Pigmented lesions of the nail unit are commonly encountered in the clinical setting. Yet, they often present a unique challenge to clinicians because of a broad differential diagnosis or unfamiliarity with clinical and histopathologic features. A wide variety of causes exist ranging from benign lesions such as subungual hemorrhage to malignant lesions such as subungual melanoma. Identifying the underlying cause is key to appropriate management and follow-up in these patients. Although emerging clinical tools such as dermoscopy can be very useful in evaluation of these lesions, histopathologic analysis remains the gold standard. In this review, we discuss and provide a summary of important clinical and histopathological concepts of pigmented lesions of the nail unit with special focus on longitudinal melanonychia, melanotic macule, melanocytic nevus, subungual melanoma, along with discussion of some nonmelanocytic lesions.

Background The anecdotic evidence of the benefits from biologic agents for psoriasis is extensive. However, data on the efficacy of biologic agents for pustular psoriasis are limited.Methods To update the data on the efficacy and safety of biologic agents for the management of pustular psoriasis. A systematic review of published data regarding biologic therapies on PubMED database, used in the management of pustular psoriasis from 2012 was undertaken.Results A total of 209 articles were identified, and 43 articles were selected for inclusion. TNF-a inhibitors were used in 205 patients, and 86 patients received ustekinumab, secukinumab, brodalumab, ixekizumab and IL-1 inhibitors. Overall response was favorable for most modalities. No serious adverse events were reported. Inconsistent measures of treatment response and study variability limited the overall evaluation of data. Conclusions Infliximab and ustekinumab have the most evidence of efficacy and safety for the treatment of pustular psoriasis. Recent evidence supports the use of IL-17 antagonists. Prospective controlled and comparative trials are needed to further explore the efficacy and safety of biologic agents in order to establish objective recommendations for the management of this challenging condition. mia, hypocalcemia, elevated erythrocyte sedimentation rate, C-reactive protein, antistreptolysin O antibody levels, and/or IgG or IgA. 7Although most cases of pustular psoriasis are believed to be idiopathic, there are several factors that can trigger disease such as pregnancy, infections, contact to allergens, drugs, and withdrawal from medications used for psoriasis, including steroids, methotrexate, and cyclosporine. 9-11 Paradoxically, the use of tumor necrosis factor (TNF)-a inhibitors may also precipitate pustular psoriasis. 12,13 Pustular psoriasis is a challenging condition to treat, and evidence regarding management strategies is limited. The National Psoriasis Foundation's (NPF) most recent guidelines of care for pustular psoriasis were published in 2012. 14 Recognizing that the "overall quality of the literature about the treatment of pustular psoriasis is weak," the group recommended acitretin, cyclosporine, methotrexate, and infliximab as first-line treatment options for adult GPP. In 2014, Levin et al. 15 suggested an algorithm for biologic treatments of GPP, recommending infliximab as first-line therapy for patients with acute, severe GPP.These recommendations are not universally accepted and have not been updated to include recently introduced biologic agents such as IL-17 inhibitors. [16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32][33]

Spitz nevus is a type of melanocytic nevus that can arise as a solitary lesion or as multiple lesions either disseminated or agminated (grouped) in different skin backgrounds (eg, grossly normal, hyperpigmented, or hypopigmented). Agminated Spitz nevi have been rarely reported and are even rarer in a background of hypopigmented skin. We present the case of a 2-month-old girl with multiple, grouped, dome-shaped, red papules arising on a hypopigmented patch with a segmental distribution. Biopsy of 2 lesions showed findings characteristic of Spitz nevus, confirming the diagnosis. We also review 4 other cases of agminated Spitz nevi arising on hypopigmented skin reported in the literature.

We report the case of a 9-year-old girl with severe plaque psoriasis refractory to multiple topical and systemic therapies. Physical examination revealed extensive, erythematous plaques with overlying thick scales that covered more than 80% of her body surface area, which included the face, scalp, trunk, and limbs. Because of the severity of the disease and lack of treatment response to other systemic therapies, she was treated with ustekinumab. Three weeks after ustekinumab was initiated, her psoriatic lesions fully cleared.

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