Nail disorders

Chronic paronychia is a distinctive clinical entity and should not be confused with other inflammatory processes.

(Image: chronic paronychia)

Acute bacterial paronychia can be confused with an herpetic whitlow - R/O with Tzanck preparation and culture.

(Image: herpetic whitlow)

Ingrown toenail: Etiology

A painful lesion typically caused by the pressure of tight shoes on the soft tissues at the edge of the nail of the great toe. Common in teen-aged boys (and girls): Made worse by rapid growth of the feet! Along with improper fitting of the shoes

Trimming Corner of Toenail

A procedure to be performed by the health care personnel Without anesthesia excise the corner of the nail with the tip of a scalpel or scissors, removing the piece of nail that causes the pain. Trim the overhanging granulations with a scalpel or scissors. Cauterize the remaining granulation tissue with a silver nitrate stick (or hyfrecator or radiosurgery if toe is anesthetized) as needed. Wear proper fitting shoes to reduce pressure, which may often relieve the symptoms completely and permanently

Subungual hematoma: Definition & incidence

Accumulation of blood under the nail matrix due usually to trauma Incidence - Any age

Onychogryphosis: Causes

Acute injury - dropping something on toe Chronic injury - from ill-fitting shoes Infection Poor blood supply Diabetes Inadequate intake of nutrients.

What are the various causes of onychogryphosis?

Acute injury - dropping something on toe Chronic injury - from ill-fitting shoes Infection Poor blood supply Diabetes Inadequate intake of nutrients.

Acute vs. chronic paronychia: PE

Acute paronychia: - Second and third finger most commonly affected. - Painful, red, and swollen - May be accompanied by an abscess or cellulitis. Chronic paronychia: - Loss of the cuticle - Slight tenderness, swelling, erythema - Sometimes separation of the nail fold from the plate. - Frequently a purulent or "cheesy" discharge and deformity of the nail plate.

Acute vs. Chronic paronychia: Labs

Acute paronychias - if not responding to appropriate empiric antibiotic therapy do a culture and possibly x-ray to rule out osteomyelitis Chronic paronychias: - Confirm candidal etiology with KOH prep on debris from under the cuticle. - Culture typically grows out mixed flora including bacteria and Candida species..

Acute vs. Chronic paronychia: Tx

Acute paronychias: - Incise and drain with scalpel or large bore needle inserted between the flesh and the nail. - Alternating hot/cold soaks - Start appropriate empiric antibiotic therapy - typically dicloxacillin or erythromycin for Staphylococcus aureus. Chronic paronychias: - Avoid prolonged exposure to wetness. - Wear gloves, preferably cotton-under-vinyl gloves. - Avoid frequent washing and manicures - Use broad-spectrum topicals, such as Lotrimin solution or other antifungal - May need to remove the nail in difficult cases!

Acute vs. Chronic paronychia: Course & Complications

Acute paronychias: - Usually not a precursor of chronic paronychia. - Typically resolves after I&D, soaks, and appropriate antibiotic therapy Chronic paronychias: - By definition they continue for a long time (even with treatment) because repeated mechanical trauma and exposure to water predisposes to the chronic infectious and inflammatory process.

Ingrown toenail: Conservative home self-care (Continued)

After every soaking, try to push the roll in a little further. Change roll daily Allow 7-15 days for the nail to grow out and stop poking the tissue. Cut the end of the nail at right angles to the axis of the toe: - Helps relieve symptoms - Reduces recurrence. A pain reliever may be helpful. If you see no improvement within five days, call your doctor.

Felon: Tx

Alternating hot and cold soaks Empiric antibiotics or herbal antimicrobials Probiotics Anti-inflammatory agents to reduce the pain and swelling Appropriate homeopathics

Subungual hematoma: SSx

Although usually relatively minor, this injury causes excruciating pain. There is marked tension in the unyielding space bounded by the firm nail above and the bone below. Relief of pain is immediate when the lesion is drained.

Ingrown toenails: Operative Treatment - Acute Cases (Part 3)

Apply a pressure bandage of a Telfa pad or Band-Aid, folded 2x2 and tube gauze and/or Coban. Change the bandage in 2 days and begin alternating warm and cold soaks twice daily. Cover the area with a Band-Aid between soaks. Have the patient wear open toed sandals or slippers at home to relieve any pressure on the operative site. Inform the patient that: - he/she may be pain free within a day or two - healing usually occurs within one week - this treatment often results in (but does not guarantee) a permanent cure.

Another cause of ingrown toenails are cutting the nails too short.

As the nail grows out, the uncut corner is pushed into the soft tissues Over time, in response to this pressure, granulation tissue ("proud flesh") forms over the sharp corner of the nail. This may produce a constant discharge of a small amount of purulent material.

List four ways to help prevent onychogryphosis.

Avoid footwear or stockings that gather tightly at the toes. Keep nails trimmed. Avoid tight fitting foot wear. Avoid nail polish which can damage the nail tissue.

Onychogryphosis: Prevention

Avoid footwear or stockings that gather tightly at the toes. Keep nails trimmed. Avoid tight fitting foot wear. Avoid nail polish which can damage the nail tissue.

The felon abscess may:

Break to the surface in the center of the pulp space and decompress spontaneously, with slough of necrotic skin over the pulp space. Rupture into the distal interphalangeal joint and develop septic arthritis Be complicated by osteomyelitis of the distal phalanx, and sequestration of the diaphysis of the phalanx. Extend into the distal end of the flexor tendon sheath, producing tenosynovitis.

Subungual hematoma: Tx 2, heat

Burning a hole in the nail: - Heat the tip of a straightened paper clip to red hot and carefully burn through the nail. - A cautery pencil works as well. - Apply the hot tip to the nail for no more than 1 second at a time or the heat will cause significant pain. - Be careful to not "burn" the underlying nail bed leading to worse pain! - You may have to repeat this several times to provide a hole that is large enough to remain open for continued drainage. - Just keep targeting the same hole made by the first pass.

What is the typical causative organism in chronic paronychia?

Candida albicans + bacteria

When the hematoma is near the fingertip or cuticle:

Carefully insert the tip of a pointed scalpel (or a large needle) just under the nail or cuticle. Will permit drainage of the hematoma usually with little or no pain without needing to use anesthesia.

Onychomycosis

Definition - chronic progressive fungal infection of the nail apparatus Known as TINEA UNGUIUM Causes: - May be Candida sp. (chronic paronyhcia) or molds. - Most fingernail and toenail infections caused by either trichophyton mentagrophytes or trichophyton rubrum - T. rubrum was imported into industrialized nations from Europe during the 1800s and started an epidemic of foot and toenail infections!

Onycholysis

Detachment of nail from its bed at distal and/or lateral attachments. Subungual space collects dirt and keratinous debris. Typically grayish-white color due to presence of air under nail But color varies from yellow to brown Area may be malodorous.

Chronic paronychia: Hx

Develop insidiously and often initially go unnoticed by the patient Swelling and inflammation of the nail fold and matrix leading to abnormal nail formation and subsequent nail dystrophy.

Onychogryphosis: SSx

Discomfort from footwear or bed sheets pressing on thickened nails Long deformed nails can impair walking. Long curved nails can penetrate adjacent toes, causing pain and infection of the skin.

Onychogryphosis: Tx

Frequently apply urea ointment (Ureacin-40) to soften nail. Cut away excess hypertrophied nail with bone-cutting forceps. If possible have the patient regularly file away the excess nail overgrowth. Apply a moisturizer on nails each time the patient washes her/his hands or feet. Soak the feet in warm salt water. Remove entire nail and kill it with phenol.

Ingrown toenails: Operative Treatment - Chronic Cases - Phenol (Part 1)

GOAL: permanent removal of the offending portion of the nail! Perform digit anesthesia Remove the offending piece of toenail. With the tourniquet in place stop the bleeding from the nail bed with pressure and silver nitrate if needed. Apply protective ointment such as Vaseline to the surrounding periungual tissues to prevent contact with the phenol solution. Perform at least three, 30-second applications of 88% liquefied phenol to the raw surfaces with a partially stripped cotton applicator (saturated, but not dripping). Keep the area dry to allow the phenol to work properly! You may opt to scrape the surface with a small curette before applying the phenol.

Subungual hematoma: Course & complications

Healing with any of these drainage methods is usually rapid without problems. If the hole clots shut soak the digit in cold water; adding peroxide will help dissolve the clot. Typically blood stains remain until the nail plate grows out. CAUTION - fracture may be hidden under a nail that has significant damage - do X-ray!

Subungual hematoma: Hx & DDx

History: - Patients typically report finger was struck by a hammer, etc. followed by marked swelling/pain. - Tight fitting boots, especially ski boots, are also common causes. DDx - In the absence of physical trauma, suspect a Proteus or Pseudomonas infection

Felon: Surgical Tx

I & D if needed Surgically fillet open the felon (below) to save the fingertip! (Please tell me that is done by a hand surgeon! That's terrifying!)

Onycholysis: Etiology

Idiopathic Systemic (e.g., thyrotoxicosis) Congenital/hereditary Cutaneous diseases (e.g., psoriasis, drug-induced photo-onycholysis) Local causes (e.g., trauma, onychomycosis, chemicals).

What are the 5 etiologies of onycholysis?

Idiopathic Systemic (e.g., thyrotoxicosis) Congenital/hereditary Cutaneous diseases (e.g., psoriasis, drug-induced photo-onycholysis) Local causes (e.g., trauma, onychomycosis, chemicals). Treatment - treat underlying condition(s)

What do you advise the patient to do if the drainage hole made in a nail for a subungual hematoma closes up and pressure and pain reoccur?

If the hole clots shut soak the digit in cold water; adding peroxide will help dissolve the clot.

Onychomycosis: SSx

In addition to unsightly appearance, onychomycosis of toenails can: - cause pain - predispose to secondary bacterial infections and ulcerations of underling nail bed These complications are more common in immunocompromised individuals and diabetics.

Onychomycosis: Lab Diagnosis

KOH prep - confirm the species of fungus before starting oral antifungal treatment in tough infections. Cultures - use a curette to obtain crumbling debris from both the proximal and distal areas of infection under several nails. Or scrape the nail surface with a curette or a #15 scalpel blade. (Pictured: different entry points for onychomycosis)

Onychomycosis: DDx

Most commonly confused with psoriasis The two diseases may coexist. The single distinguishing feature of psoriasis, pitting of the nail-plate surface, is not a feature of fungal infection. (Image: psoriatic nails)

Chronic paronychia: Predisposing Factors & cause

Predisposing factors: - trauma or maceration producing a break in the seal between the cuticle and the nail plate - this produces a pocket that holds moisture and promotes the growth of microorganisms Cause - infection usually due to Candida albicans + bacteria

What are the primary and secondary causes of ingrown toenails?

Pressure of tight-fitting shoes Cutting nails too short

In the absence of physical trauma, what appears to be a subungual hematoma might be a ___________ or __________ infection.

Proteus Pseudomonas

Ingrown toenails: Operative Treatment - Chronic Cases - Phenol (Part 2)

Repeatedly lavage the entire field with water, sterile saline, or 70% isopropyl alcohol to remove phenol. If any of the phenol solution remains in the area, the patient will experience protracted pain in the area lasting hours to days. Another option is to hyfrecate the nail bed rather than using phenol Apply Vaseline or minor surgery tincture and dressing Treating a C-shaped ingrown toenail like shown will require that all of the curled-under, embedded portion of the nail be removed for a good result!

Ingrown toenails: Operative Treatment - Acute Cases (Part 2)

Separate the portion of the nail to be removed from the nail bed and the adjoining skin with a spatula or hemostat and remove. Excise the hypertrophic granulation tissue that overhangs the nail. Cauterize the remaining granulation tissue if needed. Remove the tourniquet and control any persistent bleeding with silver nitrate sticks, hyfrecator, or radiosurgery as needed. Apply minor surgery tincture or Vaseline in the raw nail bed.

Subungual hematoma: PE

Simple case - may be only an area of dark, bluish discoloration under the nail In more severe cases: - marked swelling with distention of the eponychium - quantity of blood may be sufficient to cause separation and even ultimate damage and loss of the nail plate!

Subungual hematoma: Tx 1, puncture & drainage

Small hematomas usually do not need drainage! Best to drain early when the blood is still fluid. If hematoma lies entirely under the nail, may be necessary to make a small opening through the nail to permit its escape. This procedure is somewhat painful if much pressure is placed on the nail and/or the hot instrument strikes the nailbed in the process! Be sure to use protective eyewear when draining a nail!

How many 30-second applications of 88% liquefied Phenol would you use for attempting to permanently kill a portion of the nail bed?

Three

Zinc deficiency may produce transverse white spots on nails.

Treat with oral zinc. Removal of the nail may be needed at times along with medical treatment to help clear a fungal infection of the nail. (Did he really mean this? Maybe he put it on the wrong slide?)

When would you use Operative Treatment for an acute ingrown toenail case?

Use for ingrown toenails when there is a definite persisting infection with a heaping up of granulation tissue.

Ingrown toenails: Operative Treatment - Acute Cases (Part 1)

Use for ingrown toenails when there is a definite persisting infection with a heaping up of granulation tissue. Use digit block anesthesia Place a tourniquet at the base of the toe to provide hemostasis and help keep the anesthetic in the area. With a knife or scissors remove a 2-3 mm wide piece of the toenail being sure to cut through the proximal end of the nail bed Avoid cutting through the cuticle by pushing it back with a blunt instrument.

Ingrown toenail: Conservative home self-care

Useful if it is early in the course Soak foot in warm water 4 times a day. Keep the foot clean and dry during the rest of the day. Do not wear high heels or tight-fitting shoes - consider wearing sandals until the condition clears. Try to lift up the corner of the nail that is digging into the skin. Roll a small piece of cotton or gauze between your fingers. Place the roll between the corner of the nail and the skin to keep it elevated. Painful but is the most important part of the treatment.

All of these drainage techniques require the hematoma to be in a liquid state and are done _____ anesthetics.

Without

Paronychia: Definition

an inflammatory process of the nail fold.

Understand the concept of packing cotton under corner of ingrown nail

as described under conservative home self-care

Acute paronychia: Hx

develop rapidly, leading to marked tenderness of the nail fold.

In a felon the unyielding skin of the fingertip, contains the infection and creates tension resulting in _____.

microvascular compromise, necrosis, and abscess formation.

Acute Paronychia: Cause

most often the result of bacterial infection, commonly Staphylococcus aureus.

Acute paronychia: Incidence

occur very frequently from trauma to the cuticle.

FACT: When draining a subungual hematoma with any method you may have to repeat the procedure several times to...

provide a hole that is large enough to remain open for continued drainage.

FACT: You may need to _____ in difficult cases of chronic paronychia!

remove the nail

Felon

subcutaneous infection of the closed pulp space in the fibrous septal compartments of the distal phalanx Typically is a history of a penetrating injury Rapid and severe course! The unyielding tissue of the fingertip "traps" the infection and creates tension leading to microvascular compromise, necrosis, and abscess formation.

Onychogryphosis

thickening and distortion of the toenails or fingernails common in older people due to damage to the nail cells.

Onycholysis: Tx

treat underlying condition(s)

Leukonychia

white spots or bands that appear proximally and proceed out with the nail growth caused by minor trauma may be confused with proximal subungual onychomycosis.