PDF Nail Therapies Baran Download

Full download ebook at ebookgate.
com
Nail therapies Baran
https://ebookgate.com/product/nail-therapies-
baran/
Download more ebook from https://ebookgate.com

More products digital (pdf, epub, mobi) instant
download maybe you interests ...
Baran Dawber s Diseases of the Nails and their

Management 4th Edition Robert Baran
https://ebookgate.com/product/baran-dawber-s-diseases-of-the-
nails-and-their-management-4th-edition-robert-baran/
Nail Surgery 1st Edition Bertrand Richert
https://ebookgate.com/product/nail-surgery-1st-edition-bertrand-
richert/
Milady Standard Nail Technology 7th Edition Milady
https://ebookgate.com/product/milady-standard-nail-
technology-7th-edition-milady/
The Complete Nail Technician 2nd Edition Marian Newman
https://ebookgate.com/product/the-complete-nail-technician-2nd-
edition-marian-newman/
The Figure of the Migrant 1st Edition Thomas Nail
https://ebookgate.com/product/the-figure-of-the-migrant-1st-
edition-thomas-nail/
Transcatheter Valve Therapies 1st Edition Feldman
https://ebookgate.com/product/transcatheter-valve-therapies-1st-
edition-feldman/
Urgent Interventional Therapies 1st Edition Nicholas

Kipshidze
https://ebookgate.com/product/urgent-interventional-
therapies-1st-edition-nicholas-kipshidze/
Diseases of the Nails and Their Management 3rd Edition

Robert Baran
https://ebookgate.com/product/diseases-of-the-nails-and-their-
management-3rd-edition-robert-baran/
The Other Muslims Moderate and Secular 1st Edition

Zeyno Baran (Eds.)
https://ebookgate.com/product/the-other-muslims-moderate-and-
secular-1st-edition-zeyno-baran-eds/
NAIL
THERAPIES
Edited by
Robert Baran
Dimitris Rigopoulos
Nail Therapies
ουδε′ν ο′ϕελος εκ των απα′ντων αγαθω′ν εστι′, εα′ν το υγιαι′νειν και μο′νο απη′
Ιπποκράτης (460–370π.χ)
“If human health is missing, no other benefit can be of any value.”

Hippocrates (460–370 BC)
Nail Therapies
Robert Baran, MD
Honorary Professor of the University of Franche-Comté,
Nail Disease Centre, Cannes, France
Dimitris Rigopoulos, MD
Associate Professor of Dermatology, Athens University,
“Attikon” University Hospital, Athens, Greece
This edition published in 2012 by Informa Healthcare, 119 Farringdon Road, London EC1R 3DA, UK.
Simultaneously published in the USA by Informa Healthcare, 52 Vanderbilt Avenue, 7th Floor, New York,
NY 10017, USA.
Informa Healthcare is a trading division of Informa UK Ltd. Registered Office: Informa House, 30–32
Mortimer Street, W1W 7RE. Registered in England and Wales number 1072954.
© 2012 Informa Healthcare, except as otherwise indicated.

No claim to original U.S. Government works.
Reprinted material is quoted with permission. Although every effort has been made to ensure that all
owners of copyright material have been acknowledged in this publication, we would be glad to acknowl-
edge in subsequent reprints or editions any omissions brought to our attention.
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or trans-
mitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise,
unless with the prior written permission of the publisher or in accordance with the provisions of the
Copyright, Designs and Patents Act 1988 or under the terms of any licence permitting limited copying
issued by the Copyright Licensing Agency Saffron House, 6–10 Kirby Street, London EC1N 8TS UK, or
the Copyright Clearance Center, Inc., 222 Rosewood Drive, Danvers, MA 01923, USA (http://www.
copyright.com/ or telephone +1 978-750-8400).
Product or corporate names may be trademarks or registered trademarks and are used only for identi-
fication and explanation without intent to infringe.
This book contains information from reputable sources, and although reasonable efforts have been
made to publish accurate information, the publisher makes no warranties (either express or implied) as
to the accuracy or fitness for a particular purpose of the information or advice contained herein. The
publisher wishes to make it clear that any views or opinions expressed in this book by individual authors
or contributors are their personal views and opinions and do not necessarily reflect the views/opinions
of the publisher. Any information or guidance contained in this book is intended for use solely by medical
professionals strictly as a supplement to the medical professional’s own judgement, knowledge of the
patient’s medical history, relevant manufacturer’s instructions, and the appropriate best practice guide-
lines. Because of the rapid advances in medical science, any information or advice on dosages, proce-
dures, or diagnoses should be independently verified. This book does not indicate whether a particular
treatment is appropriate or suitable for a particular individual. Ultimately it is the sole responsibility of the
medical professional to make his or her own professional judgements, so as appropriately to advise and
treat patients. Save for death or personal injury caused by the publisher’s negligence and to the fullest
extent otherwise permitted by law, neither the publisher nor any person engaged or employed by the
publisher shall be responsible or liable for any loss, injury, or damage caused to any person or property
arising in any way from the use of this book.
A CIP record for this book is available from the British Library.
Library of Congress Cataloging-in-Publication Data available on application
ISBN: 9781841849843
Orders may be sent to: Informa Healthcare, Sheepen Place, Colchester, Essex CO3 3LP, UK
Telephone: +44 (0)20 7017 6682
Email: Books@Informa.com
Informa Healthcare Website: http://informahealthcarebooks.com
Informa website: www.informa.com
For corporate sales please contact: CorporateBooksIHC@informa.com

For foreign rights please contact: RightsIHC@informa.com
For reprint permissions please contact: PermissionsIHC@informa.com
Typeset by Exeter Premedia Services Pvt Ltd, India

Printed and bound in the United Kingdom
Contents
Acknowledgements and contributors vii
1. Anatomy and physiology of the nail unit 01

2. Abnormalities of the nail contour 04
3. Psoriasis 09
4A. Onychomycosis 17
4B. Future therapies for onychomycosis 30
5. Lichen planus 37
6 Pseudomonas infection 41
7. Herpes simplex (herpetic whitlow, herpetic paronychia) 43
8. Warts 45
9. Acrodermatitis continua of Hallopeau 50
10. Acute paronychia 52
11. Chronic paronychia 55
12. Yellow nail syndrome 58
13. Eczema 60
14. Nail fragility syndrome 62
15. Onycholysis 69
16. Onychotillomania 75
17. Nail abnormalities in oncology practice 79
18. Bowen’s disease 83
19. Squamous cell carcinoma 85
20. Melanonychia 87
21. Longitudinal erythronychia 90
22. Exostosis 92
23. Glomus tumor 95
24. Myxoid pseudo cyst (mucous cyst, ganglion) 98
25. Nail cosmetics and real nail prostheses 102
26. Onychocosmeceuticals 107
VI CONTENTS
27. Nail surgery 110

28. Complications in nail surgery 121
29. Biopsy of the nail area 126
30. Matricectomy 131
31. Removal of the proximal nail fold: Why? 133
Index 137
Acknowledgements and Contributors
Chapter 4B was kindly contributed by Chris Drummond-Main, MSc, Aditya K. Gupta, MD, PhD,
FRCPC, and Fiona Simpson HBSc, all of Mediprobe Research Inc., London, Ontario, Canada.
The medical illustrations are by Florence Richert (florencerichert@free.fr).

1 Anatomy and physiology of the nail unit
The nail plate is the permanent product of the nail matrix. Its normal appearance and growth
depend on the integrity of several components such as the tissues surrounding the nail or peri-
onychium, the bony phalanx that contribute to the nail apparatus or nail unit and so on (Fig. 1.1).
The nail is a semi-hard horny plate covering the dorsal aspect of the tip of the digit. The nail is
inserted proximally in an invagination practically parallel to the upper surface of the skin and later-
ally in the lateral nail grooves. This pocket-like invagination has a roof, the proximal nail fold and a
floor, the matrix from which the nail is derived.
The matrix extends approximately 6 mm under the proximal nail fold and its distal portion is only
visible as the white semi-circular lunula. The general shape of the matrix is a crescent concave in
its posteroinferior portion. The lateral horns of this crescent are more developed in the great toe
and located at the coronal plane of the bone. The ventral aspect of the proximal nail fold encom-
passes both a lower portion, the matrix, and an upper portion (roughly three quarters of its length)
called the eponychium.
The germinal matrix forms the bulk of the nail plate. The proximal element forms the superficial
third of the nail, whereas the distal element covers its inferior two-thirds.
The ventral surface of the proximal nail fold adheres closely to the nail for a short distance and
forms a gradually desquamating tissue, the cuticle, made of the stratum corneum of both the dor-
sal and the ventral side of the proximal nail fold. The cuticle seals and therefore protects the
ungual cul-de-sac from harmful environmental agents.
The nail plate is bordered by the proximal nail fold which is continuous with the similarly struc-
tured lateral nail fold on each side. The nail bed extends from the lunula to the hyponychium. It
presents with parallel longitudinal rete ridges.
The nail bed, in contrast to the matrix, has a firm attachment to the nail plate. Therefore, its avul-
sion produces a denudation of the nail bed. Colorless but translucent, the highly vascular connec-
tive tissue containing glomus organs transmits a pink color through the nail.
Distally, adjacent to the nail bed, the hyponychium, an extension of the volar epidermis under
the nail plate, marks the point at which the nail separates from the underlying tissue.
The distal nail groove, which is convex anteriorly, separates the hyponychium from the fingertip.
Circulation of the nail apparatus is supplied by two digital arteries that course along the digits
and send out branches to the distal and proximal arches.
The sensory nerves to the dorsum of the distal phalanx of the three middle fingers are derived
from fine oblique dorsal branches of the volar collateral nerves. Longitudinal branches of the dor-
sal collateral nerves supply the terminal phalanx of the fifth digit and the thumb.
Among its multiple functions, the nail provides counterpressure for the pulp that is essential to
the tactile sensation involving the fingers and for the prevention of distal wall tissue produced after
nail loss of the great toenail.
The nail is a musculoskeletal appendage as a part of a functional unit that is comprised of the
distal bony phalanx and several structures of the distal interphalangeal joint extensor tendon
fibers and the collateral ligaments. All these form the enthesis (Fig. 1.2). This organ is the bony
insertion point of the ligaments, the tendons and the articular capsules. It is composed of both:
● soft tissue (ligaments, tendons, and their fibrocartilages)

● hard tissue (calcified fibrocartilage, the immediately adjacent bone of the underlying trabecular
network)
Histological images confirm the link between the different structures.

Histology permits recognition of the nail matrix and nail bed that have no granular layer,
in contrast to the upper ventral aspect of the proximal nail fold called eponychium and the
hyponychium.
The hard keratin of the nail lies perpendicularly to the nail growth axis and parallel to the surface
of the nail plate.
2 NAIL THERAPIES
6
5
4 7
8
3
9
10
11
2
12
1
13
Figure 1.1 Anatomy of the nail apparatus: 1. flexor tendon; 2. middle phalanx; 3. extensor tendon; 4. eponychium; 5.
nail matrix; 6. proximal nail fold; 7. cuticle; 8. lateral nail fold; 9. lunula; 10. nail plate; 11. nail bed; 12. hyponychium;
13. terminal phalanx.
Figure 1.2 Entheses of the nail apparatus with (1) dorsal expansion of the lateral ligament at the distal interphalan-
geal joint (Guerro’s ligament).
Fingernails grow continuously on an average of 0.1 mm per day (3 mm per month). Toenails form
over a period of 12–18 months.
The nail unit is in some respects comparable to a hair follicle sectioned longitudinally and laid
on its side. The epithelial components of hair follicle and nail apparatus are differentiated epider-
mal structures which may be involved jointly in several ways, such as lichen planus, alopecia
areata, etc.
Remember
1. Only the nail matrix produces the nail plate.
2. No bone, no nail.
3. Knowledge of growth rate is often helpful in establishing the disease onset.
4. Entheses play an important role in nail anatomy.
ANATOMY AND PHYSIOLOGY OF THE NAIL UNIT 3
FURTHER READING
De Berker DAD, André J, Baran R. Nail biology and nail science. Int J Cosm Sci 2007; 29: 241–75.
McGonagle D, Tan AL, Benjamin M. The biomechanical link between skin and joint disease in psoriasis and
psoriatic arthritis: what every dermatologist needs to know. Ann Rheum Dis 2008; 67: 1–9.
Morgan AM, Baran R, Haneke E. Anatomy of the nail unit in relation to the distal digit. In: Krull EA, Zook EG,
Baran R, Haneke E, eds. Nails Surgery. A Text Atlas. Philadelphia PA, USA: Lippincott William Wilkins.
2001; 1–28.
2 Abnormalities of the nail contour
This chapter discusses nail abnormalities such as clubbing and racquet thumb, injuries and
trauma to nails, and diseases such as scabies that attack nails.
Clubbing (Fig. 2.1) changes encompass: (1) increased transverse and longitudinal curvature of
the nails; (2) enlargement of the soft tissue structures confined to the fingertips; (3) abnormal
mobility of the base of the nail which can be rocked back and forth giving the impression that it is
floating on a soft edematous pad; and (4) local cyanosis (60% of the cases).
Schamroth’s sign (Fig. 2.2) is the easiest maneuver to evidence clubbing. In the normal indi-
vidual a distinct diamond-shaped aperture or “window” is formed at the base of the nail beds, if
symmetrical fingers are placed against each other with contact on both dorsal surfaces. There is
a “window” lost with prominent distal angle between the ends of the clubbed nails.
Thoracic organ disorders are involved in 80% of cases of clubbing.
Where possible, the removal of the cause improves the shape of the nails.
Koilonychia (Fig. 2.3) shows a concave nail with the edges everted (spoon nail). In acquired
forms, avitaminoses PP, B2, and especially C in children should be looked for. Lack of iron and
cystine has been described, besides numerous causes.
BURN INJURIES OF THE PROXIMAL NAIL FOLD

Burn injuries affecting the skin overlying the proximal nail fold may lead to exposure of the nail
matrix. The associated pain, risk of infection, ragged appearance, and potential injury to the nail
matrix may be treated by a relocation of the retracted tissue and/or placement of a skin graft over
the damaged area.
WORN-DOWN NAILS (FIG. 2.4)

This condition is observed in “chronic scratchers and rubbers.” The surface of the nail becomes
glossy and shiny and the free edge is worn away.
A variant of this disorder has been reported on the middle three fingernails of the dominant
hand of unrelated women. The defect was triangular with its base lying at the free edge of the nail
where the thinning was maximal. These were fastidious women in whom the desire for cleanliness
verged on the obsessional. All were traumatizing their nails against the glazed earthenware of the
bidet (Fig. 2.5).
Distal triangular worn-out nails have been observed in some occupations like tailoring, where
tailors use the dorsum of the nails to smooth the cloth while sewing.
Figure 2.1 Nail clubbing.

ABNORMALITIES OF THE NAIL CONTOUR 5
Beau’s lines are transverse nail depressions resulting from temporary diminished matrix activity;
the involved nail, thinner than normal, reflects a deficient nail formation by the matrix (Fig. 2.6).
Diminished nutritional supply, chemotherapy, and acute febrile illness may affect matrix activity.
If nail matrix generation is completely curtailed, the formation of the nail plate will cease and the
nail will be shed after a stage of latent onychomadesis.
INCONTINENTIA PIGMENTI SUBUNGUAL TUMOURS

Management by desiccation and curettage or surgical excision is usually successful but perma-
nent nail atrophy may occur.
Curettage, excision, topical imiquimod, intralesional methotrexate, or fluorouracil and radiother-
apy usually work, despite possible recurrence where a course of systemic retinoids should be
considered: 1 mg etretinate/kg or 1.5 mg isotretinoin/kg bodyweight may produce a rapid response
Figure 2.2 Schamroth’s sign.
Figure 2.3 Koilonychia nails.

6 NAIL THERAPIES
Figure 2.4 A worn-down toenail.
Figure 2.5 Worn-down fingernails.
Figure 2.6 Beau’s lines.

ABNORMALITIES OF THE NAIL CONTOUR 7
with resolution of pain and a marked reduction of the lesion including improvement of the bony
alterations and nail deformity.
RACQUET THUMB (FIG. 2.7)

The esthetic appearance of racquet thumb may be improved by narrowing the nail plate and
creating lateral nail folds when necessary. The technique used for lateral-longitudinal nail biopsy
is performed on both sides of the thumbnail. Back stitches recreate lateral nail folds.
SCABIES (FIG. 2.8)

Subungual areas of normal fingernails of patients with scabies rarely contain mites. Conversely,
norwegian scabies presents with numerous mites.
Treatment of the subungual regions with lindane or other scabicides is recommended in all
patients with scabies. In invaded nails 40% urea avulsion permits the treatment of the nail bed in
association with oral ivermectin.
SUBUNGUAL SPLINTERS
Subungual splinters are a form of nail trauma that can easily and quickly be treated by dermatolo-
gists. Wood splinters not only cause pain, but are a portal for infectious organisms. Forceps extrac-
tion can be attempted by tugging in the direction opposite to that of the entry. Additionally, a local
Figure 2.7 Racquet thumb.
Figure 2.8 Scabies nails.

8 NAIL THERAPIES
digital block may be followed by a V-shaped cut with a nail splitter followed by elevation with a nail
spatula, then removal of the splinter. A no. 15 blade or a CO2 laser can also be used to remove the
overlying nail prior to splinter removal. Treatment with the CO2 laser may obviate the need for a
tourniquet to control bleeding.
Sea urchin granuloma may resemble a whitlow and the distal digit appears swollen, reddish
blue, and tender. Oral antibiotics and intralesional long-acting steroids are helpful and recovery is
seen within 2–3 weeks.
Remember
Proper examination of the nail contour may help with difficult diagnoses.
FURTHER READING
Baran R, Dupré A. Vertical striated sandpaper nails. Arch Dermatol 1977; 113: 1613.
Baran R, Moulin G. The bidet-nail. A French variant of the worn down nail syndrome. Br J Dermatol 1999;
140: 377.
Haneke E, Tosti A, Piraccini BM. Sea urchin granuloma of the nail apparatus: report of 2 cases. Dermatology
1996; 192: 140–2.
Higashi N. Pathogenesis of the spooning. Hifu 1985; 27: 29–34.
Mascaro JM, Palou J, Vives P. Painful subungual keratotic tumors in incontinentia pigmenti. J Am Acad
Dermatol 1985; 13: 913.
Piraccini BM, Tullo S, Iorizzo M, et al. Triangular worn-down nails; report of 14 cases. G. Ital Dermatol Venereol
2005; 140: 161–4.
Schamroth L. Personal experience. South African Med J 1976; 50: 297–300.
3 Psoriasis
Psoriasis presents in various forms involving different parts of the nail unit as shown in Table 3.1.
PITS
These are the commonest signs in psoriasis. They are mainly seen on fingernails. They are deeper
than those in alopecia areata and also more numerous. They are due to involvement of the proxi-
mal part of the nail matrix, resulting in abnormal cornification and presence of parakeratotic cor-
neocytes in the nail plate. These cells, as they are loosely attached, drop out leaving punctuate
depressions on the nail plate (resembling a thimble), which correspond to the pits (Fig. 3.1).
SUBUNGUAL HYPERKERATOSIS
This is due to the inflammation of the hyponychium and the distal nail bed and the hyperplasia of
the epidermis. The keratin layer is trapped, in a way, under the surface of the nail plate (Fig. 3.2).
OIL-DROP SIGN (SALMON PATCH)

This is a color change (yellow or salmon pink) of the nail plate, characteristic of the disease. It is
due to the trapping of neutrophils under the surface of the nail plate. It is located centrally or by the
onycholytic area (Fig. 3.3).
ONYCHOLYSIS
This is due to the detachment of the nail plate from the nail bed, due to the inflammation of the lat-
ter. It appears as a proximally whitish area, surrounded by a pink-erythematous margin (Fig. 3.4).
Table 3.1 Signs of Psoriasis

Matrix involvement Nail bed involvement Fold involvement
Pits, trachyonychia Onycholysis Paronychia
Leukonychia Oil-drop sign Nail plate disorders
Nail fragility Splinter hemorrhages
Dystrophic alterations Subungual hyperkeratosis
Beau’s lines
Onychomadesis
Mottled redness in the lunula
© Robert Baran, Dimitris Rigopoulos, and Informa
Healthcare
Figure 3.1 Pitting with parakeratotic cells on the proximal nail plate associated with distal onycholysis.
10 NAIL THERAPIES

Healthcare
Figure 3.2 Subungual hyperkeratosis.

Healthcare
Figure 3.3 Oil-drop sign.

Healthcare
Figure 3.4 Onycholysis associated with some pits.
SPLINTER HEMORRHAGES
Thin longitudinal brown-black lines are located distally on the nail plate. They are due to the pso-
riatic inflammation of the nail bed capillaries and are mainly seen on the fingernails. This is not
characteristic of nail psoriasis (Fig. 3.5)
PSORIASIS 11

Healthcare
Figure 3.5 Splinter hemorrhages.

Healthcare
Figure 3.6 Paronychia associated with erythroderma.
PARONYCHIA
Involvement of the paronychial area by psoriatic lesions leads to a secondary phase with complete
destruction of the nail plate, due to the inflammation of the underlying matrix (Fig. 3.6).
DIAGNOSIS
Diagnosis is based on the clinical appearance of the lesions, which are rather characteristic of the
disease, especially onycholysis with erythematous border, oil drops, hyperkeratosis and pits. Exis-
tence of psoriasis in other sites of the body can help the clinicians, as can also family or personal
history of psoriasis. In doubtful cases, biopsy can prove the diagnosis.
PROGNOSIS
Nail psoriasis has an unpredictable course, with remission and relapses, as happens with skin
disease. Patients with nail involvement should know that sun exposure often aggravates their dis-
ease as does trauma (Koebner phenomenon).
TREATMENT
Remember
Simple nail care is important for patients with nail psoriasis
More treatments (Table 3.2) have been introduced for psoriasis than those for virtually all the rest
of dermatology put together. Despite recent therapeutic advances, management of nail psoriasis
12 NAIL THERAPIES
Table 3.2 Treatment Algorithm

Clinical signs 1st treatment choice 2nd treatment choice
Pits, trachyonychia, proximal No treatment Smoothing lacquer(15% urea)
leukonychia, lunula with pits
Isolated onycholysis or polydacty- Removal of onycholysis and Removal of onycholysis and
lous with or without cutaneous clobetasol or combination of tazarotene
involvement betamethasone and calcipotriol
Isolated hyperkeratosis Injection of triamcinolone (40% urea Calcipotriol
before)
Polydactylous hyperkeratosis Acitretin 0.5 mg/kg MTX 15–20 mg/week
Nail ps with joint involvement MTX 5–10 mg/week Biologics
Hallopeau Acitretin 0.3 mg/kg Retinoid-PUVA
Abbreviations: ps, psoriasis.
remains protracted, tedious and sometimes unsatisfactory. Therefore, treatment of nail psoriasis
is a difficult challenge for the clinician to take up.
Treatment for nail psoriasis can be either topical or administered systemically.
The clinician should know that topical treatment for nail psoriasis is not as efficient as in skin
disease, because the nail plate prevents drug penetration. Another important point is that it takes
a long time (3–9 months) for noticeable nail improvement, due to the slow growth rate of the nail
and the patient should be informed accordingly.
Before the introduction of any treatment, some directions should be given to the patients con-
cerning hand and nail care. Patients should use gloves and even better with cotton ones under-
neath, especially when they are involved in wet work or come in touch with irritant fluids. They
should use nail moisturizers and avoid any trauma, such as over-rigorous manipulations and they
should also keep their nails short, in order to avoid any exacerbation of onycholysis.
They should avoid removing debris from beneath the nail with any instrument. They are allowed
to use colored nail enamel, but they should avoid polish removers with formaldehyde-acetone and
toluene and finally, they should avoid artificial nails.
TOPICAL TREATMENT
Topical treatment is indicated when it is not associated with severe skin psoriasis or psoriatic arthri-
tis, when systemic treatment is not recommended, or in combination with systemic treatment.
● Corticosteroids
● Vitamin D analogs (alone or with steroid combination)
● Retinoids
● Fluorouracil 1% solution in propylene glycol and urea
● Cyclosporine oily solution (not in use anymore)
● Calcipotriol + betamethasone
● Anthralin (not in use anymore)
Corticosteroids (Fig. 3.7)

Potent or superpotent topical steroids can be used once daily (at night) under occlusion. They
should be used for 4–6 months and they should be applied to the nail plate, at the hyponychium
at the nail folds and at the nail bed, in case the onycholytic nail plate is clipped back. Long-term
and repeated use can lead to nail fold atrophy, telangiectasias and atrophy of the underlying pha-
lanx (disappearing digit).
Topical treatment with corticosteroids is unable to act properly in case of subungual hyperkera-
tosis. Therefore, nail debridement, using 40% urea under occlusion, allows treatment of the nail
bed, after removal of the pathological area.
Intralesional steroids should follow patient’s counseling. Sometimes topical anesthesia with
freezing spray or distal block is needed and this depends on the patient, the technique and the size
of the needle. A 30-gauge needle locked to the syringe should be used. Triamcinolone acetonide,
in a frequency of monthly injections for 5–6 months, is the medication of choice. The injection site
PSORIASIS 13
Steroids
Injections Solution
Occlusive
Danger for nail Better results
dressing
atrophy in subungual
Short periods
painful hyperkearatosis
Figure 3.7 Treatment with steroids.
depends on the clinical symptom that we are trying to treat (nail matrix or nail bed). Should dermo-
jet be used for intralesional treatment? Most experts have abandoned this modality due to steriliza-
tion problems of the apparatus and also because of the possibility of ‘splash back’ of small quantities
of blood at the time of injecting.
Vitamin D Analogs
Calcipotriol has been used on a twice-a-day basis, for 4 up to 6 months on the nail plate, hypo-
nychium, nail bed (with the onycholytic nail clipped back) and on the nail folds. According to a
paper published by Tosti et al., the use of calcipotriol resulted in 49% reduction of fingernail and
40% of toenail hyperkeratosis.
Calcipotriol, 5 days a week with clobetasol propionate twice a week, on the nail plate, nail
folds and hyponychium, have been used in a paper published in 2002, with excellent results
after 6 and 12 months of patient evaluation (72% improvement in the 6th month, and 81% after
12 months on the fingernails and 70% which increased to 73% on the toenails, over the same
period of time).
Fluorouracil
Only one paper exists, published in 1998 indicating the use of 1% 5-FU solution in propylene gly-
col, with the addition of urea 20%. This was used twice a day for 6 months, and more than 50%
improvement in oil spots and subungual hyperkeratosis was seen.
Tazarotene
Tazarotene, which is a synthetic retinoid in the form of gel 0.1%, was used in three papers, with very
good results. It was used either with or without occlusion, for 3 up to 8 months. Improvement involved
onycholysis, salmon patches, hyperkeratosis, and pitting. In all papers, tolerability was excellent,
with only mild skin irritation and a sense of burning or desquamation of the paronychial area.
Cyclosporin Solution
Our personal experience is that this medication, despite the good results of one published paper,
does not have any effect on nail psoriasis.
Calcipotriol Plus Betamethasone

Twenty-five patients with nail psoriasis were tried on a combination of calcipotriol and betametha-
sone ointment every night for 12 weeks. A reduction in the mean Nail Psoriasis Severity Index
(NaPSI) score up to 72% was seen at the end of the study period.
Anthralin
Anthralin 0.4–2% in petrolatum applied once a day for 5 months in the treatment of nail psoriasis
has been evaluated by Yamamoto et al. Improvement was seen in 60% of the patients having
pachyonychia, pitting, and onycholysis. Patients exhibited undesired, but reversible, pigmentation
of the nail plate. It is no longer used.
14 NAIL THERAPIES
SYSTEMIC TREATMENT
Systemic treatment is indicated in the case of the involution of many nails and in the case of pus-
tular psoriasis of the nails (acrodermatitis continua of Hallopeau).
Systemic treatment can be used with the addition of topical treatment in order to reduce the
dosage of systemic treatment, or the duration of systemic treatment and also in order to maintain
the accomplished remission.
● Retinoids
● Methotrexate
● Cyclosporin
● Phototherapy and psoralens
● Superficial x-ray therapy
● Biological agents
● Laser-photodynamic
Remember
The clinician should always remember that psoriatic nails can easily be infected by dermato-
phytes, so the exclusion of this infection by direct microscopy or culture, must be kept in mind.
Retinoids
Acitretin should be administered at a lower dose than that used in skin psoriasis, 0.3–0.5 mg/kg,
in order to avoid the side effects related to retinoids, such as nail fragility, reduction of nail thick-
ness, paronychia-like lesions, and pseudopyogenic granulomas.
Etretinate was prescribed in 46 patients with pustular psoriasis with excellent results.
Acitretin was prescribed in 36 patients with nail psoriasis and it was given at a low dosage,
0.2–0.3 mg/kg, for 6 months. After treatment, the mean percentage reduction of NaPSI was 41%.
Clinical evaluation at 6 months showed complete or almost complete clearing of the nail lesions in
25% of the patients, moderate improvement in 25%, mild improvement in 33%, and no improve-
ment in 11% of the patients.
Remember
Systemic treatments have toxicity concerns.
Methotrexate
Low-medium doses of methotrexate (5–20 mg/once a week) prescribed to a patient with nail pso-
riasis can improve his disease only after a long administration period (12–18 months).
Cyclosporin
Cyclosporin can also improve psoriatic lesions on the nails. In a paper published in 2004, the
combination of cyclosporine per os and calcipotriol appeared to be more effective than cyclospo-
rine by itself (47% vs 79% improvement).
Remember
Sun can aggravate nail psoriasis.
Phototherapy and Psoralens

PUVA has been reported to improve onycholysis, salmon patches, subungual hyperkeratosis,
proximal paronychia, and onychorrhexis in a small series of patients with nail psoriasis. It has no
effect on pitting. No studies have been published since 1990.
Superficial X-Ray Therapy

This treatment modality is still in use in Germany and Switzerland.
PSORIASIS 15
Table 3.3 Efficacy of Biologics on Nails

Infliximab
56% reduction of NaPSI after 6 months
50% complete recovery after 12 months
Etanercept
Adalimumab
Ustekinumab
Abbreviation: NaPSI, Nail Psoriasis Severity Index.
Biologics
Over the last few years, a new category of medicaments for psoriasis has been added to the
therapeutic use of dermatologists. These are called biologics. Today we have two categories, the
anti-TNF-α and the anti IL-12, IL-23.
Up to now, there have been only a few publications concerning the treatment of nail psoriasis
with these medications. However the major question, concerning the use of these expensive drugs
is whether the clinician can use them in psoriasis located only on nails. This question is difficult to
answer but in my personal opinion, a useful criterion should be the impact of the nail disease on
the quality of life of the patient.
In Table 3.3, the results of different publications are listed.
Laser Photodynamic
In a recently published study, pulsed dye laser (595 nm), once a month, for 3 months and with a
pulse duration of 1.5 ms, beam diameter of 7 mm, and laser energy between 8.0 and 10.0 J/cm
appears to be effective particularly in improving onycholysis and subungual hyperkeratosis in
a small number of patients.
In another study, with a larger number of patients, PDL and photodynamic treatments were
compared. Both treatments decreased NaPSI score, both in nail matrix and nail bed involvement.
Remember
1. Do not trim nails severely as Koebner’s phenomenon can aggravate psoriasis.
2. Onycholysis and pitting are the least responsive to steroid injections.
3. Subungual hyperkeratosis and pitting are responsive to topical fluorouracil, but not onycholysis.
4. 8% clobetasol nail lacquer is effective for onycholysis, pitting, and oil-drops.
5. Relapses are common and therapies may need to be maintained or repeated.
FURTHER READING
Baran R. A nail psoriasis severity index. Br J Dermatol 2004; 150: 568–9.
De Berker D. Management of nail psoriasis. Clin Exp Dermatol 2000; 25: 357–62.
Fernández-Guarino M, Harto A, Sánchez-Ronco M, et al. Pulsed dye laser vs. photodynamic therapy in the
treatment of refractory nail psoriasis: a comparative pilot study. J Eur Acad Dermatol Venereol 2009; 23:
891–5.
Luger TA, Barker J, Lambert J, et al. Sustained improvement in joint pain and nail symptoms with etanercept
therapy in patients with moderate-to-severe psoriasis. J Eur Acad Dermatol Venereol 2009; 23: 896–904.
Oram Y, Karincaoğlu Y, Koyuncu E, et al. Pulsed dye laser in the treatment of nail psoriasis. Dermatol Surg
2010; 36: 377–81.
Ortonne JP, Baran R. Development and validation of nail psoriasis quality of life scale (NPQ10). JEADV 2010;
24: 22–7.
16 NAIL THERAPIES
Parrish CA, Sobera JO, Robbins CM, et al. Alefacept in the treatment of psoriatic nail disease: a proof of
concept study. J Drugs Dermatol 2006; 5: 339–40.
Rich P, Scher R. Nail Psoriasis Severity Index: a useful tool for evaluation of nail psoriasis. J Am Acad Derma-
tol 2003; 49: 206–12.
Rigopoulos D, Gregoriou S, Lazaridou E, et al. Treatment of nail psoriasis with adalimumab: an open label
unblinded study. J Eur Acad Dermatol Venereol 2010; 24: 530–4.
Rigopoulos D, Gregoriou S, Makris M, et al. Efficacy of Ustekinumab in nail psoriasis and improvement in
nail-associated quality of life in a population treated with ustekinumab for cutaneous psoriasis: an Open
Prospective Unblinded Study. Dermatology 2011. [Epub ahead of print].
Rigopoulos D, Gregoriou S, Stratigos A, et al. Evaluation of the efficacy and safety of infliximab on psoriatic
nails: an unblinded, nonrandomized, open-label study. Br J Dermatol 2008; 159: 453–6.
4A Onychomycosis
A revised new classiftication has been proposed in order to modify the basic model and to include
subsequent changes such as the following subtypes of fungal nail plate invasion (Fig. 4A.1). The
purpose of the revised classification is to provide a framework to assist selection of treatment,
estimate prognosis, and evaluate new diagnostic methods.
1. Distal and lateral subungual onychomycosis (DLSO)

This may be associated with four major clinical features whose contribution may vary with indi-
vidual cases.
1.1 Subungual hyperkeratosis (Fig. 4A.2).
1.2 Onycholysis (Fig. 4A.3).
1.3 Paronychia (Fig. 4A.4).
1.4 Chromonychia particularly melanonychia (Fig. 4A.5).
2. Proximal subungual onychomycosis (PSO)
2.1 With paronychia
2.1.1 So-called Candida paronychia (Fig. 4A.6). Either as a commensal or from the
colonization of a previous paronychia.
2.1.2 True Candida paronychia (very rare), usually observed in Chronic mucocutane-
ous candidosis (CMCC) or HIV-positive subjects.
2.1.3 Nondermatophyte mold paronychia, sometimes associated with leukonychia (e.g.,
Fusarium) (Fig. 4A.7).
2.1.4 Dermatophyte infection (exceptional)
2.2 Without paronychia
We call this type PSO. There are three variants of dermatophytic infection:
2.2.1 Classical PSO (Fig. 4A.8) consists of white subungual patches appearing from
beneath the Proximal nail fold (PNF).
2.2.2 Proximal transverse subungual onychomycosis (PTSO) presents as a PSO with
atypical patterns: striate leuconychia as isolated or multiple (Fig. 4A.9). Transverse
subungual white strips, separated by areas of nail which are both clinically and
histologically normal, affecting the same digit. Proximal to distal longitudinal leuk-
onychia affecting a single digit is exceptional.
2.2.3 Acute PSO: A rapidly developing form of PSO is recorded in patients with human
immunodeficiency virus, who usually have a CD4+ cell count of less than 450
cells/mm3. This acute type of nail invasion involves several digits simultaneously
(Fig. 4A.10).
2.2.4 Candida PSO has been reported in chronic mucocutaneous candidiasis (CMC).
2.2.5 Another combination pattern is seen in AIDS patients where PSO and SO
may develop at the same time and spread rapidly to involve the nail plate
(see 3.6.2).
3. Superficial onychomycosis (SO)
3.1 Classical SO type restricted to the visible NP (Fig. 4A.11) (There is a black variant).
3.2 SO from under PNF (Fig. 4A.12)
3.3 Acute SO (Fig. 4A.13)
3.4 Superficial white transverse onychomycosis (STO) (Fig. 4A.14)
3.5 SO with deep invasion (Fig. 4A.15)
18 NAIL THERAPIES
3.6 Mixed forms with 3 variants:

3.6.1 SO associated with DLSO
3.6.2 SO associated with PSO
3.6.3 SO associated with histologically restricted involvement of the ventral aspect of
the NP (bipolar type).
4. Endonyx onychomycosis (due to Trichophyton soudanense but this fungus also causes other
forms of onychomycosis) (Fig. 4A.16).
5. Total dystrophic onychomycosis (TDO)
5.1 Secondary TDO to other forms (Fig. 4A.17)
5.2 Primary TDO (CMC) (Fig. 4A.18).
SO
PSO
EO
DLSO
Healthcare
Figure 4A.1 Different means of nail penetration according to Hay–Baran’s revised classification of onychomycosis
(2011). Abbreviations: CMC, chronic mucocutaneous candidiasis; DLSO, distal and lateral subungual onychomyco-
sis; EO, endonyx onychomycosis; PWSO, proximal white subungual onychomycosis; PWTSO, proximal white trans-
verse subungual onychomycosis; SWO, superficial white onychomycosis; TDO, total dystrophic onychomycosis.
© Robert Baran, Dimitris Rigopoulos, and Informa Healthcare
Figure 4A.2 Subungual hyperkeratosis.

ONYCHOMYCOSIS
© Robert Baran, Dimitris Rigopoulos, and Informa © Robert Baran, Dimitris Rigopoulos, and Informa Health-
Healthcare care
Figure 4A.4 Paronychia.

Figure 4A.3 Onycholysis.
Figure 4A.5 Fungal melanonychia.

19
20 NAIL THERAPIES
Figure 4A.6 So-called candida paronychia.

Figure 4A.7 Nondermatophyte mold paronychia with leukonychia.
Remember
Diagnosis of onychomycosis always requires laboratory confirmation
DIAGNOSIS
The clinical pattern seen in fungal nail disease only provides a clue to the type of infection.
Although certain types of nail involvement are characteristic of certain species, usually the clinical
appearance caused by one species of fungus is indistinguishable from that caused by another.
Therefore the diagnosis of onychomycosis always requires laboratory confirmation. However false
ONYCHOMYCOSIS 21
Figure 4A.8 Classical PSO. Source: Courtesy of M. Feuilhade.

Figure 4A.9 PSO with striate leukonychia.
negative, mycological results are quite common, especially when samples are taken from a distal
nail clipping. Consequently, negative mycology does not completely rule out onychomycosis, since
direct microscopy may be negative in up to 20% of cases and cultures may fail to isolate a fungus
in up to 30% of cases. Topical antifungals may increase the risk of a false-negative culture. But
when the clinical features strongly suggest onychomycosis, it is advisable to perform microscopic
examination and culture more than once if initial investigations are negative.
22
© Robert Baran, Dimitris Rigopoulos, and

Informa Healthcare
Figure 4A.10 Acute PSO.
Figure 4A.11 Classical SO.
Figure 4A.12 SO emerging from under PNF.

NAIL THERAPIES
ONYCHOMYCOSIS 23
Figure 4A.13 Acute SO. Source: Courtesy of C Gianni (Italy).

Figure 4A.14 Superficial white transverse onychomycosis.

Figure 4A.15 SO with deep invasion.

24 NAIL THERAPIES
Figure 4A.16 Endonyx onychomycosis.

Figure 4A.17 TDO secondary to other forms.
In fact, PAS staining is the single method with the highest sensitivity, exceeding that of the gold
standard (microscopy and fungal culture) and has been considered as the “new gold standard.”
HOW TO COLLECT THE SAMPLES

The site of specimen sampling depends on the clinical type of onychomycosis. Separate samples
should be obtained from fingernails and toenails. Unfortunately, isolation of a fungus from a nail
sample does not necessarily indicate onychomycosis.
The clinician should always bear in mind that some fungi, such as yeasts and most nonderma-
tophytic molds, are nail saprophytes rather than pathogens.
ONYCHOMYCOSIS 25
© Robert Baran, Dimitris Rigopoulos,

and Informa Healthcare
Figure 4A.18 Primary TDO (CMC).
1000
Therapy Follow-up
Mean ITR conc. (NG/G)
100
Toenail conc.
Fingernail conc.
10
1
0 1 2 3 4 5 6 7 8 9 Months
Itraconazole content in the distal nailplate

(100 mg o.d. for 3 months)
Figure 4A.19 Terbinafine or itraconazole content.
Since toenail onychomycosis is frequently associated with tinea pedis, it may be best to collect
samples for mycology from the soles. The same rule applies to the palms of patients with fingernail
onychomycosis.
TREATMENT
Systemic Treatment
Griseofulvin is no longer used and Ketoconazole has produced severe cases of hepatotoxicity.
Itraconazole is given as a 200 mg dose once daily for 3 months or as a pulse therapy with inter-
mittent dosing of 200 mg twice daily for 1 week each month over a period of 2 months for fingernail
and 3 months for toenail fungal infections. This drug is effective on dermatophytes, yeast, and
sometimes on nondermatophyte molds.
Fluconazole, another azole antifungal drug of the triazol group, is mainly used (100 mg daily)
in the management of systemic disease and superficial candidiasis, especially in patients with
AIDS and in other immunosuppressed subjects as single doses (150 or 300 mg per week for
26 NAIL THERAPIES
Remember
The long-term accumulation of terbinafine and the antifungal azoles enables a relatively short period of
treatment for eradication of fungal nail infections. We use, according to N. Zaias, terbinafine 250 mg daily one
week a month for as long as needed.
Due to the persistence of the drug for 3–6 months after the end of therapy, prolongation of terbinafine
treatment duration from 3 to 6 months does not improve mycological and clinical cure rates (Fig. 4A.19).
6–12 months). Fluconazole may provide good control of chronic mucocutaneous candidiasis,
particularly in nail involvement.
Terbinafine is a member of the allylamine antifungal drug group. Terbinafine is active against a
wide range of pathogenic fungi in vitro, but in vivo is only useful for dermatophytosis 250 mg daily.
Significant recovery rates of toenail infections at 3 months and fingernails at 6 weeks.
Failure Rate
Despite significant improvements with the “new” drugs, at least 20% of patients with onychomyco-
sis still fail on antifungal therapy.
Patients Likely to Fail Therapy

During an adequate nail sampling procedure, where an affected segment of the nail is removed,
some clues may anticipate the risk of failure and indicate the best way to eradicate the pathogen:
trimming, debridement, nail bed curettage, nail abrasion, and even partial nail avulsion should be
considered as an adjunct to antifungal agents.
Patients with Decrease of Linear Nail Growth

The growth rate in fungally infected nails may be decreased during active infection, especially
when more than 50% is involved. The mechanism is not entirely clear, but involvement of both the
matrix and nail bed can contribute to slow growth.
Patients with Interruption in the Transport of the Drug

● Onycholysis (extensive)
● Lateral nail disease presenting as lateral onycholysis
● Overthickened nail plate (>2 mm)
● Dermatophytoma as spikes or massive keratin
● Patients with a history of prior infection, men and older patients less likely to reach clinical
cure
● Positive culture at 24 weeks affected mycological and clinical cure at 72 weeks negatively.
STRATEGIES TO IMPROVE EFFICACY

Supplemental Therapy
There is a window of opportunity for booster therapy until 6–9 months from start of treatment.
Intermittent Treatment
Terbinafine may be an effective treatment for DLSO when 250 mg/day are given 7 days a month
for 3 months.
Combination Therapy
The nail is sandwiched between the topical and systemic routes of drug penetration.
However, many of the conventional formulations of the antifungal agents (powders, solutions,
creams, and ointments) are not specifically adapted for use on the nails:
● They do not promote diffusion through the nail barrier.

● They are not adapted to take into account the length of treatment required to obtain a healthy nail.
● They do not remain in contact with the site of application for long periods (they are readily
removed by rubbing, wiping, and washing).
● They are not designed for sustained release of the drug.
ONYCHOMYCOSIS 27
TRANSUNGUAL DRUG DELIVERY SYSTEMS (TUDDS)

Penetration of the drug tioconazole through the plate is excellent, but is not matched by clinical
efficacy.
A further step forward has been achieved with the development of new vehicles in the form of
colorless nail lacquers known from cosmetic formulations. Two compounds, amorolfine and
ciclopirox, are currently used in a lacquer base in several countries. These formulations fulfill two
essential prerequisites. First, the active ingredient is in contact with the nail for long periods.
Second, the concentration of the active ingredient in the remaining film reservoir from which the
active agent is gradually released increases through evaporation of the solvents thus providing the
high concentration gradient essential for maximal penetration.
Eight percent ciclopirox is a hydroxyl-pyridone derivative incorporated into a clear nail lacquer.
In contrast to most antifungals, it does not interfere with sterol biosynthesis. It acts as a chelating
agent and primarily affects iron-dependent mitochondrial enzymes.
Ciclopirox exhibits a broad spectrum of activity against several dermatophytes, yeasts, and
nondermatophyte molds, including Trichophyton rubrum, Epidermophyton spp, Candida spp, and
Scopulariopsis brevicaulis. In vitro data suggest that ciclopirox is a fungicidal against a series of
fungi.
The efficacy of ciclopirox nail lacquer applied once daily for 48 weeks was assessed in the treat-
ment of mild to moderate dermatophyte toenail onychomycosis.
Eight percent ciclopirox water-soluble nail lacquer contains hydroxypropyl chitosan, horsetail
extract, and methylsulfonyl methane. This variant of ciclopirox does not necessitate nail abrasion
nor does nail enamel remover increase the linear nail growth.
Five percent amorolfine belongs to a new family of antifungal drugs, the morpholines. Amorol-
fine inhibits two steps in the pathway of ergosterol biosynthesis, namely the Δ14-reductase and
the Δ7,8-isomerase, which play an important role in regulating membrane fluidity. This leads to the
accumulation of abnormal sterols and inhibits fungal growth.
Amorolfine possesses a broad antimycotic spectrum against fungi pathogenic to plants and
humans. Amorolfine is fungicidal against yeasts, Candida albicans, Cryptococcus neofromans,
dimorphic and some dematiaceous fungi, but appears to be less active against Aspergillus, Fusar-
ium, and Mucor.
MECHANICAL INTERVENTIONS AND ROLE OF NAIL SURGERY IN THE TREATMENT OF

ONYCHOMYCOSIS
Surgery can be useful in the treatment of onychomycosis. Nail avulsion is helpful particularly
under occlusion, but only as an adjunct to oral and/or topical antifungal agent. It is the logical way
to best eradicate the pathogen, especially in patients likely to fail. For example in dermatophy-
toma the sequestered area of nail keratin does not permit penetration of the drug. In addition to
dermatophyte nail infection, nail plate avulsion is very helpful in treating onychomycosis caused
by molds.
Total surgical removal has to be discouraged: the distal nail bed may shrink and become dislo-
cated dorsally. In addition, the loss of counterpressure produced by the removal of the nail plate
allows expansion of the distal soft tissue and the distal edge of the regrowing nail then embeds
itself. This can be largely overcome by using partial nail avulsion, which can be performed under
local anesthesia, in a selected group of patients in whom the fungal infection is limited. It permits
the removal of the affected portion of the nail plate in one session, even when the disease has
reached the buried region of the subungual tissue, beneath the proximal nail fold.
In DLSO, partial surgical removal consists in sectioning the lateral or medial segment of the nail
plate. Therefore, enough normal nail is left to counteract the upward forces exerted on the distal
soft tissue when walking and this will prevent the appearance of a distal nail wall.
In Candida onycholysis, a thorough clipping away of as much of the detached nail as pos-
sible facilitates the daily application of antifungal drug until nail growth is achieved. In PSO,
removal of the nonadherent base of the nail plate cut transversely leaves the distal portion of
the nail in place, which decreases discomfort. Recalcitrant Candida paronychia with secondary
nail plate invasion may be treated by surgical excision of a crescent of thickened nail fold. In
any type of onychomycosis treated surgically, the avulsed segment must always include a
margin of normal nail.
28 NAIL THERAPIES
Good results have been obtained recently by combining surgical techniques with either intermit-
tent or short duration use of new oral antifungal drugs.
In patients at risk (immunosuppressive conditions, immunosuppressive therapy, peripheral
vascular disease), chemical avulsion is a painless method that has superseded partial surgical
avulsion. It may be repeated as often as necessary. Forty percent urea ointment appears to focus
its action on the bond between the nail keratin and the diseased nail bed; it spares the normal
nail tissue.
MANAGEMENT OF VARIOUS SUBTYPES

In primary onycholysis of big toenails, associated with dermatophyte invasion, measures should
be taken to relieve the effects of pressure and trauma such as the provision of fitted shoes, pad-
ding, and toe shields. Topical treatment with antifungal therapy and repeated trimming of the non-
adherent portion of the nails should be started.
Superficial white onychomycosis caused by dermatophytes should be abraded (sandpapered)
after confirming the diagnosis. When the culture is negative, the shaving technique of the dor-
sum of the nail or a 3-mm punch biopsy restricted to the plate is taken for histopathology. When
superficial white onychomycosis (SWO) emerges from beneath the cuticle, combination therapy
is mandatory.
NONDERMATOPHYTE MOLD ONYCHOMYCOSIS

Assuming that the pathogenic role of mold fungi isolated from the affected nails has been con-
firmed, three patterns of infection should be considered.
1. SWO caused by Acremonium, Aspergillus, or Fusarium spp. involving the visible portion of the
nail plate or emerging from beneath the proximal nail fold.
2. DLSO caused by Scopulariopsis brevicaulis, Pyrenochaeta unguium-hominis, Scytalidium
dimidiatum, and hyalinum.
3. Proximal subungual onychomycosis due to Fusarium spp.
Mechanical therapy is indispensable as partial or even total nail avulsion. Any of the three main
systemic antifungals may be tried in combination with Whitfield ointment and then followed by nail
lacquer applications.
However, good response on Aspergillus spp has been observed with terbinafine 500 mg daily
one week monthly for 3 months.
CANDIDA ONYCHOMYCOSIS
Candida onychomycosis can be treated with oral itraconazole, fluconazole, or chemical removal
with urea followed by local antifungal treatment. If these methods are unsuccessful, partial or
complete avulsion and chemotherapy should also be used.
In CMCC, itraconazole and fluconazole are effective.
INGROWING TOENAILS AS AN ADVERSE CONSEQUENCE OF EFFECTIVE TREATMENT

OF ONYCHOMYCOSIS
Clinicians should be aware that onychocryptosis may be a potential complication of effective oral
treatment for onychomycosis and the reasons for this is that clinically the therapeutic response is
a proximal clearing of the nail plate with resolution of the distal subungual debris. As the healthy
nail plate advances, it may adhere to the nail bed, cutting into the lateral nail folds. This could
explain the emergence of onychocryptosis.
Sculptured artificial nails or gels are applied on the remaining portion of the plate. When avulsion
is total, the preformed artificial plastic nail is applied on the whole nail bed and fixed onto it with a
micropore as long as needed. Both types of false nails prevent the heaping up of the distal tissue.
Finally, long-term intermittent therapy might prevent the re-establishment of tinea pedis and limit
the risk of nail reinfection. Periodic use of transungual antifungal drug delivery systems, which are
retained in nail keratin after discontinuation of therapy, appears to be a logical and safe method for
preventing recurrence.
ONYCHOMYCOSIS 29
Remember
1. Keep nails clean and short.
2. Avoid going barefoot in public places.
3. Use an antifungal foot powder daily.
4. Wear only your own shoes.
5. Old, worn footwear should be discarded.
6. Wear comfortable, wide, properly fitting shoes.
7. Wear cotton rather than synthetic socks.
8. Check family members for fungal infections and treat as necessary.
9. Prevent tinea pedis.
Confirmation in the efficacy of amorolfine nail lacquer twice a month for the prophylaxis of ony-
chomycosis over 3 years has been published.
Interestingly, ciclopirox water-soluble nail lacquer shows a residue ciclopirox amount of 8.8 µg/mg
in the nails, which is three orders of magnitude larger than the MICs for dermatophytes and yeasts.
This allows one to conclude that the active ingredient remains in the nails for at least 4 weeks.
FURTHER READING
Baran R, Hay R, Haneke H, Tosti A. Onychomycosis. 2nd edn. Boca Raton. 2006; 77–129.
Baran R, Hay R, Haneke H, Tosti A. Onychomycosis. 2nd edn. Boca Raton. 2006; 119.
Dominguez-Cherit J, Teixeira F, Arenas R. Combined surgical and systemic treatment of onychomycosis. Br J
Dermatol 1999; 140: 778–80.
Epstein E. How often does oral treatment of toenail onychomycosis produce a disease-free nail? An analysis
of published data. Arch Dermatol 1998; 134: 1551–4.
Gianni C, Romano C. Clinical and histological aspects of toenail onychomycosis caused by Aspergillus spp:
34 cases treated with weekly intermittent terbinafine. Dermatology 2004; 209: 104–10.
Goodfield MJD, Evans EGV. Combined treatment with surgery and short duration oral antifungal therapy in
patients with limited dermatophyte toenail infection. J Dermatol Treat 2000; 11: 259–62.
Gupta AK, Baran R, Summerbell R. Onychomycosis: strategies to improve efficacy and reduce recurrence.
J Europ Acad Dermatol Venereol 2002; 16: 579–86.
Gupta AK, Fleckman P, Baran R. Ciclopirox nail lacquer topical solution 8% in the treatment of toenail onycho-
mycosis. J Am Acad Dermatol 2000; 43: S70–80.
Hay R, Baran R. Onychomycosis: a proposed revision of the clinical classification. J Am Acad Dermatol 2011;
65: 1219–27.
Marty JP. Amorolfine nail lacquer: a novel formulation. J Eur Acad Dermatol Venereol 1995; 4(Suppl): S17–22.
Scher RK. Prevention, relapse and cure. Topical News Onychomycosis 2001; 3: 1–3.
Sigurgeirsson B, Olafsson JH, Steinsson JT, et al. Efficacy of amorolfine nail lacquer for the prophylaxis of
onychomycosis over 3 years. JEADV 2009. [Epub ahead of print].
Sigurgeirsson B, Paul C, Curran D, Evans EVG. Prognostic factors of mycological cure following treatment of
onychomycosis with oral antifungal agents. Br J Dermatol 2002; 147: 1241–3.
Zaias N. Onychomycosis. Arch Dermatol 1972; 105: 263–74.
4B Future therapies for onychomycosis
Aditya K. Gupta, Fiona Simpson, and Chris Drummond-Main
INTRODUCTION
The effective treatment of onychomycosis presents several significant challenges for practitioners.
The first challenge is effective therapy, as the currently available antifungal drugs result in low to
moderate efficacy. The second challenge is drug administration periods. In the status quo, onycho-
mycosis therapy is delivered daily or in pulse formats for several months. This requires a high level
of patient compliance in order to achieve a fungicidal effect. The final challenge is adverse effects
associated with endogenous off-target binding and drug interactions. Many patients with onycho-
mycosis have predisposing conditions such as diabetes, peripheral vascular disease or immuno-
supression that require polypharmacy. This can make it difficult to prescribe systemic therapy for
onychomycosis to these individuals.
PHARMACOTHERAPY
Topical Terbinafine Reformulations
Systemic terbinafine administered at 250 mg/day is currently the gold standard in onychomycosis
therapy. Due to associated adverse events and drug interactions, systemic terbinafine may not be
suitable for individuals undertaking polypharmacy for many of the conditions that predispose
patients to onychomycosis. If sufficient transungual penetrance can be achieved, topical terbin-
afine may allow effective treatment of the nail apparatus without systemic drug uptake which will
mitigate interaction-associated issues.
Terbinafine Nail Lacquer

Terbinafine nail lacquer is 10% terbinafine formulated with a permeation enhancer to increase
drug uptake in the nail plate. It is most effective when applied daily for 48 weeks.
TDT-067
TDT-067 is terbinafine enclosed in a Transfersome® particle, which is a lipid aggregate with a
hydrophilic exterior designed to increase drug transport across the nail plate. TDT-067 is adminis-
tered twice daily for 12 weeks. This treatment showed a high initial mycological cure rate which fell
off as the follow-up period reached 48 weeks.
NB-002
NB-002 is a nanoemulsion of terbinafine. It shows comparable in vitro antifungal efficacy to
ciclopirox, terbinafine, itraconazole, naftifine, and griseofulvin. NB-002 has completed phase II
clinical trials, where it showed a negative mycological culture in 25–31.7% of participants.
Azoles
Azole antifungals are the largest class of drugs used in the systemic treatment of onychomycosis.
This class currently includes fluconazole, ketoconazole, and itraconazole. Azole drugs show a
moderate level of efficacy in the treatment of onychomycosis, but they are associated with adverse
events and drug interactions due to their interactions with cytochrome P450 enzymes. The inves-
tigations into new azole molecules with a higher efficacy and fewer adverse events have resulted
in a number of new molecular entities intended for systemic and topical administration.
Topical Azoles
Bifonazole
Bifonazole is a topical triazole molecule that is currently available as a 1% cream formulation in
Europe for the topical treatment of onychomycosis. It has seen renewed interest in North America
due to its fungistatic efficacy against T. rubrum. Bifonazole is currently in phase III clinical trials.
FUTURE THERAPIES FOR ONYCHOMYCOSIS 31
Efinaconazole
Efinaconazole (IDP-108) is a new triazole molecular entity that is currently in phase II clinical trials.
There is currently no published data available on its in vitro or in vivo efficacy.
Luliconazole
Luliconazole is a topical triazole that is available as a 1% cream or solution in Japan. Luliconazole
is effective against T. rubrum, T. mentagrophytes, and E. floccosum in vitro. It is currently undergo-
ing Phase II/III clinical trials.
Systemic Azoles
Albaconazole
Albaconazole is an investigational triazole that is effective against a broad spectrum of dermato-
phyte and yeast species. It has completed phase II clinical trials for the treatment of onychomyco-
sis, but these results remain unpublished.
Posaconazole
Posaconazole has recently completed a phase II multicenter, double blind clinical trial for the treat-
ment of onychomycosis. The endpoints were negative culture (MCR) and complete cure (CCR)
which is a mycological cure with less than 10% nail involvement. This trial has shown that posacon-
azole administered at 400 mg/day or 200 mg/day for 24 weeks has a comparable efficacy to terbi-
nafine administered at 250 mg/day for 12 weeks. The percentage of participants who achieved a
negative culture was 78.8% for 400 mg/day posaconazole, 70.3% for 200 mg/day posaconazole
and 71.4% for 250 mg/day terbinafine. The complete cure rate was 45.5%, 54.1%, and 37% for
those three treatment arms, respectively. The most common adverse events reported were diar-
rhea, nausea, and fatigue.
Pramiconazole
Pramiconazole is an experimental triazole drug that is effective against Trichophyton spp., Micros-
porum spp., and Candida spp. Pramiconazole is currently in Phase II clinical trials.
Ravuconazole
Ravuconazole is a triazole antifungal drug that has undergone Phase II clinical trials. The most
effective dose regimen was 200 mg/day for 12 weeks, which resulted in 56% of participants
achieving a negative mycological culture and 46% of patients achieving a complete cure with less
than 10% nail involvement.
Voriconazole
Voriconazole is a triazole antifungal that has recently been approved for the treatment of systemic
fungal infections including candidemia and aspergillosis. It has a broad spectrum on antifungal
activity in vitro, but it has not been assayed for the treatment of onychomycosis in large scale trials.
Benzoxaboroles
Benzoxaboroles are a new class of antifungal agents based on boron-containing molecules. They
inhibit protein synthesis by inhibiting the LeuRS tRNA synthetase. This mechanism of action is
unique as most antifungals target cell wall synthesis pathways.
Tavaborole
Tavaborole is the first benzoxaborole compound to undergo clinical trials for the treatment of ony-
chomycosis. Tavaborole penetrates the lower ventral and intermediate layers of the nail plate 72
hours after application with a greater drug load than ciclopirox. In clinical trials, 5% and 7.5%
tavaborole is being administered daily for 6 months. At 60 days of treatment, 97% and 94% of
patients had negative mycological cultures for 5% and 7.5% respectively.
AN-2718
AN-2718 is a compound that is structurally related to tavaborole. AN-2718 has shown a high
level of nail penetrance, and initial data have suggested that it may be more effective for the
32 NAIL THERAPIES
treatment of T. rubrum and T. mentagrophytes than tavaborole. AN-2718 has completed Phase I
clinical trials, and will enter phase II clinical trials once tavaborole has completed Phase III
clinical trials.
Topical Polymer Barriers

A topical polymer barrier for the nail plate has been developed. This drug-free formulation coats
the nail plate occluding water and external matter from infiltrating the nail plate structure. The film
is applied 5 days a week, removed on the 6th, and restarted the following week. After 6 months,
63% of trial participants had negative mycological cultures.
DEVICE-BASED THERAPIES
Device-based therapies are the most rapidly expanding area of onychomycosis therapy. Devices
can be used to enhance drug delivery, activate topically applied drugs or photothermally kill fungi.
Device-based therapy has a number of advantages over traditional onychomycosis therapy
because they are procedures that are primarily conducted in the clinic by trained professionals,
reducing the need for patient compliance. Any drugs associated with device-based therapies are
topical, which reduces systemic interactions.
Photodynamic Therapy
Photodynamic therapy (PDT) uses visible spectrum light to activate a topically applied photosen-
sitizing agent that generates reactive oxygen species that kill fungal cells. PDT for onychomycosis
has been assayed using the commercially available photosensitizers 5-aminolevulinic acid (ALA)
and methylaminolevulate (MAL). ALA and MAL were developed for the treatment of dermal lesions
including actinic keratoses and nonmelanoma skin cancer, but they can also be used off label for
the treatment of onychomycosis. Practitioners who have published case studies and clinical trials
using ALA and MAL have used pre-treatment of the nail plate with urea in order to permeabilize
the nail plate to aid in photosensitizer uptake. The ALA or MAL has been applied for 3–5 hours and
then treated with a red light device, usually at 630 nm or a spectrum from 570–670 nm. Case stud-
ies have reported successful treatment of both dermatophyte and nondermatophyte onychomyco-
sis, but the results from the single clinical trial were poor with only 43% of patients achieving
negative culture at 6 months. An example of patient improvement is shown in Figure 4B.20.
Iontophoresis
Iontophoresis devices use electric current to increase the uptake of terbinafine into the nail plate.
Topical terbinafine in a gel or patch formulation is applied to the nail plate and electric current is
applied in order to enhance terbinafine transport into the nail plate. The nail plate acts as a reser-
voir, releasing terbinafine into the underlying tissue over time, in order to treat the full infection.
There are currently two iontophoresis devices in development. The first is a patch device powered
by printed batteries that is applied overnight. Patients treated with this device showed an 84%
mycological cure rate (negative culture) at 12-week follow-up, whereas patients treated with the
terbinafine patch formulation alone only showed a 48% mycological cure rate. The second device
uses the application of terbinafine gel and has been assayed using an ex vivo model. This model
showed increased uptake of terbinafine with iontophoresis over passive accumulation.
Laser Systems
Laser systems are the most rapidly expanding therapeutic area for the treatment of onychomycosis.
There are currently a variety of laser systems that are available for the treatment of onychomycosis.
There are a number of variables that affect the delivery of laser energy to the fungus including:
wavelength, pulse format, spot size, and energy fluence (Table 4B.1). The wavelength of the laser
determines the target and the penetrance of the laser energy into the nail plate. The pulse format
includes the length of each laser pulse (ms–ns) and the repetition rate (Hz). The shorter the laser
pulse, the higher the maximum energy of the pulse. These variables will affect the number of pulses
required to achieve a successful photothermal effect. The spot size affects the ease of treating the
nail plate: a larger spot size will facilitate better coverage of the nail plate. The energy fluence is a
measure of the laser energy delivered by area; in many cases longer pulse durations deliver higher
energy fluences, despite having a lower maximum pulse energy.
Nd:YAG Lasers
Commercial Nd:YAG lasers have been approved to treat onychomycosis at 1064 nm. Some stud-
ies are also examining the use of 532 nm and 1320 nm wavelengths. Nd:YAG 1064 nm lasers
come in three pulse durations; millisecond long pulse lasers, microsecond short pulse lasers, and
nanosecond Q-switched lasers. A study conducted using a Fotona Dynamis long pulse laser sys-
tem resulted in 93.5% of patients achieving completely clear nail plates and 100% of participants
Before After
Figure 4B.20 Clinical example of photodynamic therapy with 20% ALA. The treatment schedule included three
treatment sessions at 2-week intervals. Patients were pre-treated with 20% urea under occlusion for 10 consecu-
tive nights. Prior to irradiation, 20% ALA was applied for 3 hours under occlusion. The lesion was irradiated with
570–670 nm light with an energy fluence of 40 J/cm2. The after image was taken at 18-month follow-up following
treatment. Source: Courtesy of Dr. Sotiriou.
Table 4B.1 Commercial Laser Systems

Energy
Wavelength Pulse Repetition Spot size fluence International
Laser system (nm) duration rate (Hz) (mm) (J/cm2) approvals
Dynamis, Fotona, Inc. 1064 35 ms 1 4 35–40 EU
PinPointe FootLaser, 1064 450 µs 1 2.5 25.5 US, EU,
Nuvolase, Inc. Canada,
Australia
GenesisPlus, 1064 0.1–1 ms Up to 200 1.5, 5 5–40 US, EU,
Cutera, Inc. Canada
VARIA, CoolTouch, Inc. 1064 600 µs 5–100 2–10 - US, EU
CT3 Plus Zoom, 1320 450 µs - 2–10 - EU
CoolTouch, Inc.
JOULE ClearSense, 1064 0.3–200 ms Up to 15 Up to 6 <200 US, EU
Sciton, Inc.
Q-Clear, Light Age, Inc. 1064 3–10 ns 1–5 2.5–6 4–12 US, EU
Noveon, Nomir, Inc. 870, 930 - - - 150–190 EU
V-Raser, ConBio, Inc. 980 - - - -
34 NAIL THERAPIES
having a negative mycological culture at a 12–18 month follow-up after four laser treatments.
There have been a number of small open-label studies conducted using short-pulse laser systems
including the Nuvolase PinPointe FootLaser (Fig. 4B.21), the Cutera GenesisPlus (Fig. 4B.22),
and the Sciton JOULE ClearSense (Fig. 4B.23) laser systems. These studies have conducted
follow-up visits between 6 and 9 months where they demonstrate an increase in clear nail growth.
Before After
Figure 4B.21 Typical response to a single treatment using the PinPointe FootLaser. Patients were treated with two
consecutive passes of the laser with a 250 µs pulse duration, 25.5 J/cm2 energy fluence, and a 1 Hz repetition rate.
The after images were taken at 6-month follow-up after treatment. Source: Courtesy of Nuvolase, Inc.
Before After
Figure 4B.22 Typical response to a single treatment using the Cutera GenesisPlus. The after images were taken at
6 (top) and 9 (bottom) months’ follow-up after treatment, respectively. Source: Courtesy of Michael A. Uro, D.P.M.
(top), David L. Weiss, D.P.M. (bottom) and Cutera, Inc.
Before After
Figure 4B.23 Typical response to a single treatment using the Sciton JOULE Clear Sense. Patients were treated with a
300 µs pulse duration, 12 J/cm2 energy fluence and a 6 Hz repetition rate. The after images were taken at 6-month follow-
up after treatment. Source: Courtesy of Maria Quintano, RN (top), Mary Beth Mudd, MD (bottom), and Sciton, Inc.
An initial clinical trial was also conducted with a Q-switched laser. The Light Age Q-Clear laser
system resulted in an increase in clear nail in 95% of participants with an average clearance of the
affected area of 56%.
Diode Lasers
Diode lasers have not yet been approved to treat onychomycosis in North America; however, two
diode lasers are being investigated for the treatment of onychomycosis. The Noveon laser is a dual
wavelength 870 and 930 nm device, which has been shown to be fungicidal against T. rubrum and
C. albicans in vitro. Clinical trials with this laser resulted in a mycological cure in 30% of partici-
pants and improvements in clear linear nail growth in 85% of participants. There is an additional
clinical trial currently underway for the 980-nm V-Raser.
CONCLUSION
There are a variety of new treatments that are currently in the development pipeline or newly avail-
able for the treatment of onychomycosis. Many of these therapies have shown strong initial results,
but further study is needed to ascertain that these new options have equal or greater efficacy than
current therapy. The new options in pharmacotherapy may help to decrease adverse effects and
broaden the treatment options available for patients. Device-based therapies also have the poten-
tial to reduce adverse effects and the need for long-term patient compliance. These developments
may help to improve the efficacy of onychomycosis treatment in the near future. More research
and published data with the newer therapeutic modalities will help determine the efficacy of these
modalities in the management of dermatophyte and nondermatophyte onychomycosis.
FURTHER READING
Amichai B, Mosckovitz R, Trau H, et al. Iontophoretic terbinafine HCL 1.0% delivery across porcine and
human nails. Mycopathologia 2010; 169: 343–9.
Baran R, Tosti A, Hartmane I, et al. An innovative water-soluble biopolymer improves efficacy of ciclopirox nail
lacquer in the management of onychomycosis. J Eur Acad Dermatol Venerol 2009; 23: 773–81.
36 NAIL THERAPIES
Beutner K, Toledo-Bahena M, Barbosa-Alanis H, et al. Interim Results of a Multi-Center Study to Evaluate the
Safety and Efficacy of Topically Applied AN2690 5.0% and 7.5% Solutions for the Treatment of Onychomy-
cosis of the Great Toenail. [Available from: anacor.com/pdf/ESDR_P565.pdf]. Accessed April 4, 2011.
Capilla J, Ortoneda M, Pastor FJ, Guarro J. In vitro antifungal activities of the new triazole UR-9825 against
clinically important filamentous fungi. Antimicrob Agents Chemother 2001; 45: 2635–7.
Dominicus R, Weidner C, Tate H, Kroon HA. Open-label study of the efficacy and safety of topical treatment
with TDT 067 (terbinafine in Transfersome®) in patients with onychomycosis. BJD 2011. [Epub ahead of
print].
Elewski B, Pollak R, Ashton S, et al. A randomised, placebo- and active-controlled, parallel-group, multicentre,
investigator-blinded study of four treatment regimens of posaconazole in adults with toenail onychomyco-
sis. Br J Dermatol 2010. [Epub ahead of print].
Gupta AK, Leonardi C, Stoltz RR, Pierce PF, Conetta B, and the Ravuconazole onychomycosis group.
A phase I/II randomized, double-blind, placebo-controlled, dose-ranging study evaluating the efficacy,
safety and pharmacokinetics of ravuconazole in the treatment of onychomycosis. JEADV 2005; 19: 437–43.
Harris DM, McDowell BA, Stristower J. Laser treatment for toenail fungus. Proc SPIE 2009; 71610(M): 1–7.
Ijzerman M, Baker J, Flack M and Robinson P. Efficacy of topical nanoemulsion (NB-002) for the treatment of
distal subungual onychomycosis: a randomized, double-blind, vehicle-controlled trial. JAAD 2010; 62:
abstract P2108.
Kozarev J. Summary: clearsteps – laser onychomycosis treatment: assessment of efficacy 12 months after
treatment and beyond. J Laser Health Acad 2011; 2011: S07.
Landsman AS, Robbins AH, Angelini PF, et al. Treatment of mild, moderate, and severe onychomycosis using
870- and 930-nm light exposure. J Am Podiatr Med Assoc 2010; 100: 166–77.
Sotiriou E, Koussidou-Ermonti T, Chaidemenos G, Apalla Z, Ioannides D. Photodynamic therapy for distal and
lateral subungual toenail onychomycosis caused by Trichophyton rubrum: preliminary results of a single-
centre open trial. Acta Derm Venereol 2010; 90: 216–17.
Vanden Bossche H, Ausma J, Bohets H, et al. The novel azole R126638 is a selective inhibitor of ergosterol
synthesis in Candida albicans, Trichophyton spp., and Microsporum canis. Antimicrob Agents Chemother
2004; 48: 3272–8.
Vural E, Winfield HL, Shingleton AW, Horn TD, Shafirstein G. The effects of laser irradiation on Trichophyton
rubrum growth. Lasers Med Sci 2008; 23: 349–53.
5 Lichen planus
Lichen planus (LP) is a relatively common inflammatory skin disease that lasts from months to
years. It usually affects people between the age of 30 up to 70 and is slightly more prevalent in
women than in men. It affects about 1–2% of the general population. The name “lichen” refers to
the lichen plant which grows on rocks or trees, and “planus” means flat. The exact cause of LP is
unknown, but it seems to be triggered by stress, genetics, allergic reactions to medicine, and by
viral infections such as hepatitis C. Sowden et al. (2006) described the case of LP confined to the
nails in a patient with primary biliary cirrhosis.
Lichen planus typically affects the skin, nails, vulva, penis, and mucous membranes including
the mouth (Table 5.1). LP affects one or more nails in 1–15% of the cases. Fingernails are found
to be more commonly affected than toenails; however, both can be affected.
Five types of nail LP have been described as listed below:
1. Typical nail matrix LP (80%)

2. Nail bed LP
3. Trachyonychia
4. Idiopathic atrophy of the nails
5. Bullous-erosive LP
SPECIFIC SIGNS OF LP
Pterygium
Pterygium is due to the inflammation of the nail matrix and remains adherent to the ventral surface
of the nail plate, resulting in a subungual extension of the hyponychium and obliteration of the
distal groove. Pterygium is rather rare (<5%) and it usually affects only one nail. It is not related to
the duration of the disease (Fig. 5.1).
Remember
The first fingernails attacked are usually the most severely affected.
Yellow nail syndrome-like changes may also be a possible sign of nail LP, irrespective of the
limbs involved or the number of digits affected. The cause of the yellow color in LP is unknown, but
it is speculated that it is due to the relatively poor lymphatic circulation in the lower limbs. Nail LP
in children is not rare but probably underestimated (10% of all cases). It mostly affects men. It often
presents with atypical clinical features such as 20-nail dystrophy or idiopathic rough nails (Fig. 5.2).
Skin or mucosal involvement is rarer in children (15%) than in adults with nail LP (25%). Dorsal
pterygium formation is rare in children.
Table 5.1 Nonspecific Signs of Lichen Planus

Nail matrix Nail bed
Thinning of the nail plate Subungual hyperkeratosis
Longitudinal grooving Longitudinal erythronychia
Longitudinal melanonychia Subungual hyperpigmentation
Onychorrhexis Onycholysis
Distal splitting
Ridging of the nail plate
Irregular pitting
Eventually destruction of nail matrix
and anonychia
38 NAIL THERAPIES

Healthcare
Figure 5.1 Pterygium involving two fingernails.

Healthcare
Figure 5.2 Idiopathic rough nails in lichen planus (trachyonychia).

Figure 5.3 Superficial nail dystrophy in lichen planus.

LICHEN PLANUS 39

Healthcare
Figure 5.4 Erosive ulcerated lichen planus.
Nail bed LP is not so common and it is usually associated with nail plate abnormalities like ony-
cholysis and mild subungual hyperkeratosis. In these cases nail bed biopsy confirms the diagnosis
(Fig. 5.3).
Bullous/erosive LP is extremely rare and it is characterized by painful nail erosions (Fig. 5.4). It
usually affects one or two toenails and it may be associated with erosive LP elsewhere. Scarring
formation is usual after treatment.
DIAGNOSIS
Clinical features of LP may be difficult to diagnose. A biopsy of the nail is difficult to perform and is
rarely an imperative. Histopathologically LP is characterized by compact orthokeratosis, wedge-
shaped hypergranulosis, irregular acanthosis, damage of the basal cell layer, and a band-like
inflammatory infiltrate in the upper dermis. Lymphocytes are the predominant cells making up the
infiltrate, along with a few macrophages, eosinophils, and plasma cells. In addition, melanophages
are often found in the upper dermis adjacent to the damaged basal cells. Presence of Civatte bod-
ies (also known as colloid bodies and hyaline bodies), representing degenerated, apoptotic
keratinocytes.
Remember
Mottled erythema of the lunula can be evident, but it is not a specific sign for nail lichen planus.
Differential diagnosis includes nail changes caused by graft-vs-host disease, lichenoid drug
reactions, nail scarring after Stevens–Johnson syndrome, nail matrix trauma, and lupus erythe-
matosus.
TREATMENT
Since the etiology of the disease is unknown, treatment is symptomatic and usually anti-inflammatory.
Ungual LP can range from minor nail dystrophy to anonychia. Therefore, treatment should be
implemented immediately to avoid permanent deformity or total nail loss. This condition is generally
unresponsive to most treatments.
Remember
Do not treat dorsal pterygium, it is not reversible! Do not treat trachyonychia! It cures spontaneously!
40 NAIL THERAPIES
1. Topical steroids applied to the involved sites appear to be effective in some cases. Use with
occlusive dressing seems to have better results.
2. Triamcinolone acetonide 0.5 mg/kg im every 30 days, for 3–6 months and then tapered off, is
the treatment of choice.
3. Intralesional injection of corticosteroids, triamcinolone acetonide 0.5–0.1 mg/nail every 2 months
can also be used, but it is quite a painful therapy.
4. Oral prednisone 0.5 mg/kg for 3 weeks has been successful in some cases.
5. Acitretine as monotherapy or in combination with topical steroids.
6. Mostafa (1989) demonstrated a marked improvement of nail LP with chloroquine phosphate
250 mg twice daily after only 10 weeks, clearance was noted after 30 weeks. However, 10 weeks
after discontinuation, therapy nail lesions recurred.
7. In 2010, Ujiie et al., published five cases of nail LP, treated with Tacrolimus ointment 0.1%,
twice a day, with great improvement after 6 months, with no adverse reactions reported.
8. Alitretinoine, 30 mg once a day, may be useful.
Remember
About 50% of the patients will not be cured, despite any treatment.
A beneficial response following a short course of topically applied 5% 5-FU is anecdotal.

Biotin, 2.5 mg daily in young children and 7.5–10 mg in adults has been advised for 6 months.
Remember
1. Treat before pterygium formation.
2. Children under the age of 12 do not need treatment, unless pterygium has started to appear.
3. Patients who do not respond to systemic steroids will not improve with the addition of either azathioprine or
systemic retinoids.
FURTHER READING
Goettmann S, Zaraa I, Moulonguet I. Nail lichen planus: epidemiological, clinical, pathological, therapeutic
and prognosis study of 67 cases. J Eur Acad Dermatol Venereol 2011.
Gordon KA, Vega JM, Tosti A. Trachyonychia: a comprehensive review. Indian J Dermatol Venereol Leprol
2011; 77: 640–5.
Mostafa WZ. Lichen planus of the nail: treatment with antimalarials. J Am Acad Dermatol 1989; 20(2 pt 1):
289–90.
Piraccini BM, Saccani E, Starace M, et al. Nail lichen planus: response to treatment and long term follow-up.
Eur J Dermatol 2010; 20: 489–96.
Sehgal VN. Twenty nail dystrophy trachyonychia: an overview. J Dermatol 2007; 34: 361–6.
Sowden JM, Cartwright PH, Green JR, et al. Isolated lichen planus of the nails associated with primary biliary
cirrhosis. Br J Dermatol 2006; 121: 659–62.
Tosti A, Piraccini BM, Cambiaghi S, et al. Nail Lichen Planus in children clinical features, response to treat-
ment, and long-term follow-up. Arch Dermatol 2001; 137: 1027–32.
Ujiie H, Shibaki A, Akiyama M, et al. Successful treatment of nail lichen planus with topical tacrolimus. Acta
Derm Venereol 2010; 90: 218–19.
6 Pseudomonas infection
PARONYCHIA
Acute paronychia is caused by the Pseudomonas infection. Clinically it is characterized by
erythema and swelling of the proximal nail fold, in conjunction with pain. In recalcitrant cases dys-
trophy of the nail plate may be observed. On the other hand, chronic paronychia is among the
predisposing factors for Pseudomonas infection, as loss of the cuticle creates a gap between the
proximal nail fold and the nail plate that may advance inoculation and proliferation of bacterial
pathogens.
ONYCHOLYSIS
Onycholysis is a nonspecific sign in Pseudomonas infection. Inflammation causes separation of
the nail plate from the nail fold. On the other hand, onycholysis is commonly observed in chronic
paronychia due to trauma irritants or allergens, thus it may precede Pseudomonas infection.
GREEN CHROMONYCHIA
Remember
At the present time it is no longer believed that Candida spp. or Aspergillus spp. are responsible for the green hue.
The color of green chromonychia (Fig. 6.1) is due to pyocyanin (a virulent factor produced by Pseu-
domonas) pigment staining the nail plate. It may be pine tree green, blue-green, or black-green. It is
considered as an almost specific sign for Pseudomonas infection. This discoloration may involve part
or the entire nail plate. Green transverse striped nails may result from repeated episodes of bacterial
infection of the proximal nail fold, with deposition of organisms and pigment during each episode.
Table 6.1 Nail Signs of Pseudomonas Infection

Paronychia
Onycholysis
Green chromonychia
Fruity odor
Commonly affects 1–2 nails
Healthcare
Figure 6.1 Green nail syndrome.

Another random document with
no related content on Scribd:
INCLUDING BUT NOT LIMITED TO WARRANTIES OF
MERCHANTABILITY OR FITNESS FOR ANY PURPOSE.
1.F.5. Some states do not allow disclaimers of certain implied

warranties or the exclusion or limitation of certain types of damages.
If any disclaimer or limitation set forth in this agreement violates the
law of the state applicable to this agreement, the agreement shall be
interpreted to make the maximum disclaimer or limitation permitted
by the applicable state law. The invalidity or unenforceability of any
provision of this agreement shall not void the remaining provisions.
1.F.6. INDEMNITY - You agree to indemnify and hold the Foundation,

the trademark owner, any agent or employee of the Foundation,
anyone providing copies of Project Gutenberg™ electronic works in
accordance with this agreement, and any volunteers associated with
the production, promotion and distribution of Project Gutenberg™
electronic works, harmless from all liability, costs and expenses,
including legal fees, that arise directly or indirectly from any of the
following which you do or cause to occur: (a) distribution of this or
any Project Gutenberg™ work, (b) alteration, modification, or
additions or deletions to any Project Gutenberg™ work, and (c) any
Defect you cause.
Section 2. Information about the Mission

of Project Gutenberg™
Project Gutenberg™ is synonymous with the free distribution of
electronic works in formats readable by the widest variety of
computers including obsolete, old, middle-aged and new computers.
It exists because of the efforts of hundreds of volunteers and
donations from people in all walks of life.
Volunteers and financial support to provide volunteers with the

assistance they need are critical to reaching Project Gutenberg™’s
goals and ensuring that the Project Gutenberg™ collection will
remain freely available for generations to come. In 2001, the Project
Gutenberg Literary Archive Foundation was created to provide a
secure and permanent future for Project Gutenberg™ and future
generations. To learn more about the Project Gutenberg Literary
Archive Foundation and how your efforts and donations can help,
see Sections 3 and 4 and the Foundation information page at
www.gutenberg.org.
Section 3. Information about the Project

Gutenberg Literary Archive Foundation
The Project Gutenberg Literary Archive Foundation is a non-profit
501(c)(3) educational corporation organized under the laws of the
state of Mississippi and granted tax exempt status by the Internal
Revenue Service. The Foundation’s EIN or federal tax identification
number is 64-6221541. Contributions to the Project Gutenberg
Literary Archive Foundation are tax deductible to the full extent
permitted by U.S. federal laws and your state’s laws.
The Foundation’s business office is located at 809 North 1500 West,

Salt Lake City, UT 84116, (801) 596-1887. Email contact links and up
to date contact information can be found at the Foundation’s website
and official page at www.gutenberg.org/contact
Section 4. Information about Donations to

the Project Gutenberg Literary Archive
Foundation
Project Gutenberg™ depends upon and cannot survive without
widespread public support and donations to carry out its mission of
increasing the number of public domain and licensed works that can
be freely distributed in machine-readable form accessible by the
widest array of equipment including outdated equipment. Many
small donations ($1 to $5,000) are particularly important to
maintaining tax exempt status with the IRS.
The Foundation is committed to complying with the laws regulating

charities and charitable donations in all 50 states of the United
States. Compliance requirements are not uniform and it takes a
considerable effort, much paperwork and many fees to meet and
keep up with these requirements. We do not solicit donations in
locations where we have not received written confirmation of
compliance. To SEND DONATIONS or determine the status of
compliance for any particular state visit www.gutenberg.org/donate.
While we cannot and do not solicit contributions from states where

we have not met the solicitation requirements, we know of no
prohibition against accepting unsolicited donations from donors in
such states who approach us with offers to donate.
International donations are gratefully accepted, but we cannot make

any statements concerning tax treatment of donations received from
outside the United States. U.S. laws alone swamp our small staff.
Please check the Project Gutenberg web pages for current donation
methods and addresses. Donations are accepted in a number of
other ways including checks, online payments and credit card
donations. To donate, please visit: www.gutenberg.org/donate.
Section 5. General Information About

Project Gutenberg™ electronic works
Professor Michael S. Hart was the originator of the Project
Gutenberg™ concept of a library of electronic works that could be
freely shared with anyone. For forty years, he produced and
distributed Project Gutenberg™ eBooks with only a loose network of
volunteer support.
Project Gutenberg™ eBooks are often created from several printed
editions, all of which are confirmed as not protected by copyright in
the U.S. unless a copyright notice is included. Thus, we do not
necessarily keep eBooks in compliance with any particular paper
edition.
Most people start at our website which has the main PG search
facility: www.gutenberg.org.
This website includes information about Project Gutenberg™,

including how to make donations to the Project Gutenberg Literary
Archive Foundation, how to help produce our new eBooks, and how
to subscribe to our email newsletter to hear about new eBooks.

PDF Nail Therapies Baran Download

Uploaded by

Copyright:

Available Formats

PDF Nail Therapies Baran Download

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

PDF Nail Therapies Baran Download

Uploaded by

Copyright:

Available Formats

Full download ebook at ebookgate.

Nail therapies Baran

Download more ebook from https://ebookgate.com

Baran Dawber s Diseases of the Nails and their

Nail Surgery 1st Edition Bertrand Richert

Milady Standard Nail Technology 7th Edition Milady

The Complete Nail Technician 2nd Edition Marian Newman

Transcatheter Valve Therapies 1st Edition Feldman

Urgent Interventional Therapies 1st Edition Nicholas

Diseases of the Nails and Their Management 3rd Edition

The Other Muslims Moderate and Secular 1st Edition

“If human health is missing, no other benefit can be of any value.”

© 2012 Informa Healthcare, except as otherwise indicated.

For corporate sales please contact: CorporateBooksIHC@informa.com

Typeset by Exeter Premedia Services Pvt Ltd, India

Acknowledgements and contributors vii

1. Anatomy and physiology of the nail unit 01

27. Nail surgery 110

The medical illustrations are by Florence Richert (florencerichert@free.fr).

● soft tissue (ligaments, tendons, and their fibrocartilages)

Histological images confirm the link between the different structures.

BURN INJURIES OF THE PROXIMAL NAIL FOLD

WORN-DOWN NAILS (FIG. 2.4)

Figure 2.1 Nail clubbing.

INCONTINENTIA PIGMENTI SUBUNGUAL TUMOURS

Figure 2.2 Schamroth’s sign.

Figure 2.3 Koilonychia nails.

Figure 2.4 A worn-down toenail.

Figure 2.5 Worn-down fingernails.

Figure 2.6 Beau’s lines.

RACQUET THUMB (FIG. 2.7)

SCABIES (FIG. 2.8)

Figure 2.7 Racquet thumb.

Figure 2.8 Scabies nails.

OIL-DROP SIGN (SALMON PATCH)

Table 3.1 Signs of Psoriasis

© Robert Baran, Dimitris Rigopoulos, and Informa

Figure 3.2 Subungual hyperkeratosis.

Figure 3.3 Oil-drop sign.

Figure 3.4 Onycholysis associated with some pits.

© Robert Baran, Dimitris Rigopoulos, and Informa

Figure 3.5 Splinter hemorrhages.

Figure 3.6 Paronychia associated with erythroderma.

Table 3.2 Treatment Algorithm

Corticosteroids (Fig. 3.7)

Figure 3.7 Treatment with steroids.

Calcipotriol Plus Betamethasone

Phototherapy and Psoralens

Superficial X-Ray Therapy

Table 3.3 Efficacy of Biologics on Nails

1. Distal and lateral subungual onychomycosis (DLSO)

3.6 Mixed forms with 3 variants:

Figure 4A.2 Subungual hyperkeratosis.

© Robert Baran, Dimitris Rigopoulos, and Informa Healthcare

Figure 4A.4 Paronychia.

Figure 4A.5 Fungal melanonychia.

© Robert Baran, Dimitris Rigopoulos, and Informa Healthcare

Figure 4A.6 So-called candida paronychia.

Figure 4A.7 Nondermatophyte mold paronychia with leukonychia.