle in which up to 4 generations of nail plate overlap under the PNF&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">4</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case Description</span><p id="par0015" class="elsevierStylePara elsevierViewall">The patient was a 22-year-old man who practiced mountaineering&#44; for which he used tight boots&#46; He came to the clinic with a 1-year history of absent nail growth on the great toe of the right foot and episodes of proximal exudative paronychia&#46; Although the inflammatory signs improved to some extent with oral antibiotics&#44; the patient continued to complain of pain in the PNF&#46; He had taken ciprofloxacin during the previous 2 weeks because of growth of a culture of exudate of <span class="elsevierStyleItalic">Escherichia coli</span> that was sensitive to the antibiotic&#46; He also reported what appeared to be a cut in the proximal part of the nail plate&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Examination revealed erythema and pain in the PNF on palpation&#44; as well as proximal onychomadesis with a thick yellowish nail plate &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A&#41;&#46; Slight lateral deviation was observed in both great toes&#46; No abnormal results were reported for the bacterial and fungal cultures or radiology examination of the toe&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Ultrasound study with a multifrequency linear probe &#40;9-14<span class="elsevierStyleHsp" style=""></span>MHz&#41; and high-resolution device &#40;GE Medical Systems&#41; revealed overlapping nail plates with a hypoechoic space between them&#44; reduction of the distance between the root of the nail plate and the base of the distal phalanx at the level of the distal interphalangeal joint&#44; as well as posterior acoustic shadowing deep under the nail plate&#46; The PNF was thicker in the affected nail than in the healthy contralateral nail&#46; The Doppler signal was slightly enhanced in the proximal part of the nail bed at the root of the matrix &#40;<a class="elsevierStyleCrossRefs" href="#fig0010">Figs&#46; 2 and 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">Once the diagnosis of retronychia was confirmed&#44; surgical avulsion of the nail was performed using an anterior approach&#44; and the 2 nail plates were found to be overlapping at the proximal end&#44; with granulation tissue and keratotic material between them &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46; Histopathology confirmed these findings&#46; A new nail plate grew over the following 12 months&#44; with slight distal thickening and yellowing &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>B&#41;&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0035" class="elsevierStylePara elsevierViewall">A total of 64 cases of retronychia have been reported&#44; and most were included in multicenter studies carried out by experts from the ENS&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">2&#44;4&#8211;15</span></a> Despite the wide age range reported &#40;10-71 years&#41;&#44; the mean age is 25 years&#46; The condition mainly affects women &#40;81&#37;&#41;&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Retronychia affects the great toe unilaterally&#44; although at least 7 cases of bilateral involvement<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">1&#44;2&#44;4&#44;10&#44;13</span></a> and 9 cases of retronychia affecting the nails of the hands<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">1&#44;2&#44;7&#44;8</span></a> have been reported&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The most common triggers are repeated minor injuries&#44; such as those that occur while jogging&#44; walking&#44; and dancing and those that result from having long nails or wearing heels or uncomfortable footwear&#46; However&#44; most patients do not associate their disease with these injuries&#46; There have been at least 10 cases in which no trigger was identified<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">2&#44;4&#44;11&#44;12&#44;14</span></a>&#59; in a further 8 cases&#44; the cause was acute injury such as crushing&#44; burns&#44; and previous nail surgery&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">2&#44;4&#44;5&#44;7&#44;8&#44;10</span></a> In a small number of cases&#44; the condition developed in the setting of a systemic disease &#40;eg arthritis&#41;&#44; anorexia nervosa&#44;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">2</span></a> and admission to the intensive care unit&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">7</span></a> Lateral deviation of the great toe has been considered a potential predisposing factor&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">4&#44;6</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Retronychia manifests with local pain and difficulty walking &#40;in cases where the nails of the feet are affected&#41;&#44; and as erythema&#44; edema&#44; and exudation in the PNF and a dull&#44; thick&#44; yellowish nail plate that does not grow&#46; Also characteristic of this condition is the finding of a nail that is higher proximally than distally&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">2&#44;4&#44;6&#44;12&#44;14</span></a> Granulation tissue can sometimes be observed under the cuticle&#44; as can the sharp proximal edge of the nail plate &#40;see present case&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">4&#44;10&#44;11&#44;13&#44;14</span></a> In 1 case&#44; retronychia has also presented as paronychia that was culture-positive for gram-negative pathogens&#44; yet resistant to antibiotics&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">4</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Diagnosis of retronychia is based on clinical findings&#44; although ultrasound can be used as a noninvasive confirmatory test and in presurgical differential diagnosis&#46; The ultrasound criteria for confirmation of diagnosis are presence of &#8805;2 overlapping nail plates&#44; shortening of the distance between the root of the nail plate and the base of the distal phalanx &#40;at the level of the distal interphalangeal joint&#44; thus indicating the posterior shift of the nail&#41;&#44; and diminished echogenicity in the dermis of the PNF and proximal nail bed owing to the presence of inflammation and onycholysis&#46;<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">7&#44;8</span></a> In the present case&#44; we also observed absence of signal deeper under the nail plate&#44; which was attributed to posterior acoustic shadowing&#46; In 1 case&#44; Doppler ultrasound revealed a slight increase in blood flow in the proximal nail bed&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">7</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">The differential diagnosis of retronychia should include diseases with the appearance of chronic paronychia&#44; namely&#44; candidal or bacterial infection&#44; subungual cysts or tumors &#40;eg&#44; squamous cell carcinoma&#44; melanoma&#44; glomus tumor&#44; and enchondroma&#41;&#44; arthritic processes &#40;eg&#44; psoriasis&#41;&#44; and processes associated with medication &#40;eg&#44; retinoids&#44; ciclosporin&#44; protease inhibitors&#44; and epidermal growth factor receptor inhibitors&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">5&#44;6&#44;9&#44;11&#44;12</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Surgical avulsion of the old nail plate and the subsequent ingrowing nail plate&#40;s&#41; with a proximal approach confirms the diagnosis&#44; leads to rapid pain relief&#44; and is the curative treatment of choice for this process&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">2&#44;4&#44;6</span></a> Avulsion of the most superficial nail plate alone is not sufficient and leads to relapse&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">5&#44;11&#44;14</span></a> However&#44; relapse is unusual&#44; as is permanent postsurgical nail dystrophy&#46; In a series of young and adolescent patients&#44; the new nail was thick and yellowish and grew very slowly in 33&#37; of patients after successful surgical avulsion&#46; Medical treatment with potent topical corticosteroids was associated with a high relapse rate in the series&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">12</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">In conclusion&#44; we report a new case of retronychia that was probably triggered during the practice of mountaineering&#46; The condition was repeatedly confused with infectious paronychia&#44; and it took more than 1 year to confirm the diagnosis and provide adequate treatment&#46; These observations are consistent with reports on patients with retronychia in the literature&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">4&#44;9&#44;11&#44;13</span></a> In addition&#44; even though retronychia may not be as uncommon as previously thought&#44;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">12</span></a> only 1 case has been reported in the Spanish medical literature&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">15</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Ethical Disclosures</span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Protection of humans and animals</span><p id="par0075" class="elsevierStylePara elsevierViewall">The authors declare that no tests were carried out in humans or animals for the purpose of this study&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Confidentiality of data</span><p id="par0080" class="elsevierStylePara elsevierViewall">The authors declare that no private patient data appear in this article&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Right to privacy and informed consent</span><p id="par0085" class="elsevierStylePara elsevierViewall">The authors obtained informed consent from the patients and&#47;or subjects referred to in this article&#46; This document is held by the corresponding author&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conflicts of Interest</span><p id="par0090" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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          "titulo" => "Introduction"
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          "titulo" => "Case Description"
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          "palabras" => array:5 [
            0 => "Retronychia"
            1 => "Proximal ingrowing nail"
            2 => "Chronic paronychia"
            3 => "Ultrasound"
            4 => "Nail ablation"
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          "palabras" => array:5 [
            0 => "Retroniquia"
            1 => "U&#241;a encarnada proximal"
            2 => "Paroniquia cr&#243;nica"
            3 => "Ecograf&#237;a"
            4 => "Avulsi&#243;n ungueal"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Retronychia is a recently described disorder caused by ingrowth of the proximal nail plate into the proximal nail fold&#46; This situation provokes chronic paronychia refractory to antimicrobial therapy&#46; Ultrasound has been proposed as the noninvasive method of choice to confirm the diagnosis and rule out other differential diagnoses&#44; particularly local tumors and arthritic disease&#46; The presence of 2 or more overlapping nail plates and a reduced distance between the root of the nail plate and the base of the distal phalanx could be the ultrasound hallmarks of this condition&#46; Nail plate avulsion is the treatment of choice and is curative&#46; Knowledge of retronychia is still limited among dermatologists&#44; which can lead to diagnostic and therapeutic errors and delay&#46; This has prompted us to present this new case&#46;</p></span>"
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        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La retroniquia es un proceso emergente en el que la parte proximal de la l&#225;mina ungueal se encarna en el pliegue ungueal proximal&#44; produciendo una paroniquia cr&#243;nica refractaria a terapias antimicrobianas&#46; La ecograf&#237;a se ha postulado como la prueba no invasiva de confirmaci&#243;n y para diagn&#243;stico diferencial&#44; sobre todo con afecciones tumorales y artr&#237;ticas locales&#46; La presencia de dos o m&#225;s l&#225;minas ungueales superpuestas y la disminuci&#243;n de la distancia entre el origen de la l&#225;mina ungueal y la base de la falange distal podr&#237;an ser los criterios ecogr&#225;ficos distintivos de esta entidad&#46; La avulsi&#243;n quir&#250;rgica de la l&#225;mina ungueal es la terapia de elecci&#243;n y curativa de la misma&#46; Su conocimiento todav&#237;a est&#225; poco difundido entre los dermat&#243;logos&#44; ocasionando errores y demoras diagn&#243;sticas y terap&#233;uticas&#44; lo que nos ha motivado a la presentaci&#243;n de un nuevo caso&#46;</p></span>"
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      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Alonso-Pacheco ML&#44; de Miguel-Mendieta E&#44; Maseda-Pedrero R&#44; Mayor-Arenal M&#46; Retroniquia&#58; estudio ecogr&#225;fico y tratamiento quir&#250;rgico de un caso&#46; Actas Dermosifiliogr&#46; 2016&#59;107&#58;e33&#8211;e37&#46;</p>"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A&#44; Erythema and edema in the proximal nail fold and proximal onychomadesis&#44; with a thick&#44; yellowish nail plate&#46; B&#44; Appearance of the new nail at 12 months&#44; with distal yellowing and thickening&#46;</p>"
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Ultrasound study&#58; longitudinal image characteristic of retronychia&#44; with 2 overlapping nail plates and a hypoechoic space between them&#44; together with posterior acoustic shadowing under the lower nail plate&#46; Lower panel&#44; healthy contralateral nail&#46; DIJ indicates distal interphalangeal joint&#59; PNF&#44; proximal nail fold&#46;</p>"
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          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">A and B&#44; Ultrasound-based comparison between images from the great toes&#46; In the nail affected by retronychia &#40;A&#41;&#44; the distance between the root of the nail plate and the base of the distal phalanx &#40;at the level of the distal interphalangeal joint&#41; is reduced&#46; C&#44; Enhanced Doppler signal in the proximal part of the nail bed&#46;</p>"
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          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Surgical avulsion&#46; A&#44; Appearance of both nails before surgery&#46; B&#44; Affected nail higher proximally than distally&#46; C&#44; Proximal detachment with a Freer elevator&#46; D&#44; Removal of the nail plates using Radolf nail pulling forceps&#46; E&#44; Appearance of the nail bed after avulsion&#46; F&#44; Overlapping nail plates forming a &#8220;sandwich&#44;&#8221; with granulation tissue between them at the proximal end&#46;</p>"
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    "bibliografia" => array:2 [
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e-Case Report
Retronychia: A Case Report Including Ultrasound Imaging and Surgical Treatment
Retroniquia: estudio ecográfico y tratamiento quirúrgico de un caso
M.L. Alonso-Pachecoa,
Autor para correspondencia
mlalonsop@yahoo.es

Corresponding author.
, E. de Miguel-Mendietab, R. Maseda-Pedreroa, M. Mayor-Arenala
a Servicio de Dermatología, Hospital Universitario La Paz, Universidad Autónoma, Madrid, Spain
b Servicio de Reumatología, Hospital Universitario La Paz, Universidad Autónoma, Madrid, Spain
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          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Surgical avulsion&#46; A&#44; Appearance of both nails before surgery&#46; B&#44; Affected nail higher proximally than distally&#46; C&#44; Proximal detachment with a Freer elevator&#46; D&#44; Removal of the nail plates using Radolf nail pulling forceps&#46; E&#44; Appearance of the nail bed after avulsion&#46; F&#44; Overlapping nail plates forming a &#8220;sandwich&#44;&#8221; with granulation tissue between them at the proximal end&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The term retronychia &#40;proximal ingrowing nail&#41;&#44; was coined by Berker and Rendall<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">1</span></a> in 1999&#46; The condition emerged as a distinct entity in 2008&#44; after the presentation of a cases series by members of the European Nail Society &#40;ENS&#41;&#46; Retronychia progresses with ingrowth of the proximal nail plate into the proximal nail fold &#40;PNF&#41;&#44; the presence of 2 or more overlapping generations of nail plate under the PNF&#44; clinical signs of chronic proximal paronychia&#44; and a yellowish nail that does not grow&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">2&#44;3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The pathogenesis of retronychia is not well known&#44; although the condition is thought to be a complication of onychomadesis&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">3</span></a> Thus&#44; repeated injury to the distal end of the nail triggers onycholysis that would first break the continuity and then the alignment between the nail matrix and the nail plate&#46; By losing its proximal attachment to the nail bed and being subject to repeat injury&#44; the nail plate gradually moves backward until it embeds itself in the cul-de-sac of the PNF&#46; An inflammatory process with formation of granulation tissue is triggered in the cul-de-sac and nail bed&#44; thus accounting for the clinical signs of paronychia&#46; In addition&#44; the presence of inflammatory phenomena would prevent the attachment of the new growing nail plate to the proximal part of the nail bed&#44; thus leading again to onychomadesis&#44; backward movement&#44; and ingrowth into the PNF&#46; This process can thus generate a vicious cycle in which up to 4 generations of nail plate overlap under the PNF&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">4</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case Description</span><p id="par0015" class="elsevierStylePara elsevierViewall">The patient was a 22-year-old man who practiced mountaineering&#44; for which he used tight boots&#46; He came to the clinic with a 1-year history of absent nail growth on the great toe of the right foot and episodes of proximal exudative paronychia&#46; Although the inflammatory signs improved to some extent with oral antibiotics&#44; the patient continued to complain of pain in the PNF&#46; He had taken ciprofloxacin during the previous 2 weeks because of growth of a culture of exudate of <span class="elsevierStyleItalic">Escherichia coli</span> that was sensitive to the antibiotic&#46; He also reported what appeared to be a cut in the proximal part of the nail plate&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Examination revealed erythema and pain in the PNF on palpation&#44; as well as proximal onychomadesis with a thick yellowish nail plate &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A&#41;&#46; Slight lateral deviation was observed in both great toes&#46; No abnormal results were reported for the bacterial and fungal cultures or radiology examination of the toe&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Ultrasound study with a multifrequency linear probe &#40;9-14<span class="elsevierStyleHsp" style=""></span>MHz&#41; and high-resolution device &#40;GE Medical Systems&#41; revealed overlapping nail plates with a hypoechoic space between them&#44; reduction of the distance between the root of the nail plate and the base of the distal phalanx at the level of the distal interphalangeal joint&#44; as well as posterior acoustic shadowing deep under the nail plate&#46; The PNF was thicker in the affected nail than in the healthy contralateral nail&#46; The Doppler signal was slightly enhanced in the proximal part of the nail bed at the root of the matrix &#40;<a class="elsevierStyleCrossRefs" href="#fig0010">Figs&#46; 2 and 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">Once the diagnosis of retronychia was confirmed&#44; surgical avulsion of the nail was performed using an anterior approach&#44; and the 2 nail plates were found to be overlapping at the proximal end&#44; with granulation tissue and keratotic material between them &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46; Histopathology confirmed these findings&#46; A new nail plate grew over the following 12 months&#44; with slight distal thickening and yellowing &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>B&#41;&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0035" class="elsevierStylePara elsevierViewall">A total of 64 cases of retronychia have been reported&#44; and most were included in multicenter studies carried out by experts from the ENS&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">2&#44;4&#8211;15</span></a> Despite the wide age range reported &#40;10-71 years&#41;&#44; the mean age is 25 years&#46; The condition mainly affects women &#40;81&#37;&#41;&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Retronychia affects the great toe unilaterally&#44; although at least 7 cases of bilateral involvement<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">1&#44;2&#44;4&#44;10&#44;13</span></a> and 9 cases of retronychia affecting the nails of the hands<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">1&#44;2&#44;7&#44;8</span></a> have been reported&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The most common triggers are repeated minor injuries&#44; such as those that occur while jogging&#44; walking&#44; and dancing and those that result from having long nails or wearing heels or uncomfortable footwear&#46; However&#44; most patients do not associate their disease with these injuries&#46; There have been at least 10 cases in which no trigger was identified<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">2&#44;4&#44;11&#44;12&#44;14</span></a>&#59; in a further 8 cases&#44; the cause was acute injury such as crushing&#44; burns&#44; and previous nail surgery&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">2&#44;4&#44;5&#44;7&#44;8&#44;10</span></a> In a small number of cases&#44; the condition developed in the setting of a systemic disease &#40;eg arthritis&#41;&#44; anorexia nervosa&#44;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">2</span></a> and admission to the intensive care unit&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">7</span></a> Lateral deviation of the great toe has been considered a potential predisposing factor&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">4&#44;6</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Retronychia manifests with local pain and difficulty walking &#40;in cases where the nails of the feet are affected&#41;&#44; and as erythema&#44; edema&#44; and exudation in the PNF and a dull&#44; thick&#44; yellowish nail plate that does not grow&#46; Also characteristic of this condition is the finding of a nail that is higher proximally than distally&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">2&#44;4&#44;6&#44;12&#44;14</span></a> Granulation tissue can sometimes be observed under the cuticle&#44; as can the sharp proximal edge of the nail plate &#40;see present case&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">4&#44;10&#44;11&#44;13&#44;14</span></a> In 1 case&#44; retronychia has also presented as paronychia that was culture-positive for gram-negative pathogens&#44; yet resistant to antibiotics&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">4</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Diagnosis of retronychia is based on clinical findings&#44; although ultrasound can be used as a noninvasive confirmatory test and in presurgical differential diagnosis&#46; The ultrasound criteria for confirmation of diagnosis are presence of &#8805;2 overlapping nail plates&#44; shortening of the distance between the root of the nail plate and the base of the distal phalanx &#40;at the level of the distal interphalangeal joint&#44; thus indicating the posterior shift of the nail&#41;&#44; and diminished echogenicity in the dermis of the PNF and proximal nail bed owing to the presence of inflammation and onycholysis&#46;<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">7&#44;8</span></a> In the present case&#44; we also observed absence of signal deeper under the nail plate&#44; which was attributed to posterior acoustic shadowing&#46; In 1 case&#44; Doppler ultrasound revealed a slight increase in blood flow in the proximal nail bed&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">7</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">The differential diagnosis of retronychia should include diseases with the appearance of chronic paronychia&#44; namely&#44; candidal or bacterial infection&#44; subungual cysts or tumors &#40;eg&#44; squamous cell carcinoma&#44; melanoma&#44; glomus tumor&#44; and enchondroma&#41;&#44; arthritic processes &#40;eg&#44; psoriasis&#41;&#44; and processes associated with medication &#40;eg&#44; retinoids&#44; ciclosporin&#44; protease inhibitors&#44; and epidermal growth factor receptor inhibitors&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">5&#44;6&#44;9&#44;11&#44;12</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Surgical avulsion of the old nail plate and the subsequent ingrowing nail plate&#40;s&#41; with a proximal approach confirms the diagnosis&#44; leads to rapid pain relief&#44; and is the curative treatment of choice for this process&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">2&#44;4&#44;6</span></a> Avulsion of the most superficial nail plate alone is not sufficient and leads to relapse&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">5&#44;11&#44;14</span></a> However&#44; relapse is unusual&#44; as is permanent postsurgical nail dystrophy&#46; In a series of young and adolescent patients&#44; the new nail was thick and yellowish and grew very slowly in 33&#37; of patients after successful surgical avulsion&#46; Medical treatment with potent topical corticosteroids was associated with a high relapse rate in the series&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">12</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">In conclusion&#44; we report a new case of retronychia that was probably triggered during the practice of mountaineering&#46; The condition was repeatedly confused with infectious paronychia&#44; and it took more than 1 year to confirm the diagnosis and provide adequate treatment&#46; These observations are consistent with reports on patients with retronychia in the literature&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">4&#44;9&#44;11&#44;13</span></a> In addition&#44; even though retronychia may not be as uncommon as previously thought&#44;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">12</span></a> only 1 case has been reported in the Spanish medical literature&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">15</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Ethical Disclosures</span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Protection of humans and animals</span><p id="par0075" class="elsevierStylePara elsevierViewall">The authors declare that no tests were carried out in humans or animals for the purpose of this study&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Confidentiality of data</span><p id="par0080" class="elsevierStylePara elsevierViewall">The authors declare that no private patient data appear in this article&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Right to privacy and informed consent</span><p id="par0085" class="elsevierStylePara elsevierViewall">The authors obtained informed consent from the patients and&#47;or subjects referred to in this article&#46; This document is held by the corresponding author&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conflicts of Interest</span><p id="par0090" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La retroniquia es un proceso emergente en el que la parte proximal de la l&#225;mina ungueal se encarna en el pliegue ungueal proximal&#44; produciendo una paroniquia cr&#243;nica refractaria a terapias antimicrobianas&#46; La ecograf&#237;a se ha postulado como la prueba no invasiva de confirmaci&#243;n y para diagn&#243;stico diferencial&#44; sobre todo con afecciones tumorales y artr&#237;ticas locales&#46; La presencia de dos o m&#225;s l&#225;minas ungueales superpuestas y la disminuci&#243;n de la distancia entre el origen de la l&#225;mina ungueal y la base de la falange distal podr&#237;an ser los criterios ecogr&#225;ficos distintivos de esta entidad&#46; La avulsi&#243;n quir&#250;rgica de la l&#225;mina ungueal es la terapia de elecci&#243;n y curativa de la misma&#46; Su conocimiento todav&#237;a est&#225; poco difundido entre los dermat&#243;logos&#44; ocasionando errores y demoras diagn&#243;sticas y terap&#233;uticas&#44; lo que nos ha motivado a la presentaci&#243;n de un nuevo caso&#46;</p></span>"
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      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Alonso-Pacheco ML&#44; de Miguel-Mendieta E&#44; Maseda-Pedrero R&#44; Mayor-Arenal M&#46; Retroniquia&#58; estudio ecogr&#225;fico y tratamiento quir&#250;rgico de un caso&#46; Actas Dermosifiliogr&#46; 2016&#59;107&#58;e33&#8211;e37&#46;</p>"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A&#44; Erythema and edema in the proximal nail fold and proximal onychomadesis&#44; with a thick&#44; yellowish nail plate&#46; B&#44; Appearance of the new nail at 12 months&#44; with distal yellowing and thickening&#46;</p>"
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Ultrasound study&#58; longitudinal image characteristic of retronychia&#44; with 2 overlapping nail plates and a hypoechoic space between them&#44; together with posterior acoustic shadowing under the lower nail plate&#46; Lower panel&#44; healthy contralateral nail&#46; DIJ indicates distal interphalangeal joint&#59; PNF&#44; proximal nail fold&#46;</p>"
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          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">A and B&#44; Ultrasound-based comparison between images from the great toes&#46; In the nail affected by retronychia &#40;A&#41;&#44; the distance between the root of the nail plate and the base of the distal phalanx &#40;at the level of the distal interphalangeal joint&#41; is reduced&#46; C&#44; Enhanced Doppler signal in the proximal part of the nail bed&#46;</p>"
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          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Surgical avulsion&#46; A&#44; Appearance of both nails before surgery&#46; B&#44; Affected nail higher proximally than distally&#46; C&#44; Proximal detachment with a Freer elevator&#46; D&#44; Removal of the nail plates using Radolf nail pulling forceps&#46; E&#44; Appearance of the nail bed after avulsion&#46; F&#44; Overlapping nail plates forming a &#8220;sandwich&#44;&#8221; with granulation tissue between them at the proximal end&#46;</p>"
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    "bibliografia" => array:2 [
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Información del artículo
ISSN: 15782190
Idioma original: Inglés
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