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Nail Anatomy, Nail Psoriasis, and Nail Extensor Enthesitis Theory

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Perrin, Christophe, MD

The American Journal of Dermatopathology: June 2019 - Volume 41 - Issue 6 - p 399–409
doi: 10.1097/DAD.0000000000001244
CME Article

Abstract: The concept of the nail unit as a musculoskeletal appendage has become popular in the dermatological and rheumatological literature. However, an exact knowledge of the characteristics of mesenchyme surrounding the nail such as the composition of the collagen and elastic fibers and their arrangement is fundamental before one can propose a constitutive model. To the best of my knowledge, there is no study in the literature concerning the elastic network of the ligamentous connective tissue of the base of the distal phalanx. This study by means of elastic stains demonstrates that the so-called superficial, deep, and lateral laminae of the extensor tendon correspond to 3 different microanatomic structures: the nail dermis and its fibrous root, the subcutaneous proximal nail fold, and the periosteum. The complex fascial and adipose connective tissue of the proximal nail fold surrounds the matrical dermis and could viewed as a kind of suspensory system for the proximal nail unit. Such suspensory system protects the nail matrix epithelium from the biomechanical strain of the extensor mechanism. Near the ulnar and radial edge of the base of the phalanx, focal interconnections between the fibrous root of the apex of the matrix and the periosteum through a fascia-like structure are visible. In its most lateral zone, the matrical horns lie on a thick dermis connected to the interosseous ligament. Such lateral laminar system serves as anchoring ropes for the vault of the nail plate. The nail–extensor enthesitis theory relies on an oversimplified anatomy because the nail unit is an epidermal appendage with a specialized connection with the lateral periosteum, but not a musculoskeletal appendage. Finally, I would like to emphasize, the practical importance of recognizing the matrical hypoderm. In nail surgery, the interface between the matrical nail dermis and its submatrical loose connective tissue is potentially a new, relatively superficial, surgical cleaving plane, beside the classical deep surgical procedure usually extending to the periosteum. Recognition of this additional cleaving plane leads to an optimal nail tangential biopsy.

Staff Physician, The Laboratoire Central d'Anatomie Pathologique, Hôpital L. Pasteur, University of Nice, France.

Correspondence: Christophe Perrin, MD, Laboratoire Central d'Anatomie Pathologique, Hôpital L. Pasteur, 30 Av voie Romaine, CS 51069, 06001 Nice, Cedex 1, France (e-mail:

All authors and staff in a position to control the content of this continuing medical education activity, and their spouses/life partners (if any) have disclosed that they have no financial relationships with, or financial interests in, any commercial organizations relevant to this educational activity.

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