This report reflectsthe best data available at the time the report was prepared, butcaution should be exercised in interpreting the data; the resultsof future studies may require alteration of the conclusions orrecommendations set forth in this report.

Reprint requests: American Academy ofDermatology, P.O. Box 4014,
Schaumburg, IL 60168-4014.

J AM ACAD DERMATOL 1996;34:529-33..

Copyright 1996 by the American Academy of Dermatology, Inc.

Guidelines of care for nail disorders

Guidelines/OutcomesCommittee: Lynn A. Drake, MD, Chairman, Scott M.Dinehart,MD, Evan R. Farmer, MD, Robert W. Goltz, MD, Gloria F. Graham,MD, Maria K. Hordinsky, MD, Charles W. Lewis, MD, David M. Pariser, MD, John W.Skouge, MD, Maria L. Chanco Turner, MD,Stephen B. Webster, MD, Duane C. Whitaker, MD, Barbara Butler, CPA-SDR Consultant, and Barbara J. Lowery, MPH

Task Force:Richard K. Scher, MD, Chairman, C. Ralph Daniel, MD, Lawrence A.Norton, MD, Stuart J. Salasche, MD, and Ronald J. Siegle, MD

I. Introduction

The American Academy of Dermatology’s Guidelines/Outcomes Committee is developing guidelines of care for our profession. The development of guidelines will promote the continued delivery of quality care and assist those outside our profession in understanding the complexities and scope of care provided by dermatologists. For the benefit of members of the American Academy of Dermatology who practice in countries outside the jurisdiction of the United States, the listed treatments may include agents that are not currently approved by the U.S. Food and Drug Administration.

Definition

Nail disorders include those abnormalities that affect any portion of the nail unit. The nail unit includes the plate, matrix, bed, proximal and lateral folds, hyponychium, and some definitions include the underlying distal phalanx. These structures may be affected by heredity, skin disorders, infections, systemic disease, the aging process, internal and external medications, physical and environmental agents, trauma, and tumors, both benign and malignant.

Rationale

Scope

Nail disorders comprise approximately 10% of all dermatologic conditions. When there is an abnormality of the nail unit, the patient may have pain or interference with function, or both. Nail disorders may affect walking, the picking up of fine objects, tactile sensation, and protective function. Functional effects may result in problems wearing shoes. In many societies the aesthetic aspect of the nail unit may affect occupation, employability, and interaction with other people.

There is no significant difference in distribution of nail disorders between sexes. However, ingrown nails appear to be more common in men, particularly young athletes who may have concomitant hyperhidrosis.

Nail disorders, although infrequent in children, increase in scope throughout life and affect a high percentage of the geriatric population. This is due in part to particular susceptibility of the nail to fungal infections, faulty biomechanics from arthritis, impaired circulation, greater susceptibility to neoplasms, and the use of systemic medications.

Under certain circumstances the space beneath the nail plate, a somewhat protected area, has been shown to harbor both fungal microorganisms and the scabies mite. With respect to fungi, such a reservoir could be a source of infection elsewhere in the person, particularly cutaneous spread to the feet in cases of onychomycosis. Because of scratching, the subungual presence of scabies may reinoculate previously treated skin and result in recurrence of the infestation.

The nail unit may show specific changes that are markers for a wide range of systemic disorders. These include collagen vascular, liver, renal, endocrine, cardiac, and neoplastic diseases. In addition, a number of symptom complexes exist (e.g., nail patella and yellow nail syndromes) in which the nail unit is an integral part of multisystem diseases. Consequently, evaluation of the nails is an important component of all physical examinations.

Issue

Nail disorders respond very slowly to therapy because of the inherent slow growth of the nail unit and because of poor absorption and impaired delivery of medications to the diseased portion of the nail unit. Although there are many medical treatments currently available for the control of nail disease, often surgical techniques may be concomitantly utilized to achieve a maximum benefit. Congenital anomalies may require surgical correction.

Diagnostic criteria

Clinical

History may include

General medical history, as appropriate

Onset, duration, progression of disorders

Presence or absence at birth

Location - upper and/or lower extremities; single and/or multiple digits

Occupational and/or environmental exposures

Precipitating and/or alleviating factors

Trauma

Other cutaneous and systemic disorders

Nail cosmetics and procedures

Past and present medications and drug allergies

Past and present treatments of nail (topical, systemic, surgical)

Emotional and stress factors

For patients undergoing nail surgery, include history of

Vascular compromise

Bleeding diathesis

Medications

Diabetes mellitus

Collagen vascular disorders

Arthritis

Past infections

Past surgical procedures

Other

Physical examination

Nail cosmetics may need to be removed for adequate examination. In some instances, all 20 nails may need to be examined.

General physical examination, as appropriate

Dominant hand and changes in the proximal and lateral nailfolds

Involvement of one or more fingernails, one or more toenails, and presence or absence of bony abnormalities

Thickness, consistency, color, surface changes, onycholysis (separation of nail plate from nail bed)

Nail changes according to which component of the nail unit is involved (plate, matrix, bed, hyponychium, folds, phalanx)

Other areas including skin, hair, and mucous membranes when indicated

Particular attention should be paid to hair abnormalities, mucous membrane and dental changes, and presence or absence of immunologic disorders.

The peripheral neurovascular status of the patient when indicated

Diagnostic tests

May include, but are not limited to:

Microscopic examination

Potassium hydroxide (KOH) preparation for dermatophytes and other microbiologic organisms

Tzanck smear for viral changes

Stains for bacteria (Gram stain)

Culture

Fungal – advisable to use both cycloheximide-containing medium as well as medium without cycloheximide because yeast and nondermatophyte molds may not grow in the presence of cycloheximide

Bacterial

Viral

Nail unit compression and transillumination

In vivo nailfold capillary microscopy

Nail clippings

Hyphae

Other

Biopsy for histologic evaluation

Indications for biopsy may include diagnosis of

Medical disorder

Infection, especially fungal

Neoplasm

Structural abnormalities

Pigmentary changes

Other

Biopsy guidelines

Take the smallest amount of tissue necessary to make a definitive diagnosis.

Perform biopsy on nail bed tissue whenever possible in preference to nail matrix tissue to avoid permanent dystrophy.

Utilize the procedure with the greatest benefit and potential to minimize permanent scarring or deformity.

Punch biopsies are adequate in most situations except when operating in the proximal nail matrix, where an ellipse or fusiform biopsy is preferable and where suture may be helpful. When biopsies of the nail bed and distal nail matrix are done, suturing is not mandatory.

An adequate biopsy may require extension to the periosteum.

Biopsy stains

Hematoxylin and eosin

Special stains: periodic acid-Schiff, silver stains

Direct immunofluorescence

Other

Chemistry and serologic evaluation is indicated for

Systemic disease (thyroid, renal, pulmonary, hematopoietic, endocarditis)

Collagen vascular disease (lupus erythematosus, scleroderma, dermatomyositis, rheumatoid arthritis)

HIV infection

Syphilis

Other

Adjunctive diagnostic studies that may be indicated in certain circumstances (e.g., to rule out tumors) include

Frequently used

X ray

Rarely used

Magnetic resonance imaging

Ultrasonography

Doppler studies

Other

Inappropriate diagnostic tests

Although the use of forensic and toxicologic evaluation for vitamins and trace metals may be useful, analysis of nails for nutritional evaluation is not of proven scientific value.

Exceptions

Not applicable

Evolving diagnostic tests

Not applicable

Recommendations

Treatment

A specific diagnosis should be established before commencing therapy whenever possible. Topical, intralesional, and/or systemic therapy is indicated for many nail disorders. Other modalities such as surgery, cryotherapy, radiation, phototherapy, and laser may be indicated. Patients should be advised that treatment of nail disorders is often a prolonged and gradual process. (See Table I for indications and treatment of some of the more common nail disorders.)

Medical

Topical therapy, commonly used but not limited to

Antifungals (See "Guidelines of Care for Superficial Mycoses: Onychomycosis," J AM ACAD DERMATOL 1996;34:116-21)

Antibiotics

Antivirals

Corticosteroids

5-Fluorouracil

Salicylic acid

Tar, anthralin

a -Hydroxy acids

Chemical avulsion (potassium iodide, salicylic acid, urea)

Other

Systemic therapy includes but is not limited to

Antifungals (See "Guidelines of Care for Superficial Mycoses: Onychomycosis")

Antibiotics

Antivirals

Corticosteroids

5-Fluorouracil

Photochemotherapy

Methotrexate for severe, incapacitating psoriasis

Biotin

Other

Intralesional therapy

Intralesional corticosteroids

Intralesional bleomycin

Other

Surgical

Surgical avulsion of the total nail is not routinely recommended except for the diagnosis and management of tumors and for the alleviation of severe pain.

Specific nail surgical procedures

All nail surgical procedures should be performed under aseptic conditions

Nail plate avulsion, partial or total

Nail matrix exploration

Biopsy of one or more portions of the nail unit

Partial or total matricectomy (chemical, laser, or cold steel)

Resection of the nail bed and/or nailfolds for ingrown nails, pincer nails, and other structural abnormalities

Crescent-shaped biopsy of the proximal nailfold for periodic acid-Schiff-positive globules and direct immunofluorescence

Perforation of the nail plate for relief of subungual hematoma

Cryosurgery

Laser surgery

Other

Suggested instrumentation

Variously sized punches

Dual action nail nipper

English anvil nail splitter

Freer septum elevator

Dental spatula and other elevators

Skin hooks

Various scalpels including Beaver instruments

Appropriate needles and syringes for anesthesia (30-gauge needle preferable)

Tourniquet, when indicated

Cryosurgical unit or cotton-tipped applicator

Other

Anesthesia (See "Guidelines of Care for Local and Regional Anesthesia in Cutaneous Surgery, J AM ACAD DERMATOL 1995;33:504-9)

A digital block or distal ring block (perionychial block) may be performed. Application of a superficial freezing spray before the initial injection is suggested. Appropriate anesthetics include lidocaine, mepivacaine, and bupivacaine.

Postoperative care

Topical and/or systemic antibiotics when indicated

Bulky loose sterile dressing (2 x 2 inch or 4 x 4 inch) and tube gauze

Non-aspirin-containing pain medications for postoperative discomfort

Avoid use of aspirin and other nonsteroidal antiinflammatory drugs

Other

Other

Other

Phototherapy

X-rays

Laser

Other

Specific recommendations

Onycholysis

Establish cause, if possible, and treat or correct it

Strict irritant avoidance

No nail cosmetics (except under certain circumstances

Topical antifungals and/or drying agents as indicated

Keep the nails short

Other

Psoriasis

Avoid trauma

Keep nails short

Avoid irritants

Consider topical, systemic, and/or intralesional corticosteroids

Phototherapy

Other

Lichen planus

Avoid trauma

Keep nails short

Avoid irritants

Consider topical, systemic, and/or intralesional corticosteroids

Other

Miscellaneous

Not applicable

Supporting evidence

See Bibliography(Appendix)

Table I. Indicationsand treatments of nail disorders*

I,Intralesional; S, systemic; T, topical; X,surgical.

*This table presentsinformation on treatment of the more common nail disorders and isnot inclusive of the spectrum of nail disorders.

†For severe,incapacitating psoriasis.

VI. Disclaimer

Adherence to these guidelines will not ensure successful treatment in every situation. Further, these guidelines should not be deemed inclusive of all proper methods of care or exclusive of other methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all the circumstances presented by the individual patient. For the benefit of members of the American Academy of Dermatology who practice in countries outside the jurisdiction of the United States, the listed treatments may include agents that are not currently approved by the U. S. Food and Drug Administration.

Appendix. Bibliography

Baran R, Dawber RPR.Diseases of the nails and their management. Oxford: BlackwellScientific, 1994.

Barnett JM, Scher RK.Nail cosmetics. Int J Dermatol 1992;31:675-81.

Beltrani VP, Scher RK. Evaluation and management of melanonychia striata in apatient receiving phototherapy. Arch Dermatol 1991;127:319-20.

Daniel CR III, NortonLA, Scher RK. The spectrum of nail disease in patients with humanimmunodeficiency virus infection. J AM ACAD DERMATOL1992;27:93-7.

Drake LA, DinehartSM, Farmer ER, et al. Guidelines of care for superficial mycoticinfections of the skin: onychomycosis. J AM ACAD DERMATOL1996;34:116-21.

Drake LA, DinehartSM, Goltz RW, et al. Guidelines of care for local and regionalanesthesia in cutaneous surgery. J AM ACAD DERMATOL1995;33:504-9.

Hochman LG, Scher RK,Meyerson MS. Brittle nails: response to daily biotinsupplementation. Cutis 1993;51:303-5.

Paller AS, Moore JA,Scher R. Pachyonychia congenita tarda: a late onset form ofpachyonychia congenita. Arch Dermatol 1991;127:701-3.

Rosenzweig R, Scher RK. Nail cosmetics: adverse reactions. Am J Contact Dermatitis1993;4:71-7.

Scher RK, Barnett JM.Successful treatment of Aspergillus flavus onychomycosiswith oral itraconazole. J AM ACAD DERMATOL 1990;23:749-50.

accommodation in NiceScher RK, Daniel CR.Nails: therapy, diagnosis, surgery. Philadelphia: WB Saunders,1990.

Suarez SM, Scher RK.Idiopathic atrophy of the nails: a possible hereditaryassociation. Pediatr Dermatol 1990;7:39-41.

Suarez SM, Silvers DN, Scher RK, et al. Histologic evaluation of nail clippings fordiagnosing onychomycosis. Arch Dermatol 1991;127:1517-9.

Zaias N. The nail inhealth and disease. Norwalk, Conn: Appleton & Lange, 1990.