Nail Disease Flashcards
Describe the most common nail problem in primary care?
Ingrown toe nails
What causes ingrown toe nails?
Poorly fitted shoes Improper nail grooming Trauma Genetic Factors
Mechanism of action for ingrown toe nails?
The nail pierces the lateral fold, acting as a foreign body. This leads to the development of erythema, purulent substance and granulation tissue.
Clinical presentation of ingrown toe nails?
Painful, swelling, difficulty with ambulation. MC in great toe. Pt has a social hx of poor fitting footwear and/or improper nail care.
Discuss the sxs and tx for STAGE 1 of ingrown toe nails.
Sx: mild erythema, edema and focal tenderness.
Tx: Wear wide toe box or open toed shoes, cut nail straight across to extend pass the tissue, warms soaks bid x 20min.
Discuss the sxs and tx for STAGE 2 of ingrown toe nails.
Sx: Crusting, purulence.
Tx: Perform digital block, elevate the offending edge of the nail from the soft tissue using a cotton pledget. Cotton should be soaked with antiseptic and technique performed daily until nail gross beyond tissue.
Elevate the foot, open toed shoes, warm soaks bid x 20 min.
Discuss the sxs and tx for STAGE 3 of ingrown toe nails.
Sx: Infection with protuberant granulation tissue extending over nail plate. Tx: Remove nail margin with minor surgical procedure. Partial wedge resection or complete nail removal: destruct nail matrix with surgery or phenol + q-tip. Elevate, warm sock bid x 20min.
Complications of ingrown toe nails?
Paronychia, secondary cellulitis.
Prevention of ingrown toe nails?
Shoes with wide toe box/proper fit Nail grooming - cut nail straight across
Name this nail condition.
Ingrown toe nail
What is first-line treatment for
Distal Subungual Onychomycosis
- Terbinafine, for 12 weeks
- Risks: liver function
- clinical cure seen in only 50% of patients
What is second-line treatment for
Distal Subungual Onychomycosis
- Itraconazole
- Fluconazole
- may be helpful for dermatophyte molds or yeast
- obtain positive fungal culture before initiating either treatment
When should you refer an onychomycosis patient?
- Fungal cultures are negative
- atypical nail pattern, especially if other rashes are present
- onychomycosis that has a positive fungal culture but fails first-line therapy (Terbinafine)
What are risks with onychomycosis?
- skin injury near nail may risk infection (cellulitis, sepsis, necrosis, etc.)
- those with diabetes or HIV, and the elderly are especially at risk
Patient education of onychomycosis
- Recurrence rate is high
- wear appropriate footwear in high-exposure areas (pools, gyms, etc.)
- nails may not appear normal for up to 1 year
What is Paronychia?
Local, superfiical infection or abscess of perionychium - a break in the seal between the proximal nail fold and nail plate.
What causes acute paronychia?
Nail biting, finger sucking
Aggressive or repetitive manicures/artificial nails
Trauma, i.e., hangnails
Infection with Staph. Aureus
What causes chronic paronychia?
History of diabetes or immunosuppression
Contact irritant exposure
Occupations with prolonged water exposure, chemical use, or extensive glove wearing.
Candida albicans
How does acute paronychia differ in presentation from chronic paronychia?
Acute tends to be painful, with swelling and tenderness on lateral fold of the nail, with a collection of purulent material at nail margin.
Chronic lasts 6 weeks or more, area of finger nail fold is tender and skin is boggy, swollen, and erythematous but not fluctuant.
What is the diagnosis for paronychia?
Culture to determine if bacterial or fungal.
What is the treatment for acute (bacterial) paronychia?
Warm soakes 3-4x daily
PO antibiotics with gm- coverage
Incision and drainage
What is the treatment for chronic paronychia?
Avoid exposure to moist environments, irritants, and nail manipulation
Wear cotton gloves under vinyl gloves
Topical antifungals
Oral antifungals for aggressive cases (may be more necessary in DM or immunocompromised patients)
What is key about follow-up for paronychia?
Monitoring is required to prevent progression into deeper infections, as it can result in more serious infections (tenosynovitis, osteomyelitis)
Describe clubbing of the nails
Clubbing of the nails is loss of the normal angle between the nail and the proximal nail fold (angle increases to 180 degrees or more).
Schamroth’s window is not present with nail clubbing (see attachment).
Predisposing conditions include malignancies, lung cancer, bronchiecasis, empyema, lung abcesses, pulmonary fibrosis, congenital heart disease, endocarditis, and pericarditis.
Define/describe melanonychia.
Melanonychia is black or brown pigmentation on the nail plate often caused by increased production of melanin in the nail matrix.
It comes in 2 forms: diffuse melanonychia or longitudinal melanonychia
Predisposing Conditions for Melanonychia
systemic diseases (endocrine)
trauma
inflammatory disorders
fungal infections
drugs
benign moles/nevi
melanoma
age
darkly pigmented skin
