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Acute Pustular Eruption on the Hands
Acute Pustular Eruption on the Hands
THE DIAGNOSIS: Neutrophilic Dermatosis of the Dorsal Hands
Histopathology showed a unilocular pustule with a dense neutrophilic infiltrate of the superficial dermis. Minimal vascular alterations also were observed. These findings were consistent with a diagnosis of neutrophilic dermatosis of the dorsal hands (NDDH). Our patient was treated successfully with systemic corticosteroids (1 mg/kg/d) with rapid improvement after 10 days of treatment.
Neutrophilic dermatosis of the dorsal hands is an evolving disease concept that was first described as pustular vasculitis by Strutton et al1 in 1995. Galaria et al2 subsequently identified NDDH as a clinical entity associating tender erythematous plaques, pustules, bullae, and/or ulcers on the dorsal hands with histologic features of Sweet syndrome (SS). After reviewing 9 cases of NDDH—all of which demonstrated clinical, laboratory, and histologic characteristics of SS—Walling et al3 concluded that NDDH was best understood as a distributional variant of SS.
Our patient presented with vascular alterations described as a reactive response to the neutrophilic infiltration. The presence of vasculitis in SS and NDDH biopsies is considered as an occasional epiphenomenon and should not rule out the diagnosis of NDDH.3 A literature review of 123 cases of NDDH revealed the presence of vasculitis in 36 (29.5%) patients.4 With regard to other clinical findings, it has been suggested that an increased white blood cell count and elevated C-reactive protein level, as was seen in our patient, may be observed in NDDH, albeit less frequently than in classical SS.4
While palmar involvement of NDDH is considered rare, the recent review of 123 cases of NDDH identified palmar lesions in 5 patients (4.1%).4 Earlier reviews had identified 12 historical cases.5 Palmar manifestations of NDDH have been shown to be associated with erythematous nonulcerated lesions (as opposed to the classical ulcerative or pustular plaques) and a lower association with hematologic malignancies.5
In our patient’s case, dyshidrosis was excluded due to the presence of painful ulcerative plaques rather than pruritic, deep-seated vesicles. Pustular psoriasis typically manifests with sterile pustules on the palms and soles; however, the rapid onset of ulcerative, necrotic plaques and substantial edema are more specific to NDDH. Poststreptococcal pustulosis generally follows a streptococcal infection and lacks the violaceous undermined borders seen in NDDH. Reactive arthritis manifests with hyperkeratotic plaques and is associated with the clinical triad of urethritis, conjunctivitis, and arthritis, which were absent in our patient.
The histologic differential diagnosis of NDDH includes infection, pyoderma gangrenosum, bowel-associated dermatosis-arthritis syndrome, rheumatoid neutrophilic dermatitis, and erythema elevatum diutinum3,4; however, these conditions typically manifest with distinct clinical features that allow for differentiation, despite histologic similarities. The wide histologic spectrum of neutrophilic dermatosis may contribute to variable clinical manifestations and an evolving disease concept, as the classification of NDDH has changed from a primary vasculitis to a variant of SS. However, this evolution does not affect the appropriate management, as they all have shown good response to corticosteroid treatment.4,6
- Strutton G, Weedon D, Robertson I. Pustular vasculitis of the hands. J Am Acad Dermatol. 1995;32(2 pt 1):192-198.
- Galaria NA, Junkins-Hopkins JM, Kligman D, et al. Neutrophilic dermatosis of the dorsal hands: pustular vasculitis revisited. J Am Acad Dermatol. 2000;43(5 pt 1):870-874.
- Walling HW, Snipes CJ, Gerami P, et al. The relationship between neutrophilic dermatosis of the dorsal hands and sweet syndrome: report of 9 cases and comparison to atypical pyoderma gangrenosum. Arch Dermatol. 2006;142:57-63
- Micallef D, Bonnici M, Pisani D, et al. Neutrophilic dermatosis of the dorsal hands: a review of 123 cases. J Am Acad Dermatol. 2023;88:1338-1344.
- Arandes-Marcocci J, Altemir-Vidal A, Iglesias-Plaza A, et al. Neutrophilic dermatosis of the hands with palmar involvement: does it have clinical implication? Int J Dermatol. 2020;59:736-738.
- Del Pozo J, Sacristán F, Martínez W, et al. Neutrophilic dermatosis of the hands: presentation of eight cases and review of the literature. J Dermatol. 2007;34:243-247.
THE DIAGNOSIS: Neutrophilic Dermatosis of the Dorsal Hands
Histopathology showed a unilocular pustule with a dense neutrophilic infiltrate of the superficial dermis. Minimal vascular alterations also were observed. These findings were consistent with a diagnosis of neutrophilic dermatosis of the dorsal hands (NDDH). Our patient was treated successfully with systemic corticosteroids (1 mg/kg/d) with rapid improvement after 10 days of treatment.
Neutrophilic dermatosis of the dorsal hands is an evolving disease concept that was first described as pustular vasculitis by Strutton et al1 in 1995. Galaria et al2 subsequently identified NDDH as a clinical entity associating tender erythematous plaques, pustules, bullae, and/or ulcers on the dorsal hands with histologic features of Sweet syndrome (SS). After reviewing 9 cases of NDDH—all of which demonstrated clinical, laboratory, and histologic characteristics of SS—Walling et al3 concluded that NDDH was best understood as a distributional variant of SS.
Our patient presented with vascular alterations described as a reactive response to the neutrophilic infiltration. The presence of vasculitis in SS and NDDH biopsies is considered as an occasional epiphenomenon and should not rule out the diagnosis of NDDH.3 A literature review of 123 cases of NDDH revealed the presence of vasculitis in 36 (29.5%) patients.4 With regard to other clinical findings, it has been suggested that an increased white blood cell count and elevated C-reactive protein level, as was seen in our patient, may be observed in NDDH, albeit less frequently than in classical SS.4
While palmar involvement of NDDH is considered rare, the recent review of 123 cases of NDDH identified palmar lesions in 5 patients (4.1%).4 Earlier reviews had identified 12 historical cases.5 Palmar manifestations of NDDH have been shown to be associated with erythematous nonulcerated lesions (as opposed to the classical ulcerative or pustular plaques) and a lower association with hematologic malignancies.5
In our patient’s case, dyshidrosis was excluded due to the presence of painful ulcerative plaques rather than pruritic, deep-seated vesicles. Pustular psoriasis typically manifests with sterile pustules on the palms and soles; however, the rapid onset of ulcerative, necrotic plaques and substantial edema are more specific to NDDH. Poststreptococcal pustulosis generally follows a streptococcal infection and lacks the violaceous undermined borders seen in NDDH. Reactive arthritis manifests with hyperkeratotic plaques and is associated with the clinical triad of urethritis, conjunctivitis, and arthritis, which were absent in our patient.
The histologic differential diagnosis of NDDH includes infection, pyoderma gangrenosum, bowel-associated dermatosis-arthritis syndrome, rheumatoid neutrophilic dermatitis, and erythema elevatum diutinum3,4; however, these conditions typically manifest with distinct clinical features that allow for differentiation, despite histologic similarities. The wide histologic spectrum of neutrophilic dermatosis may contribute to variable clinical manifestations and an evolving disease concept, as the classification of NDDH has changed from a primary vasculitis to a variant of SS. However, this evolution does not affect the appropriate management, as they all have shown good response to corticosteroid treatment.4,6
THE DIAGNOSIS: Neutrophilic Dermatosis of the Dorsal Hands
Histopathology showed a unilocular pustule with a dense neutrophilic infiltrate of the superficial dermis. Minimal vascular alterations also were observed. These findings were consistent with a diagnosis of neutrophilic dermatosis of the dorsal hands (NDDH). Our patient was treated successfully with systemic corticosteroids (1 mg/kg/d) with rapid improvement after 10 days of treatment.
Neutrophilic dermatosis of the dorsal hands is an evolving disease concept that was first described as pustular vasculitis by Strutton et al1 in 1995. Galaria et al2 subsequently identified NDDH as a clinical entity associating tender erythematous plaques, pustules, bullae, and/or ulcers on the dorsal hands with histologic features of Sweet syndrome (SS). After reviewing 9 cases of NDDH—all of which demonstrated clinical, laboratory, and histologic characteristics of SS—Walling et al3 concluded that NDDH was best understood as a distributional variant of SS.
Our patient presented with vascular alterations described as a reactive response to the neutrophilic infiltration. The presence of vasculitis in SS and NDDH biopsies is considered as an occasional epiphenomenon and should not rule out the diagnosis of NDDH.3 A literature review of 123 cases of NDDH revealed the presence of vasculitis in 36 (29.5%) patients.4 With regard to other clinical findings, it has been suggested that an increased white blood cell count and elevated C-reactive protein level, as was seen in our patient, may be observed in NDDH, albeit less frequently than in classical SS.4
While palmar involvement of NDDH is considered rare, the recent review of 123 cases of NDDH identified palmar lesions in 5 patients (4.1%).4 Earlier reviews had identified 12 historical cases.5 Palmar manifestations of NDDH have been shown to be associated with erythematous nonulcerated lesions (as opposed to the classical ulcerative or pustular plaques) and a lower association with hematologic malignancies.5
In our patient’s case, dyshidrosis was excluded due to the presence of painful ulcerative plaques rather than pruritic, deep-seated vesicles. Pustular psoriasis typically manifests with sterile pustules on the palms and soles; however, the rapid onset of ulcerative, necrotic plaques and substantial edema are more specific to NDDH. Poststreptococcal pustulosis generally follows a streptococcal infection and lacks the violaceous undermined borders seen in NDDH. Reactive arthritis manifests with hyperkeratotic plaques and is associated with the clinical triad of urethritis, conjunctivitis, and arthritis, which were absent in our patient.
The histologic differential diagnosis of NDDH includes infection, pyoderma gangrenosum, bowel-associated dermatosis-arthritis syndrome, rheumatoid neutrophilic dermatitis, and erythema elevatum diutinum3,4; however, these conditions typically manifest with distinct clinical features that allow for differentiation, despite histologic similarities. The wide histologic spectrum of neutrophilic dermatosis may contribute to variable clinical manifestations and an evolving disease concept, as the classification of NDDH has changed from a primary vasculitis to a variant of SS. However, this evolution does not affect the appropriate management, as they all have shown good response to corticosteroid treatment.4,6
- Strutton G, Weedon D, Robertson I. Pustular vasculitis of the hands. J Am Acad Dermatol. 1995;32(2 pt 1):192-198.
- Galaria NA, Junkins-Hopkins JM, Kligman D, et al. Neutrophilic dermatosis of the dorsal hands: pustular vasculitis revisited. J Am Acad Dermatol. 2000;43(5 pt 1):870-874.
- Walling HW, Snipes CJ, Gerami P, et al. The relationship between neutrophilic dermatosis of the dorsal hands and sweet syndrome: report of 9 cases and comparison to atypical pyoderma gangrenosum. Arch Dermatol. 2006;142:57-63
- Micallef D, Bonnici M, Pisani D, et al. Neutrophilic dermatosis of the dorsal hands: a review of 123 cases. J Am Acad Dermatol. 2023;88:1338-1344.
- Arandes-Marcocci J, Altemir-Vidal A, Iglesias-Plaza A, et al. Neutrophilic dermatosis of the hands with palmar involvement: does it have clinical implication? Int J Dermatol. 2020;59:736-738.
- Del Pozo J, Sacristán F, Martínez W, et al. Neutrophilic dermatosis of the hands: presentation of eight cases and review of the literature. J Dermatol. 2007;34:243-247.
- Strutton G, Weedon D, Robertson I. Pustular vasculitis of the hands. J Am Acad Dermatol. 1995;32(2 pt 1):192-198.
- Galaria NA, Junkins-Hopkins JM, Kligman D, et al. Neutrophilic dermatosis of the dorsal hands: pustular vasculitis revisited. J Am Acad Dermatol. 2000;43(5 pt 1):870-874.
- Walling HW, Snipes CJ, Gerami P, et al. The relationship between neutrophilic dermatosis of the dorsal hands and sweet syndrome: report of 9 cases and comparison to atypical pyoderma gangrenosum. Arch Dermatol. 2006;142:57-63
- Micallef D, Bonnici M, Pisani D, et al. Neutrophilic dermatosis of the dorsal hands: a review of 123 cases. J Am Acad Dermatol. 2023;88:1338-1344.
- Arandes-Marcocci J, Altemir-Vidal A, Iglesias-Plaza A, et al. Neutrophilic dermatosis of the hands with palmar involvement: does it have clinical implication? Int J Dermatol. 2020;59:736-738.
- Del Pozo J, Sacristán F, Martínez W, et al. Neutrophilic dermatosis of the hands: presentation of eight cases and review of the literature. J Dermatol. 2007;34:243-247.
Acute Pustular Eruption on the Hands
Acute Pustular Eruption on the Hands
A 56-year-old woman was referred to the dermatology department for a painful acral pustular eruption of 6 days’ duration. Her medical history was otherwise unremarkable. Physical examination revealed multiple pustules on the hands with large blisters on an erythematous base and painful surface ulceration (top). Papulonodular infiltrated lesions also were observed on the dorsal aspect of the hands (bottom). There were no additional systemic symptoms. Routine laboratory tests showed hyperleukocytosis at 17.9×103/mm3 (reference range, 4-10×103/mm3) with neutrophils at 12.3×103/mm3 (1.8-7.5×103/mm3) and elevated C-reactive protein at 67 mg/L (<5 mg/L). Screening for hematologic neoplasms, solid tumors, and inflammatory bowel disease was negative. An incisional biopsy was performed on a pustule on the palm of the left hand.
Nail Alterations From Musical Instruments: Insights for Dermatologists Treating Musicians
A variety of skin problems can occur in musicians due to the repetitive movements of playing instruments.1,2 Musicians’ nails are continuously exposed to the mechanical forces and chemical substances characteristic of their instruments.3 Occupational nail alterations in musicians caused by repetitive physical trauma, allergic contact dermatitis, and/or infection may lead to disability and compromise their professional career.
We conducted a systematic review of the literature on the clinical features of musical instrument–related nail alterations to optimize the management and prevention of these conditions.
Methods
We conducted a systematic review of PubMed, Scopus, and Google Scholar databases for eligible publications on instrument-related nail alterations in musicians using the search terms musicians with nail, onychopathy, and Raynaud. No time or language criteria were applied. Reviews, editorials, and articles not related to the topic were excluded. Bibliographies/reference lists were checked to find any additional relevant publications. Relevant articles in English and French were screened by 2 independent reviewers (A.G. and N.L.), and the following data were extracted for qualitative synthesis: sex, age, musical instrument, clinical features, number of years practicing the instrument, laboratory investigations, and disease course.
Results
The literature search yielded 11 publications. Sixteen additional articles were identified by other methods (ie, references, related publications). Overall, 3 full-text articles described general nail alterations but did not describe the clinical data, and 11 publications were editorials, commentaries, reviews, or not relevant. Thirteen contributions fulfilled the inclusion criteria and were eligible for qualitative synthesis. The flow diagram illustrates the screening process (Figure 1).
Twenty-three patients were included. The instruments identified were divided into 2 groups: string instruments (ie, guitar, violin, harp) and percussion instruments (ie, drums, piano, slap bass). Nail alterations were clinically expressed as: (1) modifications of the nail surface; (2) nail bed, soft-tissue, and bone abnormalities; and (3) periungual tissue and distal pulp disorders. All cases are summarized in the Table.4-16 Three articles described occupational Raynaud phenomenon.12-14
Comment
Modifications of the Nail Surface—Onychodystrophy, such as deformity or discoloration of the nail plate, was described in 6 patients among a cohort of 295 musicians and an additional 6 patients among 199 musicians with induced skin lesions. This condition was most common in string instrument players and pianists due to injury and irritation.
One patient, who had been a professional violist for 27 years, presented with lamellar onychoschizia, which corresponds to a horizontal splitting of the nail toward its distal portion (Figure 2). The 3 fingernails of the dominant hand were involved with a V-shaped incision of the distal margin of the nail due to the repetitive friction of the nails with the strings.6
Striations of the nail plate were reported in a guitarist who played for 10 years.7 Physical examination revealed linear transverse ridges alternating with depressions on the central aspect of the nail plate of the right thumbnail, as the patient was right-handed. This condition, attributed to sustained pressure on the string applied by the thumb, also has been called habit tic deformity.7
Nail Bed, Soft-Tissue, and Bone Lesions—Purpura (or hemorrhage) of the nail bed was associated with a percussion instrument (ie, piano) in 1 patient, affecting the second, third, and fourth fingernails of the right hand.8 Especially when performing ascending glissando passages, the pianist applies pressure that may damage the finger and cause fingernail purpura. This condition improved after the patient stopping practicing glissandi.8
Three patients—2 guitarists and 1 violist—had onycholysis, defined by a loss of the attachment between the nail bed and the nail plate (Figure 3). It may result from repetitive trauma when strings are plucked.6,9,10
Acro-osteolysis associated with pain was reported in 2 guitarists.10,11 This condition is defined as transverse lytic bands in the distal phalanges (Figure 4). Acro-osteolysis may be secondary to multiple causes, such as vinyl chloride exposure, connective tissue diseases, thermal injuries, neuropathic diseases, hyperparathyroidism, nutritional deficiencies, psoriasis, and biomechanical stress.10 In musicians playing instruments, the mechanical stress to the guitar-playing fingers is the causative factor.17
Periungual Tissue and Distal Pulp Disorders—Paronychia is an important occupational hazard of harpists, violists, and pianists.2 It represents an inflammatory condition involving the folds of tissue surrounding fingernails. Pizzicato paronychia is related to infection in the nail fold in string players and secondary to pizzicato playing, whereby the musician plucks the instrument strings with the nails and fingertips.3
Acrylates in artificial nails frequently are used among guitarists to strengthen their nails. A case of occupational allergic contact dermatitis induced by acrylic gel nails in a flamenco guitarist was described.9 The patient developed dystrophy, onycholysis, and paronychia involving the nails of the right hand where acrylic materials were used, which resolved following the removal of the artificial nails. Patch tests were performed and were positive for 2-hydroxyethyl methacrylate, 2-hydroxyethyl acrylate, ethylene glycol dimethacrylate, and 2-hydroxypropyl methacrylate, supporting the diagnosis of allergic contact dermatitis to acrylates.9 Therefore, musicians should be aware of the sensitizing potential of acrylates and adopt preventive measures.
Unilateral Raynaud phenomenon of the dominant hand was noted in 3 cases of musicians who played string instruments due to the increased tendency to vasospasm in the digital capillaries from the direct transmission of vibrations of the strings (>100 Hz).12-14 Consequently, the disruption of the digital blood circulation leads to an abnormal reaction to cold, which is called vibration-induced white fingers or vasospastic white finger disease.19 In these 3 patients, capillaroscopy showed a nonspecific pattern with a lack of morphologic homogeneity of capillaries, the presence of enlarged capillaries, ectasia of the efferent tract of the loops, tortuous capillaries, local hemorrhages, and neoangiogenesis.13,14
A middle-aged professional concert pianist presented with paronychia with hyperkeratosis of the lateral nail fold. Histopathology revealed a subungual keratoacanthoma eroding the distal phalanx tip, which was removed by surgical excision. The repeated fingertip trauma associated with pianistic activity was suspected to be the causative event.16
Callosities also are common on the fingertips of musicians, including 18.4% of patients in a cohort of 628 musicians, and involving fingers in 64.6% of these patients.4 These callosities are explained by the chronic mechanical forces and characterize the way musicians grasp and hold their instruments. Callosities could be preceded by soreness and blisters of the fingertips in a harpist (harpist’s finger).1,15 Calluses were located on the lateral fourth fingertip of a drummer corresponding to the friction with the drumsticks (drummer’s digit) and on the thumb of a bassoon player. Trumpet calluses generally overlie the proximal interphalangeal joint of the left index finger.
Conclusion
Healthy nails are essential for playing a musical instrument. This review highlights the occurrence of fingertip callosities, paronychia, onycholysis, and subungual hemorrhages among musicians who play instruments. Additionally, the transmission of string-vibratory movements can produce microvascular damage and occupational Raynaud phenomenon in some musicians. These occupational nail disorders are underrecognized and may be underdiagnosed. Thus, musicians and clinicians must be aware of these alterations to adopt preventive measures and to provide adequate treatment.
- Rimmer S, Spielvogel RL. Dermatologic problems of musicians. J Am Acad Dermatol. 1990;22:657-663.
- Adams RM. Skin conditions of musicians. Cutis. 2000;65:37-38.
- Vine K, DeLeo V. Dermatologic manifestations of musicians: a case report and review of skin conditions in musicians. Cutis. 2011;87:117-121.
- Patruno C, Napolitano M, La Bella S, et al. Instrument-related skin disorders in musicians. Dermatitis. 2016;27:26-29.
- Baccouche D, Mokni M, Ben Abdelaziz A, et al. Dermatological problems of musicians: a prospective study in musical students . Article in French. Ann Dermatol Venereol. 2007;134(5 Pt 1):445-449.
- Piraccini BM, Antonucci A, Iorizzo M, et al. Occupational nail fragility in a professional violist. Contact Dermatitis. 2004;51:35-36.
- Wu JJ. Habit tic deformity secondary to guitar playing. Dermatol Online J. 2009;15:16.
- Kluger N. Piano glissando purpura: another cutaneous curiosity in musicians. J Eur Acad Dermatol Venereol. 2016;30:683.
- Alcántara-Nicolás FA, Pastor-Nieto MA, Sánchez-Herreros C, et al. Allergic contact dermatitis from acrylic nails in a flamenco guitarist. Occup Med (Lond). 2016;66:751-753.
- Baran R, Tosti A. Occupational acroosteolysis in a guitar player. Acta Derm Venereol. 1993;73:64-65.
- Destouet JM, Murphy WA. Guitar player acro-osteolysis. Skeletal Radiol. 1981;6:275-277.
- Jepsen JR, Simonsen JA. Raynaud’s phenomenon in a slap bass player: a case report. Med Probl Perform Art. 2016;31:51-53.
- Sirufo MM, Catalogna A, De Pietro F, et al. Raynaud’s phenomenon in a drummer player: microvascular disorder and nailfold video capillaroscopic findings. EXCLI J. 2021;20:1526-1531.
- Sirufo MM, Ginaldi L, De Martinis M. Raynaud’s phenomenon and the nailfold capillaroscopic findings in a guitar player. QJM. 2019;112:531-533.
- Cohen PR. Harpist’s finger: case report of a trauma-induced blister in a beginner harpist and review of string instrument-associated skin problems in musicians. Cutis. 2008;82:329-334.
- De Vasconcelos P, Soares-Almeida L, Filipe P. Subungual keratoacanthoma in a pianist. G Ital Dermatol Venereol. 2016;151:455-456.
- Young RS, Bryk D, Ratner H. Selective phalangeal tuft fractures in a guitar player. Br J Radiol. 1977;50:147-148.
- Vázquez-Osorio I, Espasandín-Arias M, García-Gavín J, et al. Allergic contact dermatitis due to acrylates in acrylic gel nails: a report of 3 cases. Actas Dermosifiliogr. 2014;105:430-432.
- Atashpaz S, Ghabili K. Color triad in guitarist’s fingers: a probable case of Raynaud’s phenomenon due to string vibration phenomenon. Med Probl Perform Art. 2008;23:143.
A variety of skin problems can occur in musicians due to the repetitive movements of playing instruments.1,2 Musicians’ nails are continuously exposed to the mechanical forces and chemical substances characteristic of their instruments.3 Occupational nail alterations in musicians caused by repetitive physical trauma, allergic contact dermatitis, and/or infection may lead to disability and compromise their professional career.
We conducted a systematic review of the literature on the clinical features of musical instrument–related nail alterations to optimize the management and prevention of these conditions.
Methods
We conducted a systematic review of PubMed, Scopus, and Google Scholar databases for eligible publications on instrument-related nail alterations in musicians using the search terms musicians with nail, onychopathy, and Raynaud. No time or language criteria were applied. Reviews, editorials, and articles not related to the topic were excluded. Bibliographies/reference lists were checked to find any additional relevant publications. Relevant articles in English and French were screened by 2 independent reviewers (A.G. and N.L.), and the following data were extracted for qualitative synthesis: sex, age, musical instrument, clinical features, number of years practicing the instrument, laboratory investigations, and disease course.
Results
The literature search yielded 11 publications. Sixteen additional articles were identified by other methods (ie, references, related publications). Overall, 3 full-text articles described general nail alterations but did not describe the clinical data, and 11 publications were editorials, commentaries, reviews, or not relevant. Thirteen contributions fulfilled the inclusion criteria and were eligible for qualitative synthesis. The flow diagram illustrates the screening process (Figure 1).
Twenty-three patients were included. The instruments identified were divided into 2 groups: string instruments (ie, guitar, violin, harp) and percussion instruments (ie, drums, piano, slap bass). Nail alterations were clinically expressed as: (1) modifications of the nail surface; (2) nail bed, soft-tissue, and bone abnormalities; and (3) periungual tissue and distal pulp disorders. All cases are summarized in the Table.4-16 Three articles described occupational Raynaud phenomenon.12-14
Comment
Modifications of the Nail Surface—Onychodystrophy, such as deformity or discoloration of the nail plate, was described in 6 patients among a cohort of 295 musicians and an additional 6 patients among 199 musicians with induced skin lesions. This condition was most common in string instrument players and pianists due to injury and irritation.
One patient, who had been a professional violist for 27 years, presented with lamellar onychoschizia, which corresponds to a horizontal splitting of the nail toward its distal portion (Figure 2). The 3 fingernails of the dominant hand were involved with a V-shaped incision of the distal margin of the nail due to the repetitive friction of the nails with the strings.6
Striations of the nail plate were reported in a guitarist who played for 10 years.7 Physical examination revealed linear transverse ridges alternating with depressions on the central aspect of the nail plate of the right thumbnail, as the patient was right-handed. This condition, attributed to sustained pressure on the string applied by the thumb, also has been called habit tic deformity.7
Nail Bed, Soft-Tissue, and Bone Lesions—Purpura (or hemorrhage) of the nail bed was associated with a percussion instrument (ie, piano) in 1 patient, affecting the second, third, and fourth fingernails of the right hand.8 Especially when performing ascending glissando passages, the pianist applies pressure that may damage the finger and cause fingernail purpura. This condition improved after the patient stopping practicing glissandi.8
Three patients—2 guitarists and 1 violist—had onycholysis, defined by a loss of the attachment between the nail bed and the nail plate (Figure 3). It may result from repetitive trauma when strings are plucked.6,9,10
Acro-osteolysis associated with pain was reported in 2 guitarists.10,11 This condition is defined as transverse lytic bands in the distal phalanges (Figure 4). Acro-osteolysis may be secondary to multiple causes, such as vinyl chloride exposure, connective tissue diseases, thermal injuries, neuropathic diseases, hyperparathyroidism, nutritional deficiencies, psoriasis, and biomechanical stress.10 In musicians playing instruments, the mechanical stress to the guitar-playing fingers is the causative factor.17
Periungual Tissue and Distal Pulp Disorders—Paronychia is an important occupational hazard of harpists, violists, and pianists.2 It represents an inflammatory condition involving the folds of tissue surrounding fingernails. Pizzicato paronychia is related to infection in the nail fold in string players and secondary to pizzicato playing, whereby the musician plucks the instrument strings with the nails and fingertips.3
Acrylates in artificial nails frequently are used among guitarists to strengthen their nails. A case of occupational allergic contact dermatitis induced by acrylic gel nails in a flamenco guitarist was described.9 The patient developed dystrophy, onycholysis, and paronychia involving the nails of the right hand where acrylic materials were used, which resolved following the removal of the artificial nails. Patch tests were performed and were positive for 2-hydroxyethyl methacrylate, 2-hydroxyethyl acrylate, ethylene glycol dimethacrylate, and 2-hydroxypropyl methacrylate, supporting the diagnosis of allergic contact dermatitis to acrylates.9 Therefore, musicians should be aware of the sensitizing potential of acrylates and adopt preventive measures.
Unilateral Raynaud phenomenon of the dominant hand was noted in 3 cases of musicians who played string instruments due to the increased tendency to vasospasm in the digital capillaries from the direct transmission of vibrations of the strings (>100 Hz).12-14 Consequently, the disruption of the digital blood circulation leads to an abnormal reaction to cold, which is called vibration-induced white fingers or vasospastic white finger disease.19 In these 3 patients, capillaroscopy showed a nonspecific pattern with a lack of morphologic homogeneity of capillaries, the presence of enlarged capillaries, ectasia of the efferent tract of the loops, tortuous capillaries, local hemorrhages, and neoangiogenesis.13,14
A middle-aged professional concert pianist presented with paronychia with hyperkeratosis of the lateral nail fold. Histopathology revealed a subungual keratoacanthoma eroding the distal phalanx tip, which was removed by surgical excision. The repeated fingertip trauma associated with pianistic activity was suspected to be the causative event.16
Callosities also are common on the fingertips of musicians, including 18.4% of patients in a cohort of 628 musicians, and involving fingers in 64.6% of these patients.4 These callosities are explained by the chronic mechanical forces and characterize the way musicians grasp and hold their instruments. Callosities could be preceded by soreness and blisters of the fingertips in a harpist (harpist’s finger).1,15 Calluses were located on the lateral fourth fingertip of a drummer corresponding to the friction with the drumsticks (drummer’s digit) and on the thumb of a bassoon player. Trumpet calluses generally overlie the proximal interphalangeal joint of the left index finger.
Conclusion
Healthy nails are essential for playing a musical instrument. This review highlights the occurrence of fingertip callosities, paronychia, onycholysis, and subungual hemorrhages among musicians who play instruments. Additionally, the transmission of string-vibratory movements can produce microvascular damage and occupational Raynaud phenomenon in some musicians. These occupational nail disorders are underrecognized and may be underdiagnosed. Thus, musicians and clinicians must be aware of these alterations to adopt preventive measures and to provide adequate treatment.
A variety of skin problems can occur in musicians due to the repetitive movements of playing instruments.1,2 Musicians’ nails are continuously exposed to the mechanical forces and chemical substances characteristic of their instruments.3 Occupational nail alterations in musicians caused by repetitive physical trauma, allergic contact dermatitis, and/or infection may lead to disability and compromise their professional career.
We conducted a systematic review of the literature on the clinical features of musical instrument–related nail alterations to optimize the management and prevention of these conditions.
Methods
We conducted a systematic review of PubMed, Scopus, and Google Scholar databases for eligible publications on instrument-related nail alterations in musicians using the search terms musicians with nail, onychopathy, and Raynaud. No time or language criteria were applied. Reviews, editorials, and articles not related to the topic were excluded. Bibliographies/reference lists were checked to find any additional relevant publications. Relevant articles in English and French were screened by 2 independent reviewers (A.G. and N.L.), and the following data were extracted for qualitative synthesis: sex, age, musical instrument, clinical features, number of years practicing the instrument, laboratory investigations, and disease course.
Results
The literature search yielded 11 publications. Sixteen additional articles were identified by other methods (ie, references, related publications). Overall, 3 full-text articles described general nail alterations but did not describe the clinical data, and 11 publications were editorials, commentaries, reviews, or not relevant. Thirteen contributions fulfilled the inclusion criteria and were eligible for qualitative synthesis. The flow diagram illustrates the screening process (Figure 1).
Twenty-three patients were included. The instruments identified were divided into 2 groups: string instruments (ie, guitar, violin, harp) and percussion instruments (ie, drums, piano, slap bass). Nail alterations were clinically expressed as: (1) modifications of the nail surface; (2) nail bed, soft-tissue, and bone abnormalities; and (3) periungual tissue and distal pulp disorders. All cases are summarized in the Table.4-16 Three articles described occupational Raynaud phenomenon.12-14
Comment
Modifications of the Nail Surface—Onychodystrophy, such as deformity or discoloration of the nail plate, was described in 6 patients among a cohort of 295 musicians and an additional 6 patients among 199 musicians with induced skin lesions. This condition was most common in string instrument players and pianists due to injury and irritation.
One patient, who had been a professional violist for 27 years, presented with lamellar onychoschizia, which corresponds to a horizontal splitting of the nail toward its distal portion (Figure 2). The 3 fingernails of the dominant hand were involved with a V-shaped incision of the distal margin of the nail due to the repetitive friction of the nails with the strings.6
Striations of the nail plate were reported in a guitarist who played for 10 years.7 Physical examination revealed linear transverse ridges alternating with depressions on the central aspect of the nail plate of the right thumbnail, as the patient was right-handed. This condition, attributed to sustained pressure on the string applied by the thumb, also has been called habit tic deformity.7
Nail Bed, Soft-Tissue, and Bone Lesions—Purpura (or hemorrhage) of the nail bed was associated with a percussion instrument (ie, piano) in 1 patient, affecting the second, third, and fourth fingernails of the right hand.8 Especially when performing ascending glissando passages, the pianist applies pressure that may damage the finger and cause fingernail purpura. This condition improved after the patient stopping practicing glissandi.8
Three patients—2 guitarists and 1 violist—had onycholysis, defined by a loss of the attachment between the nail bed and the nail plate (Figure 3). It may result from repetitive trauma when strings are plucked.6,9,10
Acro-osteolysis associated with pain was reported in 2 guitarists.10,11 This condition is defined as transverse lytic bands in the distal phalanges (Figure 4). Acro-osteolysis may be secondary to multiple causes, such as vinyl chloride exposure, connective tissue diseases, thermal injuries, neuropathic diseases, hyperparathyroidism, nutritional deficiencies, psoriasis, and biomechanical stress.10 In musicians playing instruments, the mechanical stress to the guitar-playing fingers is the causative factor.17
Periungual Tissue and Distal Pulp Disorders—Paronychia is an important occupational hazard of harpists, violists, and pianists.2 It represents an inflammatory condition involving the folds of tissue surrounding fingernails. Pizzicato paronychia is related to infection in the nail fold in string players and secondary to pizzicato playing, whereby the musician plucks the instrument strings with the nails and fingertips.3
Acrylates in artificial nails frequently are used among guitarists to strengthen their nails. A case of occupational allergic contact dermatitis induced by acrylic gel nails in a flamenco guitarist was described.9 The patient developed dystrophy, onycholysis, and paronychia involving the nails of the right hand where acrylic materials were used, which resolved following the removal of the artificial nails. Patch tests were performed and were positive for 2-hydroxyethyl methacrylate, 2-hydroxyethyl acrylate, ethylene glycol dimethacrylate, and 2-hydroxypropyl methacrylate, supporting the diagnosis of allergic contact dermatitis to acrylates.9 Therefore, musicians should be aware of the sensitizing potential of acrylates and adopt preventive measures.
Unilateral Raynaud phenomenon of the dominant hand was noted in 3 cases of musicians who played string instruments due to the increased tendency to vasospasm in the digital capillaries from the direct transmission of vibrations of the strings (>100 Hz).12-14 Consequently, the disruption of the digital blood circulation leads to an abnormal reaction to cold, which is called vibration-induced white fingers or vasospastic white finger disease.19 In these 3 patients, capillaroscopy showed a nonspecific pattern with a lack of morphologic homogeneity of capillaries, the presence of enlarged capillaries, ectasia of the efferent tract of the loops, tortuous capillaries, local hemorrhages, and neoangiogenesis.13,14
A middle-aged professional concert pianist presented with paronychia with hyperkeratosis of the lateral nail fold. Histopathology revealed a subungual keratoacanthoma eroding the distal phalanx tip, which was removed by surgical excision. The repeated fingertip trauma associated with pianistic activity was suspected to be the causative event.16
Callosities also are common on the fingertips of musicians, including 18.4% of patients in a cohort of 628 musicians, and involving fingers in 64.6% of these patients.4 These callosities are explained by the chronic mechanical forces and characterize the way musicians grasp and hold their instruments. Callosities could be preceded by soreness and blisters of the fingertips in a harpist (harpist’s finger).1,15 Calluses were located on the lateral fourth fingertip of a drummer corresponding to the friction with the drumsticks (drummer’s digit) and on the thumb of a bassoon player. Trumpet calluses generally overlie the proximal interphalangeal joint of the left index finger.
Conclusion
Healthy nails are essential for playing a musical instrument. This review highlights the occurrence of fingertip callosities, paronychia, onycholysis, and subungual hemorrhages among musicians who play instruments. Additionally, the transmission of string-vibratory movements can produce microvascular damage and occupational Raynaud phenomenon in some musicians. These occupational nail disorders are underrecognized and may be underdiagnosed. Thus, musicians and clinicians must be aware of these alterations to adopt preventive measures and to provide adequate treatment.
- Rimmer S, Spielvogel RL. Dermatologic problems of musicians. J Am Acad Dermatol. 1990;22:657-663.
- Adams RM. Skin conditions of musicians. Cutis. 2000;65:37-38.
- Vine K, DeLeo V. Dermatologic manifestations of musicians: a case report and review of skin conditions in musicians. Cutis. 2011;87:117-121.
- Patruno C, Napolitano M, La Bella S, et al. Instrument-related skin disorders in musicians. Dermatitis. 2016;27:26-29.
- Baccouche D, Mokni M, Ben Abdelaziz A, et al. Dermatological problems of musicians: a prospective study in musical students . Article in French. Ann Dermatol Venereol. 2007;134(5 Pt 1):445-449.
- Piraccini BM, Antonucci A, Iorizzo M, et al. Occupational nail fragility in a professional violist. Contact Dermatitis. 2004;51:35-36.
- Wu JJ. Habit tic deformity secondary to guitar playing. Dermatol Online J. 2009;15:16.
- Kluger N. Piano glissando purpura: another cutaneous curiosity in musicians. J Eur Acad Dermatol Venereol. 2016;30:683.
- Alcántara-Nicolás FA, Pastor-Nieto MA, Sánchez-Herreros C, et al. Allergic contact dermatitis from acrylic nails in a flamenco guitarist. Occup Med (Lond). 2016;66:751-753.
- Baran R, Tosti A. Occupational acroosteolysis in a guitar player. Acta Derm Venereol. 1993;73:64-65.
- Destouet JM, Murphy WA. Guitar player acro-osteolysis. Skeletal Radiol. 1981;6:275-277.
- Jepsen JR, Simonsen JA. Raynaud’s phenomenon in a slap bass player: a case report. Med Probl Perform Art. 2016;31:51-53.
- Sirufo MM, Catalogna A, De Pietro F, et al. Raynaud’s phenomenon in a drummer player: microvascular disorder and nailfold video capillaroscopic findings. EXCLI J. 2021;20:1526-1531.
- Sirufo MM, Ginaldi L, De Martinis M. Raynaud’s phenomenon and the nailfold capillaroscopic findings in a guitar player. QJM. 2019;112:531-533.
- Cohen PR. Harpist’s finger: case report of a trauma-induced blister in a beginner harpist and review of string instrument-associated skin problems in musicians. Cutis. 2008;82:329-334.
- De Vasconcelos P, Soares-Almeida L, Filipe P. Subungual keratoacanthoma in a pianist. G Ital Dermatol Venereol. 2016;151:455-456.
- Young RS, Bryk D, Ratner H. Selective phalangeal tuft fractures in a guitar player. Br J Radiol. 1977;50:147-148.
- Vázquez-Osorio I, Espasandín-Arias M, García-Gavín J, et al. Allergic contact dermatitis due to acrylates in acrylic gel nails: a report of 3 cases. Actas Dermosifiliogr. 2014;105:430-432.
- Atashpaz S, Ghabili K. Color triad in guitarist’s fingers: a probable case of Raynaud’s phenomenon due to string vibration phenomenon. Med Probl Perform Art. 2008;23:143.
- Rimmer S, Spielvogel RL. Dermatologic problems of musicians. J Am Acad Dermatol. 1990;22:657-663.
- Adams RM. Skin conditions of musicians. Cutis. 2000;65:37-38.
- Vine K, DeLeo V. Dermatologic manifestations of musicians: a case report and review of skin conditions in musicians. Cutis. 2011;87:117-121.
- Patruno C, Napolitano M, La Bella S, et al. Instrument-related skin disorders in musicians. Dermatitis. 2016;27:26-29.
- Baccouche D, Mokni M, Ben Abdelaziz A, et al. Dermatological problems of musicians: a prospective study in musical students . Article in French. Ann Dermatol Venereol. 2007;134(5 Pt 1):445-449.
- Piraccini BM, Antonucci A, Iorizzo M, et al. Occupational nail fragility in a professional violist. Contact Dermatitis. 2004;51:35-36.
- Wu JJ. Habit tic deformity secondary to guitar playing. Dermatol Online J. 2009;15:16.
- Kluger N. Piano glissando purpura: another cutaneous curiosity in musicians. J Eur Acad Dermatol Venereol. 2016;30:683.
- Alcántara-Nicolás FA, Pastor-Nieto MA, Sánchez-Herreros C, et al. Allergic contact dermatitis from acrylic nails in a flamenco guitarist. Occup Med (Lond). 2016;66:751-753.
- Baran R, Tosti A. Occupational acroosteolysis in a guitar player. Acta Derm Venereol. 1993;73:64-65.
- Destouet JM, Murphy WA. Guitar player acro-osteolysis. Skeletal Radiol. 1981;6:275-277.
- Jepsen JR, Simonsen JA. Raynaud’s phenomenon in a slap bass player: a case report. Med Probl Perform Art. 2016;31:51-53.
- Sirufo MM, Catalogna A, De Pietro F, et al. Raynaud’s phenomenon in a drummer player: microvascular disorder and nailfold video capillaroscopic findings. EXCLI J. 2021;20:1526-1531.
- Sirufo MM, Ginaldi L, De Martinis M. Raynaud’s phenomenon and the nailfold capillaroscopic findings in a guitar player. QJM. 2019;112:531-533.
- Cohen PR. Harpist’s finger: case report of a trauma-induced blister in a beginner harpist and review of string instrument-associated skin problems in musicians. Cutis. 2008;82:329-334.
- De Vasconcelos P, Soares-Almeida L, Filipe P. Subungual keratoacanthoma in a pianist. G Ital Dermatol Venereol. 2016;151:455-456.
- Young RS, Bryk D, Ratner H. Selective phalangeal tuft fractures in a guitar player. Br J Radiol. 1977;50:147-148.
- Vázquez-Osorio I, Espasandín-Arias M, García-Gavín J, et al. Allergic contact dermatitis due to acrylates in acrylic gel nails: a report of 3 cases. Actas Dermosifiliogr. 2014;105:430-432.
- Atashpaz S, Ghabili K. Color triad in guitarist’s fingers: a probable case of Raynaud’s phenomenon due to string vibration phenomenon. Med Probl Perform Art. 2008;23:143.
Practice Points
- Long-term practice and performance with a musical instrument predispose musicians to several skin conditions and nail disorders.
- Nail alterations in musicians include onychodystrophy, callosities of the fingertips, paronychia, distal onycholysis, lamellar onychoschizia, striations, subungual hemorrhage, and occupational Raynaud phenomenon.
- Nail lesions in musicians may be caused by localized pressure, friction-induced mechanical forces, allergic or irritant contact dermatitis, or infections.
