Nail Disorders

4 Interesting Facts of Nail Disorders 

Nail disorders can arise at any age.

About half of all nail disorders are of infectious origin, 15% are due to inflammatory or metabolic conditions, and 5% are due to malignancies and pigment disturbances.

The differential diagnosis of nail disorders is often an area of uncertainty.

1. The most common toenail disorder is onychocryptosis.
2. Intrinsic factors such as fungal or bacterial infections cause most toenail disorders.
3. Other deformities can be caused by mechanical issues.
4. Direct trauma can lead to damage to the nail plate and bed.

A review study based on publications and guidelines retrieved by a selective search in PubMed, including Cochrane reviews, meta-analyses, and AWMF guidelines showed the below results.

Nail disorders are a common reason for derma – tologic consultation.

They are assessed by clinical inspection, dermatoscopy, diagnostic imaging, microbiological (including mycological) testing, and histopathological examination.

Some 10% of the overall population suffers from onychomycosis, with a point prevalence of around 15%.

Bacterial infections of the nails are rarer than fungal colonization. High-risk groups for nail disorders include diabetics, dialysis patients, transplant recipients, and cancer patients.

Malignant tumors of the nails are often not correctly diagnosed at first.

For subungual melanoma, the mean time from the initial symptom to the correct diagnosis is approximately 2 years; this delay is partly responsible for the low 10-year survival rate of only 43%.

Onychocryptosis (Ingrowing Nail)

What is Onychocryptosis?

• •Most likely present on the great toe but can occur in any toes
• •Subjective pain along the edge of the nail; worsens in tight-fitting shoes
• •Possibility of drainage from beneath the nail
• •Admitted improper nail trimming or history of trauma

Physical Examination – What are the symptoms of Onychocryptosis?

• •Observation
  • •Stage One: erythema, mild edema, irritation of the nail fold, no pus or drainage
  • Stage Two: increased erythema and edema, hyperplasia of nail fold, active pus or drainage
  • •Stage Three: further erythema and edema, granulation tissue, additional hypertrophy of nail fold, increase in signs of active infection
• •Palpation
  • •Affected nail fold tenderness increases with each stage.
  • •In the latter stages, purulence may be expressed from beneath the nail.

Differential Diagnosis of Onychocryptosis

• •Onychomycosis: fungal infection of the nail
• •Paronychia: superficial infection of the nail fold
• •Subungual exostosis: bony growth beneath the nail
• •Onychophosis: callus in the nail groove
• •Trauma

How is Onychocryptosis treated?

• Stage One: Recommend warm soaks, proper nail trimming, and more accommodative footwear.
• Stage Two: In addition to the above, also consider oral antibiotics and or a partial nail excision under digital block
• Stage Three: Partial versus complete nail excision and ablation of the nail matrix.

When to Refer someone with Onychocryptosis

• •Recurrent stage three disease or failure of nonoperative treatment

Prognosis of Onychocryptosis

• •Recurrence is common.

Patient Instructions

• •Explain importance of proper footwear, nail care, and hygiene to patient.

Considerations in Special Populations

• •Surgery should be considered sooner in patients at high risk for recurrent infection or sepsis, such as those with total joint replacements or diabetes 

Onychomycosis (Nail Fungal Infection)

What is Onychomycosis?

• •The Prevalence of Onychomycosis increases with age and is greatest in those older than 65 years of age.
• •Found more often in men than women
• •Most common pathogen is Trichophyton rubrum, followed by Trichophyton interdigitale

Physical Examination – What are the symptoms of Onychomycosis?

• •Observation
  • •Brittle, deformed, discolored, thickened nail plate 

• Palpation
  • •Tenderness may or may not be present.
  • •Rough, thickened nail
• •Special tests
  • •Fungal cultures may be obtained from nail debris.
  • •Hyphae may be seen when nail scrapings are examined under light microscopy prepared with potassium hydroxide.

Differential Diagnosis

• Onychocryptosis: ingrown toenail
• Onychogryphosis: significant curling and thickening of the nail plate
• Psoriasis
• Trauma

How is Onychomycosis treated?

• •Begin with simple debridement and trimming of the nail plate
• •Consider topical versus systemic antifungal medications

When to Refer someone with Onychomycosis

• •Recalcitrant cases may necessitate nail matrix ablation

Prognosis of Onychomycosis

• •Smaller lesions respond well to conservative treatments.
• •Larger lesions do not respond as well to these measures and often require permanent nail removal.

Patient Instructions

• •Stress the importance of foot hygiene.

Considerations in Special Populations

• •Systemic antifungals are to be avoided in patients with hepatic disease or pregnant women.

Seek Additional Information

• Alavi A, Woo K, Sibbald RG: Common nail disorders and fungal infections. Adv Skin Wound Care 2007; 20: pp. 346-357.
• In Armstrong AD, Hubbard MC (eds): Essentials of Musculoskeletal Care., 5th ed 2016. American Academy of Orthopaedic Surgeons, Rosemont, IL
• In Coughlin MJ, Saltzman C, Anderson RB (eds): Mann’s Surgery of the Foot and Ankle., 9th ed 2014. Elsevier, Philadelphia
• Mayeaux EJ: Nail disorders. Prim Care 2000; 27: pp. 333-351.