Ingrown and pincer nails: evaluation and treatment

Ingrown toenails are mainly a condition of children and young adults, whereas ingrown fingernail and pincer nails are seen in adults. Their etiology is multifactorial. Different types of ingrowing nails require different treatments. Neonatal ones are always treated conservatively. The hypertrophic lateral nail wall seldom requires surgery. Congenital misalignment of the big toenail may resolve spontaneously, but delay in treatment may cause permanent nail dystrophy. The juvenile type is most common and is treated conservatively in its early stages. Selective matrix horn phenolization or excision is the treatment of choice for later stages. Pincer nails are due to widening of the base of the distal phalanx. Treatment is aimed at reducing the outward pressure of the lateral osteophytes on the matrix horns and permanently flattening the nail. A variety of different methods are discussed.     

Treatment of severe nail psoriasis with acitretin: an impressive therapeutic result

Nail psoriasis is common in adult psoriatic patients. Although several new drugs have recently been introduced for the treatment of skin psoriasis, treatment of nail psoriasis still remains a challenge. Topical treatments (e.g., corticosteroids, tazarotene, 5‐fluorouracil, calcipotriol) are the first line in the management of skin psoriasis. The efficacy of these drugs in nail disease, however, is limited, mainly due to the difficulty in penetrating the nail bed and nail matrix. In cases of nail disease resistant to topical treatment, methotrexate, ciclosporin, acitretin, or biological agents can be used. The present authors introduce a 73‐year‐old patient affected by impressive psoriatic nail disease involving all her fingernails and toenails treated by acitretin, a traditional systemic treatment. After 2 months of treatment there was a marked improvement. The clinical improvement of the nails was progressive and 6 months later it was stable and satisfactory. The remarkable response to treatment in this case suggests that oral acitretin, in association to urea nail lacquer, might be useful in the management of disabling severe nail psoriasis even in absence of severe cutaneous involvement.     

Nail cosmetics in nail disorders

The clinical features of nail dystrophies depend on the part of the nail that has been damaged. Due to the important functions of fingernails and toenails, any abnormality of the nail causes impaired function of the hand or foot. Moreover, the aesthetic aspect of the nail may affect employability, self-esteem, and interaction with other people. Because the nails are often difficult to treat, cosmetology may be an effective support to medical treatment. Nail cosmetics may help the patient to cope with his or her nail dystrophy while waiting for treatment to show its efficacy. It may also be the only choice to hide nail dystrophy where the nail is irreversibly damaged. Nail cosmetics may also function at treatment for onychtillomania, nail biting, and nail ingrowing.     

Surgical management of ingrown toenails – an update overdue

For decades, every year sees a wide number of articles about treatment of ingrown toenails. There is still a debate about the cause of this painful condition. Surgical treatments rely on two main approaches: either narrowing the nail plate or debulking the soft tissues. It is up to the surgeon to select the most appropriate approach in each case. All procedures cited in this article have high cure rates as long as they are properly performed. As with all surgical procedures, they are operator dependent. Chemical cautery is the easiest and most versatile technique that may help in almost all instances for lateral ingrowing. For distal embedding and very hypertrophic and exuberant lateral folds, debulking with secondary intention healing is the most effective and easy to perform, with great results.     

Today's treatments options for onychomycosis

Onychomycosis can be cured even if fungi are sometimes difficult to eradicate; the treatment is often lengthy and requires patience. The choice of agents should be based on numerous factors including patient's age and health, causative organism, clinical type of onychomycosis, number of affected nails and severity of nail involvement. We review current and future treatments for onychomycosis. We will also consider treatment options in patients with poor prognostic factors suggesting possible treatment failure.     

Treatment of brittle nail with a hydroxypropyl chitosan‐based lacquer,alone or in combination with oral biotin: A randomized,assessor‐blinded trial

We evaluated in a randomized, assessor‐blinded, study the efficacy of a hydroxypropyl chitosan‐based nail lacquer (HPC‐NL) alone or in combination with oral biotin (HPC‐NL + B) in the treatment of brittle nail syndrome (BNS). Fifty subjects (21 men; mean age 64 years) with BNS were enrolled. Twenty‐six were randomly assigned to HPC‐NL and 24 to the HPC‐NL and biotin, 10 mg/daily (+B). Topical and oral treatments lasted for 4 consecutive months. The primary outcome was the evolution of the Onychodystrophy Global Severity Score (OGSS) assessing nail dystrophy, lamellar and longitudinal splitting, dyschromia, and pitting. At baseline, the OGSS, mean (SD), was 8.4 (2.1) in the HPC‐NL group and 11.8 (2.3) in the HPC‐NL + B group. The OGSS was significantly reduced during treatments in both groups. At Month 4, OGSS was reduced by 57% (HPC‐NL) and 62% (HPC‐NL + B). At the end of study period, the percentage of subjects with an OGSS reduction of ≥50% in comparison with baseline was 53% in the HPC‐NL group and 80% in the HPC‐NL + B group (p = .05). Both treatments were well tolerated. In subjects with BNS, HPC‐NL alone is associated with a clinically relevant improvement of nail appearance. The combination of HPC‐NL and oral biotin is associated with further clinical improvement.     

Metoprolol‐induced psoriatic nail disease

We describe the development of psoriatic nail disease due to metoprolol in a 58‐year‐old woman who was being treated for cardiac arrhythmias. The nail condition was unresponsive to topical and systemic treatments but resolved completely with the withdrawal of metoprolol. The reaction recurred with drug rechallenge and resolved when the drug was ceased.     

Systemic itraconazole in the yellow nail syndrome

Although a number of treatments have been reported to be effective with yellow nail syndrome (YNS), vitamin E at high doses is the only one that has been successfully utilized in a consistent number of patients affected by YNS. Recent data indicate that itraconazole pulse regimen may be effective in this disease. We report our experience with itraconazole treatment in patients affected by YNS. Systemic itraconazole was administered in eight patients (five males and three females; mean age 55.2 years), at a dosage of 400 mg daily for 1 week a month for 6 months. Nail growth was measured every 3 months. Complete cure was achieved in two of eight patients, with mild improvement in two and no improvement in four. The results of our study show that itraconazole cannot be considered effective for YNS, especially if compared with vitamin E, the efficacy and tolerability of which is already proven.     

Toenail onychomycosis: current and future treatment options

Onychomycosis is a common disease affecting as much as 8% of the general population. Treatment of onychomycosis is challenging, complicated by low cure rates and relatively high relapse rates. This paper reviews the efficacy of current oral, topical, and surgical treatment options. Currently, the treatment of choice for toenail onychomycosis is oral terbinafine because of its high efficacy, low relapse rates, and cost-effectiveness. Oral itraconazole or fluconazole could be considered for infections caused by Candida. Topical therapies may be a useful adjunct to these systemic therapies, but are less effective when used alone. More research is needed to determine the best measures for preventing reinfection.     

Nail dystrophy, an unusual presentation of incontinentia pigmenti

We describe a 57-year-old woman with a history of nail dystrophy since the age of 11 years. Multiple nail clippings were negative and multiple empirical treatments for presumed onychomycosis were unsuccessful. The patient has a daughter with classical incontinentia pigmenti. Molecular genetic analysis was positive for the NEMO gene deletion on the X chromosome, confirming the diagnosis of incontinentia pigmenti. Nail dystrophy was the sole feature of the disease in our patient.     

Nail abrasion: a new treatment for ingrown toe-nails

A simple new method for the treatment of ingrown toe-nails was devised and applied to 33 toe-nails in 22 patients. The entire nail surface, except for the margin, was abraded until the nail became flexible with a Schreu's skin grinder equipped with a steel bar. When there was infection or granulation of the nail wall, the imbedded nail corner was trimmed before abrasion. The patients underwent additional treatments when one treatment was not enough to achieve cure or when discomfort appeared, which was the first symptom of recurrence. The average number and duration of treatments was 2.9 times and 16 months, respectively. Relief from pain occurred in all patients soon after abrasion was performed. Recurrence of infection and granulation was observed in only one patient. Five patients (23%) remained problem-free for more than one year without any additional treatment, because their incurved nail was gradually improved in shape by repetition of this procedure. This therapy was particularly effective in patients with severely incurved nails.     

Marked improvement in nail psoriasis during treatment with etanercept

Psoriasis is a chronic inflammatory skin condition that affects approximately 3% of the population. Up to 50% of patients with psoriasis have concurrent nail psoriasis, up to 30% of patients with skin psoriasis also have psoriatic arthritis and of these, approximately 80% have nail disease. The treatment of nail psoriasis is often challenging, and there is a need for new therapeutic options. Effective biological agents used in the treatment of moderate to severe chronic plaque psoriasis may represent a new therapeutic modality for this disease. A case of rapid improvement is reported in nail psoriasis under etanercept monotherapy with maintained efficacy following the withdrawal of continued therapy.     

Periungual and subungual pyogenic granuloma

Background Nail pyogenic granuloma (PG) is common, often seen as an urgent case, given the recent onset as a bleeding nodule. Nail PGs are due to different causes that act through different pathogenetic mechanisms and may be treated in several ways. Both causes and treatments of nail PG have never been classified. Objectives To classify nail PG according to the pathogenesis, describe the clinical and pathological features and provide guidelines for a correct diagnosis and treatment. Methods A retrospective, observational study was performed reviewing epidemiological and clinical features of 58 cases of PG seen at our Departments in the last 5 years. A review of the literature was also carried out, using PubMed database and dermatological textbooks. Results Nail PG is usually due to the following causes: drugs, local trauma and peripheral nerve injury. Histopathology shows similar features in every type of PG, irrespective of cause and location. Conclusions The localization of nail PG, the number of digits involved and clinical history help to identify the cause. When PG is single, especially if it involves the nail bed, histological examination is necessary to rule out malignant melanoma. Treatment must be chosen according to the underlying cause.     

Current psoriasis treatments in an Italian population and their association with socio‐demographical and clinical features

Background Patient adherence is a key element for therapeutic success and represents a major concern for all healthcare professionals. Objective Aim of our study was to assess the frequency of use of treatments currently available for psoriasis and its association with specific socio‐demographical and clinical variables. Methods The study population consisted of 1689 patients, aged 12–85 years. Information concerning socio‐demographical variables, clinical features and the type of current treatment was collected. Items on patients’ satisfaction of current treatments and of dermatologist‐patient relationship were also included. The chi‐squared test was used to estimate the association between the categorical variables, whereas Wilcoxon and Kruskal–Wallis tests were applied to the interval and ordinal variables. The Cochran–Mantel–Haenszel chi‐squared trend test was used to evaluate the degree of satisfaction related to dermatologist–patient relationship. Results Of the 1689 psoriatic patients, 54.1% did not use any treatments and 45.9% used at least one treatment. The use of drugs was significantly associated exclusively to severity of disease and affected body surface area. Systemic therapies, both traditional treatments and biological agents, were mainly used in patients with disease duration >10 years and disease severity. Treatment adherence was significantly associated to the degree of patient’s satisfaction of his/her relationship with the dermatologist. Alternative treatment such as over the counter medications and acupuncture were used by 33% of patients. Conclusion The majority of psoriatic patients do not use any treatments. However, treatment adherence significantly increases when dermatologists clarify the treatment schedule, inform patients and meet the patients’ needs.     

Nail psoriasis: a combined treatment with 8% clobetasol nail lacquer and tacalcitol ointment

Background   Nail involvement is a common and distressing feature in the course of psoriasis. Although much progress has been made in the treatment of the disease, the presence of psoriasis in the nail continues to pose a challenge. In recent years, vitamin D3 analogs and a new formulation containing 8% clobetasol-17-propionate in a colourless nail lacquer vehicle have produced good results for the control of nail psoriasis.
Objective   To determine the efficacy and safety of the combined treatment of 8% clobetasol-17-propionate in a lacquer vehicle and tacalcitol ointment in nail psoriasis.
Methods   Fifteen patients with both nail bed and nail matrix psoriasis were included in the study. They were treated with a colourless nail lacquer containing 8% clobetasol-17-propionate applied at bedtime at the weekend, and with tacalcitol ointment under occlusion on the remaining days, for 6 months.
Results   All 15 patients responded well to treatment. The therapeutic effect was very fast and directly related to the length of therapy. All nail alterations, including nail pain, were reduced, and the modified target Nail Psoriasis Severity Index fell by an average of 78% compared to baseline levels (±59.6, P  < 0.0001).
Conclusions   Combined treatment with tacalcitol ointment and 8% clobetasol-17-propionate in a nail lacquer is a safe, effective treatment for nail bed and nail matrix psoriasis.     

Recommendations for treatment of nail psoriasis during the COVID‐19 pandemic

The novel coronavirus disease 2019 (COVID‐19) pandemic has resulted in a paradigm shift in disease management. Since immunosuppression may cause increased susceptibility to COVID‐19, there is uncertainty as to whether systemically treated nail psoriasis patients are at increased infection risk. While specific data on nail psoriasis treatments and COVID‐19 is lacking, we present clinical trial data on rates of upper respiratory infections, nasopharyngitis, viral infection, pneumonia and overall infections. Some systemic medications and biologics are associated with increased in infections risk compared to placebo in clinical trials. However, this data should be regarded cautiously since clinical trials on nail psoriasis, particularly controlled studies, are lacking. Our recommendations may be helpful in guiding physicians managing nail psoriasis patients during the COVID‐19 pandemic.     

Comparative study between nail retraining with gauze bandaging and the nail remodeling with acrylics as a conservative treatment for stage I and IIa onychocryptosis

Objective

Onychocryptosis is one of the most prevalent onychopathies, being a frequent reason for consultation in podiatric clinical practice. Conservative treatments are the first therapeutic choice, with nail remodeling using clotrimazole gel emerging as an alternative, although its medium-term effectiveness is unknown. The objective of this study was therefore to compare the efficacy of the technique of nail retraining using gauze bandaging with that of nail remodeling for the conservative treatment of stage I and IIA onychocryptosis.

Methods

An analytical, randomized clinical trial study was performed following a longitudinal and prospective design. A sample was selected of 20 subjects presenting stage I and IIA onychocryptosis. Of these, 10 cases formed the group of nail retraining using gauze bandaging, and the other 10 the nail remodeling group. The presence of recurrence in a 3-month period was evaluated.

Results

Before the intervention, the patients in the retraining group presented pain of 6.7 ± 1.9 vs. 6.8 ± 1.6 in the remodeling group, with no significant difference between the two (p = 0.900). After the 3-month follow-up period, seven of the retraining group patients presented recurrence of onychocryptosis vs. only one in the remodeling group.

Conclusion

The technique of nail remodeling has a lower recurrence rate than that of nail retraining with gauze bandaging, with the pain, inflammation, and infection reported being less, and with greater patient satisfaction.     

The medical treatment of cicatricial alopecia

The best outcome of current treatments of cicatricial alopecia is induction of a clinical remission with arrest of symptoms and signs, but the progression of hair loss may continue insidiously. Current treatments do not arrest the underlying disease process. A scalp biopsy is the first step in management. Selection of treatment described herein is guided by the histopathologic findings, including the type, location and extent of the predominant cellular inflammatory infiltrate, and clinical disease activity. Cicatricial alopecias with predominantly lymphocytic infiltrates are treated with immunomodulating agents, and those with predominantly neutrophilic infiltrates are treated with antimicrobial agents. Treatment selection may be challenging and requires flexibility, as histopathologic features frequently overlap, are not clear cut, or change over time. In the future, cellular and molecular biology studies will hopefully identify unique markers for the clinically distinct cicatricial alopecias and lead to better treatments and a cure.     

Identification of nail features associated with psoriasis severity

There are no detailed studies of the prevalence of nail psoriasis and clinical characteristics of psoriatic nail involvement, including nail features associated with disease severity. Therefore, we designed a study to investigate the prevalence and characteristics of psoriatic nail involvement in patients with psoriasis and determine the relationship between psoriatic nail features and severity of nail psoriasis and cutaneous psoriasis. The Nail Psoriasis Severity Index (NAPSI) was used for evaluation of the severity of nail lesions. The presence of nail fold psoriasis (NFP) was also assessed. The severity of psoriasis was evaluated by calculating the Psoriasis Area and Severity Index (PASI). As a result, the prevalence of nail psoriasis was 85.5%. Pitting was the most common clinical feature (55.6%). The severity of nail psoriasis was not affected by medical parameters, although patients with localized pustular psoriasis tended to have more severe nail psoriasis than did those with chronic plaque psoriasis. When comparing the mean NAPSI and the mean PASI according to nail lesions, we found that subungual hyperkeratosis (SH) and NFP were significantly associated with the severity of both nail psoriasis and cutaneous psoriasis. Psoriatic nail changes were most common in the first digit. Conclusively, the majority of patients with psoriasis had psoriatic nail involvement, and Koebner's response seems to be closely related to the induction of nail psoriasis. To limit progression of the disease, psoriatic patients with SH or NFP should be examined thoroughly because those clinical features reflect the levels of severity of both nail and cutaneous psoriasis.     

Follow up of 12 patients with trachyonychia

A follow-up study was performed to determine the outcomes of all patients (five males and seven females, mean age 18.4 years) who were referred to a specialist nail clinic with trachyonychia. The average number of affected nails per patient was 8.8 fingernails and 6.2 toenails. None of our patients tested positive for onychomycosis. Nail biopsies were performed in two patients, revealing non-specific changes. Eight patients did not present with or develop accompanying skin or mucosal disease. Two patients presented with alopecia areata and two others with psoriasis. Of our patients, 50% showed total resolution or marked improvement in their nail disease within the first 6 years regardless of treatment.