Pincer nail: aesthetic concept in surgery

Although pincer nail deformity (PND) treatment is time consuming independent of whether it is based on surgical or conservative procedures, long lasting beneficial results are found only after surgical intervention. Typically destruction of the lateral matrix horns either surgically or by phenol cauterization or even ablation of the matrix is performed. In the past these procedures mainly aimed at relief from pain; however, currently more patients ask for the preservation of the nail unit and a good cosmetic outcome. Today reconstructive results that meet the patient expectations are available. An adapted novel surgical method which will preserve the matrix horns while correcting the shape of the phalanx and preventing renewed adhesion of the nail bed to the phalanx is presented. Therefore the restoration of a normal width-to-length ratio of the nail plate with a cosmetically appealing result becomes possible. Surgical steps in an affected right toenail are presented.     

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.     

Nail sampling in onychomycosis: comparative study of curettage from three sites of the infected nail

Background: Onychomycosis is a common problem.Obtaining accurate laboratory test results before treatment is important in clinical practice since the treatment of onychomycosis requires expensive oral antifungal therapy with potentially serious side‐effects. The purpose of this study was to compare results of curettage technique of nail sampling in the diagnosis of onychomycosis from three different sites of the affected nail to establish the best location of sampling. Patients and Methods: We evaluated 194 patients suffering from distal and lateral subungual onychomycosis (DLSO) and lateral subungual onychomycosis (LSO) using curettage technique. KOH examination and fungal culture were used for detection and identification of fungal infection. Results: The culture sensitivity improves significantly as the location of the sample is more proximal. Trichophyton rubrum was by far the most common pathogen detected from all sampling sites. Conclusions: We found that the culture sensitivity improved as the location of the sample was more proximal. More types of pathogens were detected in samples taken from proximal parts of the affected nails.     

Congenital malalignment of the big toe nail

Congenital malalignment of the big toe nail is based on a lateral deviation of the nail plate. This longitudinal axis shift is due to a deviation of the nail matrix, possibly caused by increased traction of the hypertrophic extensor tendon of the hallux. Congenital malalignment of the big toe nail is typically present at birth. Ingrown toenails and onychogryphosis are among the most common complications. Depending on the degree of deviation, conservative or surgical treatment may be recommended.     

Total nail ablation for onychodystrophy with optimized gauze–phenol application

Background Nail disorders are frequent among the geriatric population and unfortunately, repeat avulsion procedures often result in complications. Objective To utilize a phenol‐based total matricectomy technique for permanent nail ablation and evaluate its effectiveness. Methods We performed total nail ablation on 34 toenails of the hallux (30 patients) with a gauze–phenol application technique and evaluated the degree of pain reported by the patient 12 months postoperatively compared with the preoperative stage. Furthermore, we evaluated the patients’ satisfaction with the final cosmetic appearance as well as their satisfaction with the overall procedure. Results All patients reported ‘too much’ or ‘severe’ pain prior to surgery and 94.11% reported ‘no pain’ 12 months post‐surgery. A vast majority of the patients (82.35%) felt pleased with the cosmetic results and all patients reported that they were ‘very satisfied’ or ‘strongly satisfied’ with the procedure when interviewed at their 12 month follow‐up examination. Limitations There were a limited number of participants in this study across an extensive timeframe. Conclusion Phenol‐based total nail ablation with specific gauze application is safe, inexpensive and has a high rate of patient satisfaction.     

Comparative study of nail sampling techniques in onychomycosis

Onychomycosis is a common problem. Obtaining accurate laboratory test results before treatment is important in clinical practice. The purpose of this study was to compare results of curettage and drilling techniques of nail sampling in the diagnosis of onychomycosis, and to establish the best technique and location of sampling. We evaluated 60 patients suffering from distal and lateral subungual onychomycosis and lateral subungual onychomycosis using curettage and vertical and horizontal drilling sampling techniques from three different sites of the infected nail. KOH examination and fungal culture were used for detection and identification of fungal infection. At each sample site, the horizontal drilling technique has a better culture sensitivity than curettage. Trichophyton rubrum was by far the most common pathogen detected by both techniques from all sampling sites. The drilling technique was found to be statistically better than curettage at each site of sampling, furthermore vertical drilling from the proximal part of the affected nail was found to be the best procedure for nail sampling. With each technique we found that the culture sensitivity improved as the location of the sample was more proximal. More types of pathogens were detected in samples taken by both methods from proximal parts of the affected nails.     

Onychomycosis and the diagnostic significance of nail biopsy

Onychomycosis is the most common cause of deformed nails. It is often confused clinically with other nail diseases such as psoriasis. A cross sectional study was carried out in 120 clinically suspected onychomycosis patients to assess the diagnostic utility of nail unit histopathology. The majority of the patients were males (72.5%) in the age group of 20-40 years (55%). Involvement of fingernails alone (37.5%) was found to be more common than toenails (12.5%). Distal and lateral subungual onychomycosis [DLSO] (76.6%) was the predominant morphological type noted. Direct microscopy with 10% potassium hydroxide (KOH) preparation revealed fungal filaments in 82.5% of the cases. Mycological culture on Sabouraud's dextrose agar with and without cycloheximide indicated fungal isolates in 44% of the cases, with Trichophyton mentagrophytes being the most common isolate (38.3%). The combined approach with KOH preparation and culture showed the evidence of fungus in 103 cases (85.8%). Of the rest of the 17 cases in whom both these procedures failed to confirm a diagnosis, nail unit biopsy was carried out in 15 consenting patients. Fungal hyphae (better demonstrable on PAS staining) were evident in 14 cases (93.3%). Other histopathological features observed among these patients were subungual hyperkeratosis, neutrophilic infiltrate, parakeratosis, hemorrhage, and serum crusts. We concluded that histopathological examination of nails is a valuable diagnostic aid in onychomycosis, especially if routine parameters fail to establish a diagnosis.     

Ciclopirox nail lacquer for the treatment of onychomycosis: An open non-comparative study

Onychomycosis is a relatively common disease accounting for up to 50% of all nail disorders. Topical treatment, although less effective than systemic, is usually preferred by patients. Topical antifungal nail lacquers have been formulated to provide better delivery of the antifungal agent to the nail unit. The purpose of this research is to evaluate the efficacy and safety of ciclopirox nail lacquer in the treatment of onychomycosis. Patients suffering from distal and lateral subungual toenail onychomycosis (DLSO) and lateral subungual onychomycosis (LSO) were treated by ciclopirox nail lacquer once daily for 9 months. Every week the nail lacquer was removed using acetone. Clinical nail status, KOH examination and mycological culture were recorded by the same investigator at 0, 3, 6 and 9 months. Thirty-six patients completed the 9-month regimen. Trichophyton rubrum was the most common pathogen. At the end of the study, good improvement to complete cure was observed in 13 patients (36%), 12 patients showed only mild to moderate improvement and 11 patients (31%) had no clinical improvement. No adverse effects were noted throughout the treatment period. Ciclopirox nail lacquer seems to be slightly more effective than other topical modalities and could be used in patients who cannot or do not want systemic treatment.     

Treating ingrown toenails by nail splinting with a flexible tube: an Indian experience

Ingrown toenail is a common problem, and currently available treatments are either quite invasive or associated with unacceptably high recurrence rate. Recently a new non-invasive therapy. "Nail splinting", has been introduced. In this procedure, the nail is splinted with a longitudinally incised plastic tube. We conducted the present study to evaluate the efficacy and safety of this procedure in fifty patients (68 nail edges in 61 nails) with ingrown toenails at all stages. The pain disappeared almost immediately, and inflammation subsided in about one week in all nail edges. Thirty-nine patients came for regular follow-up for six months after removal of the tube. Eight (20.5%) of these patients showed recurrence of the problem. No serious side effects were noted.     

Tangential excision debulking with vertical sections prior to Mohs micrographic surgery

The tangential excision technique for removal of skin tumours has been previously described for truncal superficial BCCs but never before as an option for debulking prior to Mohs micrographic surgery (MMS). Tangential excision debulking with vertical sections represents an alternative to traditional curettage debulking and offers many advantages, most notably a far better tissue specimen for histopathological analysis.     

Ingrown Nails: A Comparison of the Nail Matrix Phenolization Method with the Elevation of the Nail Bed-Periosteal Flap Procedure

Seventy-five procedures were performed on 62 patients with ingrown nails from 1992 to 1996. Those consisted of 51 nail matrix phenolization methods (NMP) and 24 elevation of the nail bed-periosteal flap procedures (ENF). Ingrown nails were classified into type A (normal nail plate) and type B (incurved nail plate). The duration and intensity of postoperative pain were assessed, and the recurrence rate was monitered. The recurrence rate was 3.9% in the NMP group and 4.1% in the ENF group. Concerning the recurrence rate, there was no statistical significance between ENF and NMP in both types. Postoperative pain intensity was less in the NMP group than in the ENF group in both types (P<0.01). The same tendency was seen in postoperative pain duration. However, the NMP group had longer duration of wound healing compared with the ENF group in type A (P<0.01). We conclude that NMP is a recommendable treatment for most ingrown nails.     

Ingrown toenails: an evaluation of elevating the nail bed-periosteal flap.

Many procedures to correct ingrown toenails are available; however, they cannot avoid recurrence and nail deformities. We have performed a procedure which corrects ingrown toenail without reducing the width of the nail plate by elevating the nail bed-periosteal flap. Sixty patients were observed for longer than six months and exhibited excellent results. Only two cases of incurvated nails (2) required re-operation.     

New criteria for the laboratory diagnosis of nondermatophyte moulds in onychomycosis

Background  Nondermatophyte moulds (NDM) may be found as aetiological agents or as contaminants in onychomycosis. The classic and most used criteria for the diagnosis of NDM are those established by English in 1976.
Objectives  The aim of this article is to re-evaluate the laboratory criteria for the diagnosis of NDM in onychomycosis.
Patients and methods  Patients with suspected NDM of the nail underwent five consecutive examinations by both KOH and mycological culture; at the first visit, three samples from the affected nail were taken and were examined separately. Later those patients underwent four consecutive examinations; during this stage only a single sample for both KOH and culture was taken. We compared the culture results obtained from the three nail samples obtained at the first visit with the results from the four consecutive visits.
Results  We noted a clear trend showing that as the number of positive cultures increases (one to three cultures) during the first examination, the percentage of subsequent positive cultures, taken during the four consecutive visits, also increased.
Conclusions  We suggest that when NDM infection is found in the first culture, the patient should be re-examined in a subsequent visit in which three separate samples are taken from the affected nail. If NDM is confirmed in all three cultures, the diagnosis of NDM is established. Treatment should be recommended in patients who show positive results in all three cultures.     

Evaluation and treatment of nail disorders utilizing practical nail surgical techniques

Nail disorders frequently seen in daily practice may be inflammatory, infectious, tumoral, traumatic, or cicatricial. Surgical correction of the most common disorders is reviewed here. Treatment of the different types of ingrown nails as representative of the inflammatory diseases, the peculiarities in the treatment of an acute or a chronic hematoma, management of infectious diseases like chronic and acute paronychia, and different surgical techniques to treat a nail tumor depending where the problem is located, trying to prevent permanent postsurgical dystrophies are discussed.     

Ultra high‐frequency ultrasound: New capabilities for nail anatomy exploration

Recent development of ultra high‐resolution ultrasound systems, with frequencies as high as 70 MHz and capability resolution as fine as 30 μm, could permit new diagnostic applications to small parts. A variety of superficial targets within the first 1 cm of the skin surface could be imaged, including dermatological applications such as assessment of skin layers, hair follicles and the nail unit. Nail disorders are frequent but they are diagnosed mainly based on clinical examination; although biopsies and scrapings can provide clinically significant information, most patients do not perceive biopsies positively. To image the skin layer and annexes is often difficult with conventional ultrasound but, because of anatomical details obtained with the newest systems, this method holds great promise for addressing important biomedical applications offering unique advantages over the existing non‐invasive imaging modalities. This will enable physicians to assess and manage the conditions involving the nails of a large and growing segment of the population in a better way.     

The physical basis of cosmetic defects of the nail plate

Cosmetic defects of the nail cover a range of changes. Some are variants of normal which are considered unattractive, others are part of the normal ageing process and some changes are manifestations of local or systemic disease. Interpretation of these changes relies on recognition of the specific characteristics in question and an understanding of the anatomy and biology of nails. In many instances, therapies are limited and explanation of the changes represents one of the most useful contributions the professional can make to the affected individual. This article covers some of the most common cosmetic defects of nail involving colour, surface, brittleness and behaviour of surrounding tissues. Understanding of the physical basis of these defects is limited in many cases, but current thinking is recorded.     

Hyperkeratotic nail discoid lupus erythematosus evolving towards systemic lupus erythematosus: therapeutic difficulties

Nail changes occur in about 25% of systemic lupus erythematosus (SLE) cases. Onycholysis has been reported as the most frequent abnormality in SLE. Nailbed hyperkeratosis may be observed in both SLE and discoid lupus erythematosus (DLE). Involvement of the nail apparatus in DLE is extremely uncommon and never restricted to it. We report on a patient in whom the clinical features on the proximal nailfold were similar to those observed on the skin of a patient with typical DLE. This has, to the best of our knowledge, not yet been reported. The patient also exhibited a very distinctive prominent subungual hyperkeratosis. Interestingly, the patient developed biological alterations suggesting a systematization of the disease. Only a combination of systemic corticoids, retinoids and antimalarials was able to achieve nail improvement and this partial resistance to therapy may be explained by the very unusual subungual hyperkeratosis.     

Onychocryptosis – decrypting the controversies

Onychocryptosis, or ingrown toenail, is a frequent, painful condition affecting young individuals. Controversies still exist regarding its etiopathogenesis and treatment options, including conservative and surgical techniques. The choice of treatment method depends on the stage of disease as conservative measures are mostly effective in early stages and surgical procedures are required in the later stages. Among surgical techniques, phenol cauterization of lateral nail matrix has been the most effective, safe, and commonly performed method. Other more destructive surgical procedures are rarely done nowadays. In this review, we briefly discuss the etiopathogenesis, clinical features, and different treatment options of ingrown toenail.     

Pincer nail deformity and pseudo-Kaposi's sarcoma: complications of an artificial arteriovenous fistula for haemodialysis

Pseudo-Kaposi's sarcoma which develops due to arteriovenous fistulae for haemodialysis is relatively well known. In contrast, nail changes associated with pseudo-Kaposi's sarcoma or venous hypertension are rare. We report a novel case of pincer nail deformity associated with pseudo-Kaposi's sarcoma and venous hypertension, complications of an arteriovenous fistula for haemodialysis, and review eight similar cases reported in the literature. Most of the subjects presented with similar findings, having circulatory disturbance due to an arteriovenous fistula and/or increased venous pressure, and swelling, discoloration and papules/nodules of the skin distal to the shunt. Of the nine patients, three had overcurvature of the nails, in which the lateral edge of the nail pressed deeply into the lateral nail fold. Pincer nail deformity associated with pseudo-Kaposi's sarcoma after placement of an arteriovenous fistula may be relatively common and should be recognized as a specific sign of circulatory disturbance due to the arteriovenous fistula.