Noninvasive imaging techniques are playing an increasingly significant role in dermatologic diagnosis, risk evaluation, and the monitoring of therapeutic outcomes. In the August issue of the Journal, we highlight how dermoscopy, onychoscopy, trichoscopy, and line-field confocal optical coherence tomography (LC-OCT) can refine clinical decision-making across acral melanocytic lesions, onycholysis, primary cicatricial alopecia, and hyperkeratotic actinic keratoses. These papers show that imaging is most useful when tailored to anatomical and clinical context, advancing standardized and clinically actionable imaging approaches.

Langerhans cell histiocytosis (LCH) is a rare myeloid neoplastic disorder driven by somatic MAPK pathway mutations, most commonly BRAFV600E, characterized by clonal proliferation of CD1a+/CD207+ dendritic cells forming granulomatous lesions in various tissues. Nail involvement is an uncommon but clinically significant manifestation, often associated with multisystem disease and a potentially poorer prognosis. We report 2 pediatric cases of LCH presenting with nail changes as the initial clinical feature. Case 1, a 2-year-old boy, was presented with longitudinal grooving, onycholysis, subungual hyperkeratosis, and purpuric striae of nearly all fingernails. Staging investigations revealed only mild lymphadenopathy, and BRAF mutation testing was negative. He was treated with methylprednisolone and vinblastine, achieving metabolic inactivity at 9 months. Case 2, a 19-month-old boy, was presented with diffuse fingernail and toenail dystrophy followed by cutaneous papules and was found to have multisystem disease involving bone and lungs. Nail bed, skin, and bone biopsies confirmed LCH. Systemic chemotherapy with vinblastine and prednisone led to marked improvement in nail, skin, pulmonary, and osseous lesions. These cases illustrate that nail changes may be the earliest manifestation of LCH and should prompt thorough systemic evaluation. Early recognition of nail involvement can facilitate timely diagnosis and risk-adapted treatment, potentially improving outcomes in affected patients.

Erdafitinib is a fibroblast growth factor receptor 1-4 inhibitor used for locally advanced or metastatic urothelial carcinoma in patients who have experienced disease progression after at least 1 prior systemic therapy. Various cutaneous side effects of erdafitinib have been reported, most commonly stomatitis and nail changes such as onycholysis, nail dystrophy, and paronychia. However, onychomadesis is a rarer nail toxicity that can cause significant discomfort and may necessitate treatment interruption. We present the case of a 61-year-old White man with metastatic urothelial carcinoma treated with 8 mg of erdafitinib daily who developed diffuse onychomadesis within a few months of initiating therapy. Awareness of the potential cutaneous side effects of erdafitinib and timely referral for specialty dermatologic care are important to allow treatment continuation.

Hand, foot, and mouth disease (HFMD) is a self-limiting viral illness predominantly affecting children under 10 years of age, with peak incidence in those aged one to four years. Recent outbreaks of Coxsackievirus A6 (CVA6) have increased its incidence across all age groups, including adults. Onychomadesis, a proximal nail plate detachment due to transient matrix arrest, is a recognized but underreported delayed complication of HFMD. We report a case of a 60-year-old man who developed onychomadesis three weeks after clinical recovery from CVA6-induced HFMD. Initial symptoms included fever, sore throat, gastrointestinal disturbances, and vesiculopapular lesions on the hands, feet, scalp, and oropharynx. He later presented with Beau's lines, onycholysis, and complete nail shedding involving all 10 fingernails and two toenails on each foot. Conservative management led to complete nail regrowth within eight to 12 weeks. Although the pathophysiology of HFMD-associated onychomadesis is not fully understood, potential mechanisms include direct viral cytotoxicity, localized inflammation, and systemic stress. CVA6 has been increasingly linked to adult cases, often with more severe mucocutaneous and nail manifestations compared to other serotypes. This case highlights CVA6 as an important and emerging cause of onychomadesis in adults following HFMD. Clinician awareness is essential for timely recognition, appropriate patient reassurance, and avoidance of unnecessary investigations. Further studies are needed to explain the underlying mechanisms and risk factors.

Onychopapilloma (OP) is a benign nail unit tumor of the distal nail matrix and nail bed that typically presents as solitary longitudinal erythronychia with distal subungual hyperkeratosis and focal onycholysis. Atypical OP is a newly recognized and evolving concept in dermatopathology. Herein, we present a histopathologically-proven atypical OP with a classic clinical appearance that developed during pregnancy. A 37-year-old Gravida two Para one woman presented with a red longitudinal band on the left thumbnail that appeared during the first trimester of an uncomplicated pregnancy. The lesion was asymptomatic; however, it was gradually increasing in size, prompting a longitudinal excisional biopsy of the lesion post-partum. Histopathologic evaluation of the nail unit revealed common features of an OP, including acanthosis and papillomatosis of the nail bed with focal matrix metaplasia. There were focal areas of cytologic atypia and mitotic figures with corresponding increased suprabasilar Ki-67 expression. The tumor was excised with Mohs micrographic surgery in one stage, and the resulting defect healed with secondary intention. No recurrence was observed at 6-month follow-up. This case expands the current literature on histopathologically-proven atypical OP and describes the novel occurrence during pregnancy.

BackgroundFutibatinib, a novel FGFR inhibitor, is a promising therapy for cancers with FGFR alterations. However, its safety profile remains under investigation. This study evaluates futibatinib-associated adverse events using the FDA Adverse Event Reporting System (FAERS).MethodsA retrospective pharmacovigilance analysis was conducted using FAERS data from January 1, 2013, to March 9, 2025. Disproportionality analysis was performed via OpenVigil 2.1, with signals defined by a reporting odds ratio (ROR) > 2.00 and a 95% confidence interval lower bound >1.00. Events with at least two reports were included after deduplication and standardization.ResultsStrong safety signals were identified. Hyperphosphatasemia showed the highest association (ROR 1612.73; 6 events), followed by elevated blood phosphorus (ROR 603.85; 3 events). Dermatologic toxicities, including onycholysis (ROR 520.15) and onychoclasis (ROR 126.20), were also notable.ConclusionThese findings highlight the range of adverse events associated with this agent. These events may reflect direct drug effects and individual variability. Further studies are needed to clarify mechanisms and inform clinical management.

Green nail syndrome (GNS) is classically characterized by a triad of green nail discoloration, paronychia, and onycholysis. Although Pseudomonas aeruginosa (P. aeruginosa) is the primary etiologic agent, infections involving co-pathogens are uncommon and pose considerable diagnostic and therapeutic challenges due to the absence of standardized management guidelines. We herein report a rare case of GNS caused by a co-infection with P. aeruginosa and the Burkholderia cepacia complex (BCC) in a woman with a history of manicures and frequent domestic exposure to water and detergents. The diagnosis was confirmed through bacterial culture and antimicrobial susceptibility testing. Targeted therapy involving a combination of oral and topical levofloxacin, guided by the antimicrobial susceptibility profile, resulted in the successful resolution of the infection. This case underscores the critical importance of microbiological identification for guiding effective treatment of non-classical GNS and demonstrates the efficacy of tailored antibiotic regimens in managing complex co-infections.

Atopic dermatitis (AD) is a common chronic, recurrent inflammatory disease, yet its accompanying nail abnormalities have long received insufficient attention. The clinical characteristics, underlying mechanisms, and assessment systems for nail dystrophy in AD remain unclear. AD-associated nail dystrophy can manifest in various forms, including Beau's lines, nail pitting, koilongchia, trachyonychia, leukonychia, brachyonychia, melanoychia, onychomadesis, onychoschizia, onycholysis, and paronychia. Current treatments face limitations such as slow onset of action and uncertain efficacy with traditional therapies, particularly with limited drug options for the pediatric populations. With the deepening of research into the Th2 inflammatory pathway, biologics such as dupilumab have shown therapeutic potential. Through retrospective analysis, this paper presents the effectiveness and safety of dupilumab in five pediatric AD patients with nail dystrophy under 12 years old. After at least 12 weeks of treatment, their skin lesions and nail dystrophy both showed marked improvement. Additionally, we reviewed four reported cases in the literature of adult AD patients with nail dystrophy who experienced significant improvement in nail changes after dupilumab treatment. These results suggest that dupilumab may be an effective treatment for nail dystrophy in AD. This case series provides the first evidence demonstrating the significant efficacy of dupilumab for nail dystrophy in pediatric AD patients. However, further large-scale prospective studies are still needed to better guide clinical practice.